Antipsychotic and other tranquilising medicines are prescribed to help care staff manages behaviour in one-quarter of older people living in Australian long-term care homes. While these medicines pose significant health risks, particularly for people with dementia, reliance on their use occurs when staff are not educated to respond to resident behaviour using nonpharmacological approaches. The Halting Antipsychotic use in Long-Term care (HALT) single-arm study was undertaken to address this issue with 139 people 60 years and over with behaviours of concern for staff living in 24 care homes. A train-the-trainer approach delivered person-centred care education and support for 22 HALT (nurse) champions and 135 direct care staff, dementia management education for visiting general practitioners (GP) and pharmacists, use of an individualised deprescribing protocol for residents, and awareness-raising for the resident’s family. The HALT champions completed open-ended questionnaires and semistructured interviews to identify the contextual elements they considered most critical to facilitating, educating care staff, and achieving success with the study intervention. They reported that person-centred approaches helped care staff to respond proactively to resident behaviours in the absence of antipsychotic medicines; the champions considered that this required strong managerial support, champion empowerment to lead change, reeducation of care staff, and the cooperation of families and GPs.
Dementia is one of the leading causes of disability in people aged > 65 years. Currently there is no approved treatment available to prevent progression or cure dementia. It is classified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [
In these circumstances, people with dementia require supported care services, including long-term care [
One of the major reasons that antipsychotic medicines continue to be used in long-term care is that the majority of direct care staff have limited training in dementia care work, and no qualifications in nursing or allied health specialities. They often lack the basic knowledge required for providing quality dementia care and have limited skills in dementia-specific communication and behavioural management [
As well, without dementia-specific knowledge direct care staff have less hopeful attitudes towards people with dementia, do not anticipate meaningful responses from them, and have low expectations of improvements in the person’s functional and cognitive ability [
Dementia education based on a person-centred care framework [
For person-centred care to become a practical reality in reducing, or eliminating, the use of psychotropic medicines in people with dementia, its application must be interpreted in the context of the person and their personal characteristics, collegiate relationships, and the healthcare organisational circumstances [
In response to the continued reliance on antipsychotic medicines for people with behaviours that cause difficulties for long-term care staff, we conducted the Halting Antipsychotic use in Long-term care (HALT) study [
This HALT substudy aimed to identify the champions’ experiences with applying the person-centred care training when providing leadership to direct care staff in person-centred dementia care. In this article we focus on the champions’ use and satisfaction with the training program resources and recommended techniques, their perceptions of the enablers and barriers to person-centred approaches in practice and whether the person-centred care approach helped to reduce resident behaviours, and their reflections on how the person-centred care approach adopted had an influence on the culture of dementia care.
The HALT study
HALT was conducted as a single-arm longitudinal study in a convenience sample of 24 long-term care homes (12 private, 10 charitable, and 1 community-based, each with >60 beds) in the greater Sydney region, Australia. Informed proxy consent was obtained for all but one of the study participants; one resident was able to provide her own consent. Appointed nurses from each of the homes recruited 149 people aged 60 or older, who lived in the home for ≥1 month and were taking regular antipsychotic medicines for ≥3 months, of whom 139 were eligible. Eligibility was assessed via staff interviews and file audits. Residents were excluded if terminal illness or a primary psychotic condition was present, or if they had extreme behaviour that might be too difficult to manage in the long-term care setting (score ≥50 on the nursing home version of the Neuropsychiatric Inventory (NPI-NH) [
The 22 HALT champions recruited to the study were volunteer registered nurses from each of the participating homes who were identified by their managers as having leadership qualities in educating/training and supervising direct care staff in person-centred care techniques for participating residents. The study’s project coordinator recruited and consented one or two experienced senior nurses within each of the 24 participating care homes to take on the champion role.
The person-centred education/training and support component of the multifaceted study intervention used an evidence-based train-the-trainer approach to deliver person-centred dementia care education and support
Experiential and adult learning techniques were used in the training program, including role play of person-centred approaches with champion-identified examples of known residents with behaviour that was concerning for direct care staff; trainer demonstration of how these behaviours might be investigated and approached during role play; group activities which encouraged expression of feelings through sharing observations, and engaging with emotions by entering into the reality of the person with dementia and not simply trying to distract them; and facilitating shared learning by assisting the champions to use the different learning resources and techniques in preparation for their role, such as care planning with reference to residents recruited to the study, and use of practice memos and mini-tutorials on person-centred approaches that they planned to use during staff handovers.
Along with a range of strategies to facilitate person-centred care practice with direct care staff, the champions were provided with helpful resources such as person-centred care plans which focused on maintaining resident function, engagement, and well-being; care management and behaviour prevention/reduction techniques and protocols; case management and team leadership techniques; the VIPS[
Champion education and supervision of 135 direct care staff occurred in consultation with their managers, the project coordinator, and the dementia nurse specialist, which continued on a regular basis until follow-up. The dementia nurse specialist and the project manager provided on-site and phone support to the champions as they commenced educating and supervising direct care staff in person-centred care and behaviour management.
The HALT substudy identified the contextual elements that the champions considered most critical in facilitating, adhering to and achieving success with the person-centred care component of the HALT intervention, and how this change process impacted on care delivery and outcomes for participating residents from the champions’ perspectives. To obtain these data a questionnaire was completed by HALT champions before and after they participated in the education/training program, and they were interviewed at study follow-up.
The pre/post education/training questionnaire was based on process evaluation principles and included eight opened-ended questions on the champion’s learning needs, expectations, and achievements, including their knowledge of dementia and dementia care, application of dementia care skills/strategies, and knowledge and application of person-centred responses to behaviour in dementia. One additional item was included in the posteducation course questionnaire which asked the participants to rate the program quality on a Likert scale ranging from 1 ‘did not meet learning needs’ to 4 ‘met all learning needs’. Questionnaires were administered by the research assistants immediately prior to and at the conclusion of the champion’s education/training course, and participant responses were handwritten. Completed questionnaires were returned to the study research assistants in sealed envelopes for data entry and analyses.
One-on-one champion interviews were informed by the substudy aims. The interviews were conducted by the project coordinator in private rooms within the aged care home, using a semistructured interview guide. For a small number of champions who were unable to be interviewed during working hours, one-on-one interviews were conducted by telephone. Interview questions included a mix of closed and open-ended items, and items which asked participants to give ratings to fixed questions using Likert scale responses, such as ‘none’, ‘a little’, ‘some’, ‘a lot’ and ‘substantial’ and ‘very low’, ‘low’, ‘neutral’, ‘high’, and ‘very high’. The 10 topics covered included work-related demographics; progress and details on instituting person-centred approaches in care for included residents; barriers and enablers with instituting the person-centred approach; strategies used successfully in reducing triggers and resident behaviours; impact of person-centred approaches on resident behaviour; impact of on-site person-centred education, training, and supervision on care practices; and factors involved in instituting a person-centred workplace culture. Champion responses were tape recorded and key statements were hand-recorded on the survey and interview forms. Handwritten statements were checked for accuracy with participants at the end of the survey. Since the tape recordings were transcribed verbatim, they were not returned to participants for their review.
Questionnaire responses, interview transcripts, and notes recorded by the data collector were sorted and classified with computer software, NVivo 8[
The substudy results are presented according to the questions which guided the champion questionnaires and interviews, concluding with the themes derived from these data.
The 22 champions were all female registered nurses, with a range of educational qualifications and working at different levels of authority. Educational preparation included hospital-training certificate and/or diploma and/or a bachelor and/or a master degree in a health discipline. Champion work roles included senior registered nurse (n=6), clinical nurse specialist (n=4), clinical nurse consultant (n=5), nurse practitioner (n=1), quality manager (n=3), deputy director of nursing (n=1), and care unit manager (n=2). Most of the champions had participated previously in some form of dementia-specific education within the care home or externally, ranging from certificate to degree-level courses.
All 22 champions responded that the education/training course had met many of their learning objectives, particularly on how to use a person-centred care approach to reduce the incidence and severity of resident behaviour, techniques in communicating with residents with dementia and behavioural issues, and how to change staff’s reliance on antipsychotic medicines for resident behaviours they found difficult to manage. They considered the course had taught them strategies which they intended to utilise in practice as a way of facilitating implementation of person-centred care. The following statement of one champion’s satisfaction with the education and support received was similar to sentiments expressed by most Champions:
“Staff have received excellent education and feel confident and involved in the project. They have found that the process has been very consultative” (SC02).
The most useful strategies included how to interpret a need from behaviour, procedures for managing complex change, showing direct care staff how to be therapeutic agents, how to use practice improvement memos, microtraining and person-centred care planning, and how to use the VIPS [
All 22 champions were positive about the HALT program before and after its introduction, and this sentiment continued at follow-up. As one of the champion’s reflected:
“I think the project has created awareness that anti- psychotic medications are dangerous and not always the answer. It has allowed staff to witness first-hand the behaviours of residents who have been successfully de-prescribed. It has shown that it is a myth that behaviours automatically increase when antipsychotic medications are decreased” (MC01)
The champions reported that once they introduced the strategies they learned through the education/training course within the care home, the majority of the direct care staff were enthusiastic about the person-centred care approach and were willing to apply these approaches for behaviour that was troubling for the resident and themselves. Direct care staff were also curious to see whether person-centred approaches to behaviour prevention and management were useful. Most of the champions found that direct care staff were willing “…to give it a try and see how it goes” (VC01).
It was universally agreed that the managers provided good support for the champions and enabled them to undertake the level of education, training, and support they needed to pass on the learning obtained during the education/training course. Time was set aside for champions to work directly with staff. Shared governance with champions was a feature of the managerial leadership for the project, evidenced by the initiatives taken by champions to educate staff in person-centred approaches to care, and in the learning strategies they used for person-centred responses to resident behaviour. However, 18 out of 22 champions advised that they undertook a high level of unpaid out-of-hours work to initiate and continue the education, training support for staff. In a few cases the managers rostered champions off-duty, but paid them, to provide staff education/ training and support.
For the most part champions were fully involved in implementing the onsite education/training using many of the learning resources provided, including person-centred care and lifestyle plans, mini-tutorial and case conference protocols, practice memos, role play guidelines, and behaviour response flow charts. They took a range of opportunities to educate, train, and support staff colleagues, including during shift handover times, in targeted education sessions with care staff, in regular debriefing sessions to review progress with targeted staff, and conducted case study reviews with the whole team, case conferences with the family, nurses and allied health staff, and supervision of staff in daily practice. These sessions ranged from “
The champions attempted to educate, train, and support as many staff as possible, estimating that they reached approximately 75-80% of all staff, including staff working on weekends in some of the homes. Education techniques were based on the HALT person-centred care training program folder and resources, supplemented by education provided by external consultants and via DVDs and other online resources provided by dementia support and training services. All 22 champions considered that staff’s level of knowledge and awareness of nonpharmacological management of resident behaviour improved with the education, training, and support they received through the HALT intervention. They recounted different ways that the techniques taught in the course helped them to understand and work on minimising triggers which individual residents found distressing. One of the champions explained this process:
“We checked the reasons for agitation, such as constipation, pain and thirst, and attended to any issues that seemed to be a trigger. We also asked the doctor to attend to issues quickly, such as pain” (SLC01).
While the support from the study dementia nurse specialist and project coordinator was appreciated by champions, it was generally thought that more onsite and on-going education was needed for all staff. Two of the champions requested that “
An issue raised by six of the champions was the need for additional onsite education of person-centred approaches for direct care staff from culturally and linguistically diverse backgrounds (CALD), where more discussion and experiential education for understanding these concepts and their practical application were required. Where a facility had a high proportion of CALD families and residents, it was suggested that translators and written translations would assist in the implementation and acceptance of the person-centred approach. This issue was explained by one of the champions:
“These staff need to first of all be helped to understand the concept of helping residents to make decisions for themselves and to express their own personality, then feel confident to try different approaches to meet the resident’s needs, because all residents are different, and they have different issues and respond differently to triggers that support their well-being and also ill-being. If the information about the care model could be translated for the overseas-born staff that would help” (BPC02).
The context of the care environment proved to have the greatest impact on the operationalisation of person-centred care practices. Champions reported that their work cultures were developed to value, respect, empower, and give choice for the champions, the staff, and the residents. The organisational climate and culture created by the managers supported the committed vision of a person-centred approach to behaviour reduction and management and also influenced the actions and interactions of the staff providing the care. The champions spoke of how direct care staff were encouraged and assisted to put their relationship with the person before the tasks they needed to undertake. This was greatly helped by champions working with staff to plan care and behaviour management in ways that focused on the person’s unique preferences and needs. The perceived enablers and barriers to making these practice changes are listed in Table
Enablers and barriers to implementing person-centred care approaches.
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Enablers | Examples provided by Champions |
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Management support for incorporating personalized care into daily care practices | “… |
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Management allowing Champions and staff to try out new ideas | “ |
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Shared governance in decision-making | “… |
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Clear communication between managers, nurses, direct care staff, the Champions, the resident’s family and the GPs | ‘… |
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| |
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Barriers | Examples provided by Champions |
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Reluctance of residents’ families to agree to deprescribing | |
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Reluctance of resident’s GP to deprescribe | |
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Reluctance of some nurses to support deprescribing | “ |
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Negative family attitudes towards non-pharmacological management of behaviour | “ |
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Task-focused care culture | |
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Time to implement person-centred behaviour responses | ‘…(direct care staff) |
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Lag time in reporting of the study findings | “….(Champions) |
The 22 champions considered that the majority of direct care staff derived deep satisfaction and meaning from their work and the relationships that they formed with the residents, particularly after learning how dementia affects the resident’s communication and other abilities. They advised that most of the direct care staff worked together to provide a sensitive way of understanding and responding to each resident’s needs and unique personality. Champions identified that this approach helped to provide culturally appropriate solutions in regard to behaviour management, “
An important change for direct care staff was the incentive for them to minimise, and challenge systems-driven services that were not in the best interests of the resident. This was enabled by managerial and champion leadership in shifting in the organisation’s control over care schedules, and their role in negotiating schedules and care/treatment priorities with families and GPs. This leadership created a climate throughout the care home and allowed the majority of champions sufficient time and resources to lead the change process.
The champions reported seeing improvements in the quality of care for residents with facilitated learning in practice. Words used to describe these improvements included staff ‘
It was noted by nine of the champions, however, that some direct care “
The major strategies that all champions found useful when helping direct care staff to become aware of potential triggers for individual residents included searching out information on the resident’s previous lifestyle and history from family and client records, discussing the resident’s unique needs with nursing care and allied health teams in dedicated meetings and at case conferences, and spending more time with the resident to learn about their preferences in care. As one champion noted:
“… taking small, well-planned steps (towards change) helps to convince the staff of how important it is to take notice of what the resident is trying to tell us” (SBC01).
Another champion identified that
“…. helping one resident (to be less agitated), helps other resident to feel settled” (VC01).
A frequent example given of the type of change made by direct care staff included paying attention to the potential for residents to experience pain, which resulted in “
A further strategy reported by 17 of the champions in reducing behaviour triggers was allocating time for direct care to communicate with residents when verbal agitation was present, and where this appeared to be “
Since all 22 champions facilitated person-centred care with direct care staff, they recounted numerous examples of their observed changes to care practices and the impact these changes had on participating residents. All champions considered that the person-centred approach was helpful for the majority of residents, not just those enrolled in the study. Reported improvements in outcomes for participating residents were described in terms of functional status, overall well-being, and behaviour reduction. Improvements reported included the residents being calmer, more cooperative, more social, more independent in activities of living, and less anxious. The champions reported that these positive changes tended to occur gradually at first, but “
Nevertheless, some resident behaviours and activities of living were not observed to improve with deprescribing. Two of the champions noted that these residents were “
Champions recounted many examples of how their care home managers, champions, and direct care staff developed a coordinated system of sharing the common values of person-centred dementia care, while understanding the value that their unique roles played in caring for residents. Improved communication systems between 19 of the 22 champions, managers, and direct care staff also helped to share knowledge about residents, in order to develop greater awareness of what precipitated and helped to reduce agitation and other behaviours in residents. The champions recalled how positive interactions between direct care and therapy staff, and managers, were key to supporting the personhood of individual residents; this occurred mainly by developing empathetic working relationships.
The other important approach to developing a person-centred culture occurred through the champions working hard to establish care partnerships, through enabling direct care staff, residents, and families to have direct involvement in decision-making in care schedules and treatment regimens. Champions spoke of how partnerships were formed with families through staff developing an understanding that each resident had a unique history and that residents and/or families were entitled to indicate their preferences in daily living activities and the way that care was provided. As one champion found:
“Helping the family to get involved in discussing their relative’s issues and needs, and what might be causing their distress, this will help the staff to feel more connected and more willing to work with the family to sort out these issues.” (AHC01).
By taking this approach, direct care staff learned how to humanise care practices, how to help residents maintain their personhood, dignity, and decision-making; and how to individualise care and therapy activities that were preferred by the resident and/or their family, because “
Champion recommendations for further development of a person-centred workplace culture included: “
This substudy of the HALT trial provided data on the champion’s experiences of how person-centred training program helped them to provide the groundwork for a change in dementia care, their observations of the impact it had on resident behaviour, and their perceptions of its influence on dementia care culture in relation to the underlying mechanisms of the care context, management systems, staffing arrangements, and resident issues. While this substudy does not report on the answers to these questions from the perspective of the study’s GPs, families, direct care staff, and care managers, the champions’ insights provide valuable guidance on how staff leaders can progress needed change, and in identifying what structural factors play their part in successful implementation of person-centred care. The main themes arising from these data focus on organisational and staff readiness to accept, believe in and embrace practice change, by instituting a planned change management procedure, empowering champions to drive the change process, and empowering direct care staff to adopt the change in care practices. The champion interview findings indicate that success with implementation related to four key factors: behaviour management improvement was considered a priority for champions and managers; leadership was in place to support person-centred care across the care unit; a ‘bottom-up’ change model worked alongside ‘top-down’ change approach; and the person-centred approach to behavioural issues was appropriate to the context.
These findings contribute to the literature by explaining the discrepancies between the expected and observed outcomes for some residents, help in understanding how the care context influenced outcomes, and provide insights to aid future implementation of person-centred care for residents with behaviours that are concerning for direct care staff [
The positive outcomes reported by the champions were dependent on their acquisition of detailed knowledge, skills, confidence, and competencies for leading the change process. It appears that many of the different resources and strategies gained through the training course, such as practice memos, mini-tutorials, person-centred care plans, and the VIPS [
Nevertheless, as four of the champions reported finding it more difficult to institute required changes in care practices, despite managerial support and authority delegation, the shift from knowledge gain to knowledge translation may be related to the characteristics of the individual. This finding indicates that one-off education/training courses were insufficient to arm even senior nurses with the knowledge and skills they needed for initiating and providing leadership in practice change [
Similar to other studies of the person-centred care model in long-term dementia care, managerial leadership and cooperation, direct care staff understanding, knowledge, acceptance, and perseverance in applying these approaches, as well as GP and family acceptance, were considered essential to implementation success [
The study findings support the contention that person-centred improvements in long-term care services are largely a function of organisational structure, workforce capabilities, organisational climate, communication structures, staff readiness, and leadership [
While the study findings are most informative in reporting details on how to introduce and sustain person-centred approaches to behaviour management in long-term care, they are limited to the experiences and recommendations of the study champions who provided onsite leadership and facilitated the approach with direct care staff. An acknowledged limitation is that the champion interviews were undertaken by the project coordinator, which may have introduced bias in the champions’ responses. Nevertheless, these data provide detailed reflections on the factors the champions observed as having influenced resident outcomes with a person-centred approach and enhance the HALT study’s contribution to the nonpharmacological management of behaviour in dementia [
There is strong evidence in the literature to suggest that person-centred responses can help reduce behaviours in long-term care residents which care staff find challenging, in respect of being able to provide them with personal care without resistance and in helping the person attain well-being, despite physical, social, and cognitive limitations [
Some of the data are currently still being analysed for other studies and will not be available until all articles are published.
The study sponsor(s) played no role in the data collection, analysis, and interpretation of data, in the writing of the article, or in the decision to submit the manuscript for publication.
The authors declare that there are no conflicts of interest regarding the publication of this article. Over the last three years, author Henry Brodaty has been on advisory boards of or a consultant to Eli Lilly and Nutricia. His department has received payment to participate in drug trials for Alzheimer’s disease by Tau Therapeutics. Authors Lynn Chenoweth and Henry Brodaty have been recipients of grants for research by the National Health and Medical Research Council and Australian Department of Health and Ageing.
Lynn Chenoweth contributed to HALT study planning and design, provided training and supervision to nurse champions in nonpharmacological prevention and reduction of BPSD, contributed to data analysis and interpretation, and led the writing of the manuscript; Tiffany Jessop coordinated the HALT study, contributed to data collection, analysis, interpretation, and reporting, and contributed to writing the manuscript; Fleur Harrison and Monica Cations undertook participant recruitment and data collection, data entry, and database management and contributed to data interpretation and writing the manuscript; Janet Cook contributed to data analysis and writing the manuscript; and Henry Brodaty led the HALT planning, study design, recruitment, and interpretation of the data and contributed to writing the manuscript.
The HALT study was funded by the Australian Department of Health under the Aged Care Service Improvement and Healthy Ageing Grant Fund and supported by the Dementia Centre for Research Collaboration, UNSW Sydney. The authors acknowledge the contributions of other HALT study team members, Perminder Sachdev, Brian Draper, Sarah Hillmer, and Megan Heffernan. The authors also thank the contributions of the HALT study steering committee members, Jacqui Close, Juanita Westbury, Lee-Fay Low, Aine Heaney, Marie Alford, Stacy Wake, Janet Mitchel, Millie Marinkovich, and Jenny Blennerhassett. Linda Nattrass, Anne-Nicole Casey, Emily Trigge, and Tiffany Chau are acknowledged for their assistance with administration and data entry.
The HALT emergency behaviour response protocol was used by the study’s nurses and champions when investigating, interpreting, and responding to resident behaviour that staff found extremely challenging, including person-centred approaches.