Evaluating a dementia focused performance management programme

Background

There has been much interest in England in promoting training among professionals working with people with dementia. This reflects concerns that people working in social care services providing support for people with dementia are the staff who are least likely to have been offered or to have attended any training (Hussein & Manthorpe, 2012). While many training initiatives focus on frontline workers, there are also developments aimed at more senior staff and this brief paper describes and discusses one management programme that combined managerial development with dementia practice.

A ‘Dementia Focused Performance Management Programme’ was commissioned by the Care Sector Alliance Cumbria (CSAC) in 2011. This alliance is a group of employer and other stakeholders in social care that seeks to improve the sector’s performance and productivity through collaboration and investment in the workforce. The weekly programme, which ran for seven weeks, was attended by 13 senior care managers and care home managers working in 10 care homes with nursing in the rural area of west Cumbria, England. Sessions or modules covered:

Organisation communication and leadership;

The programme was designed to improve organisational performance and contract compliance and was informed by an audit of Adult Social Care compliance reports which had been undertaken by Cumbria County Council in 2011. Potential participants were also consulted about the contents of the programme in advance. Some participants attended on the recommendation of the local authority Adult Social Care Contracts Team, indicating that the local authority considered that there was need for improvement in some of the care homes.

Methods

The programme was evaluated by independent researchers. To collect participants’ views, a focus group was held with participants on the final day of the programme (n = 8). Those who missed the final day were later followed up for interview (n = 4). The focus group and the interviews employed the same topic guide, with questions focusing on: general satisfaction with programme; the extent to which the programme was perceived to be useful in terms of the day to day management challenges facing managers and senior care staff; and whether, as a result of participating, participants planned to implement any changes to their own management practices or the wider procedures and policies of the care home. Participants were also asked to reflect on how the programme compared to other training programmes they had experienced and what other kinds of training or support would be useful. A brief telephone interview was conducted with one participant (n = 1) who had signed-up for but did not attend the programme to ask the reasons why.

A seven point (0–6) Likert scale set of questions was also sent to participants before and after the programme to explore possible change across each module domain (seven domains: communication skills, present knowledge of dementia care, skills in managing change, promoting person centred values, managing conflict in the workplace, motivating staff, supervision skills). This was completed by 12 participants. A separate end of programme report was also produced by the programme leaders and this provided another view of the aims and running of the programme.

Findings

Most participants said that they enjoyed the programme and that they found it useful. They especially appreciated the opportunity to learn from peers and colleagues. The programme enabled them to reflect upon and alter some aspects of their management practice. Changes were reported particularly at the level of improved confidence and feeling more skilful in communicating with staff. The Likert scale demonstrated an average 0.6 improvement across each of the seven domains mentioned above.

Participants provided many specific changes they had made as managers to improve their homes’ dementia care. One participant described that on the recommendation of the programme she had introduced colour contrasting toilet seats to the care home where she worked. Another participant had changed the information provided to residents and families:

We have implemented quite a few things from the training … and when you get feedback from your staff to say it’s working – that’s fantastic.

However, negative comments were brought to the attention of the programme commissioners. They considered the venue too far from many participants’ workplaces. Some felt that the aims and objectives of the programme had not been clearly explained at the outset. Many participants had assumed that the programme was going to be wholly dementia focused and were surprised that a large part of the content was focused on generic management training applicable to all social care settings. Furthermore, the management training itself was considered to be too basic or low level and perhaps more suited to participants new to management. While some participants said it was useful to have a ‘refresher course’, other more experienced managers felt strongly that it was not a good use of their time. Overall, the mix of dementia training with basic management training was perceived not to have worked well.

Participants made a number of suggestions about improving such a programme. These were directed to their own managers – to ensure that expressions of commitment to continuing professional development within the sector were matched by the offer of adequate staff cover to enable senior staff to attend training. Lack of cover was the reason given for a high number of participants missing sessions and although participants would have liked to receive course materials when they had missed a session, this would not have compensated for reduced opportunities for engagement.

Participants described the difficulties they faced in keeping their staff motivated and engaged in the process of continuous quality improvement and seemed to doubt their own ‘worthiness’ for training when others’ needs were greater:

It’s not that we need some more of [this training] but that [our front line staff] need some of it too … Maybe not at this level but something which gives them some self awareness about how they [can] affect the running of the home. Because then they could see where all these big decisions come from and that it is not just coming from their manager sitting in their office.

This suggests that there may be some resistance to performance improvement initiatives that target one level of an organisation. Participants also observed that those running managerial programmes need to be mindful that care home managers have only limited scope to implement change (for example, in care planning and supervision practices) without approval from their own managers or home owners at local or corporate levels.

Like many middle managers they described being often subject to conflicting advice about what constitutes ‘best practice’. For example, in their experience each Care Quality Commission (CQC) inspector held very different expectations of ‘care plans’. The programme gave participants the opportunity to voice responses to these variable demands:

I think we can see now that we are all in the same boat – it’s not just our home … You get an inspector coming in saying ‘[Those] care plans are no good – I want them rewritten.’ But from talking here we are all in the same boat. We are not on our own.

However, participants expressed a wish for more tailored support around the aspects of dementia care management practice they found most challenging. These related to day to day relationships within the care system and the interface of the care home with the outside world:

Working in dementia care is very emotional and challenging for staff – how can we adapt our supervision practices to reflect that?

We will just be getting ourselves on the right track and [the requirement to make another practice or procedural change comes] along and knocks [the staff] and then it’s trying to motivate them again.

Teams can be doing great things but then one of the more disruptive members of staff will disrupt them and can spoil the whole team – managing team dynamics.

[When you] have done a lot of this training before, you become quite self-aware, but you are going in managing people who are not at that level, they have not got that level of self awareness and that’s the toughie … They have never been asked questions about their values – all that stuff that [this kind of training] opens our eyes too …

I think it’s very hard to turn a nursing home around. If you go into a home and there is lots of issues you have got to have nerves of steel to go in there to take [the staff] on. It can be very challenging.

Some participants stated that management training alone would not be adequate in addressing these challenges and that more participatory and collegiate styles of learning were needed. Their ideas included developing a mentorship scheme or setting up a forum where managers could share experiences and ideas. They acknowledged that staffing constraints and the competitive nature of the commercial care home sector were significant barriers to achieving this.

Recommendations

The evaluation findings were discussed with the Programme Leaders and the Workforce Development Manager. The following recommendations were made to the programme commissioners and may be generalisable:

Dementia training may best be delivered as a ‘stand alone’ programme and commissioned from dedicated/specialist providers.

The programme and its evaluation enabled local care workforce stakeholders in the form of the CSAC (1) to identify ‘management challenges’ from a number of different standpoints, (2) to acquire information about the potential to address these issues through more collegiate working (learning from peers) and (3) to have evidence about which advanced/specialist (potentially interdisciplinary) management training was seen as a priority. In this way the first programme was able to focus on dementia services management and offered an opportunity for the managers themselves to shape future activity.