NIHR Signal Training programme to improve communication between staff and patients with dementia in hospital shows promise
Published on 5 March 2019
Communication with people with dementia can be challenging for healthcare professionals. A new two-day training programme shows potential to help professionals become more confident in managing difficult situations on the ward.
After analysis of 41 videoed exchanges between 26 healthcare professionals and 26 people with dementia in acute hospitals, researchers identified particular challenges. These included requests for action, such as asking them to take a drink or get out of bed, and at the end of an encounter when people failed to recognise cues that the conversation had ended. The researchers also identified features of successful encounters.
The research and a review of relevant evidence fed into a training programme. Although the course was tested by a limited number of healthcare staff, this study represents a robust and thoughtful development and testing of an intervention in an overlooked and important area.
- Health management, Public and patient involvement, Dementia, Nursing, Acute and general medicine
Why was this study needed?
As many as 25% of beds in acute general hospitals are used by people living with dementia, making them a sizeable part of the hospital population. People living with dementia can easily become disorientated in hospital.
However, the effects of the condition on understanding and language skills mean that communications between healthcare professionals and people with dementia are often challenging. Communication difficulties can be distressing for patients, harm care and be time-consuming for hospital staff. Strategies and skills taught to professionals in general communication training may not be adequate for this population.
This study aimed to:
- understand the existing evidence base for communications training
- identify how healthcare professionals interact with people with dementia in practice
- identify problem areas and potential solutions
- identify skills or strategies that can be taught
- develop a training course
- evaluate the course and identify barriers to putting it in place.
What did this study do?
The study used mixed methods to develop and then test an intervention in practice. It began with a literature review to look at content and format of communication skills training. The researchers then video-recorded interactions between 26 volunteer healthcare professionals and patients with dementia on acute hospital wards.
They used conversation analysis to video the verbal and non-verbal interactions between patients and professionals. This identified areas of difficulty, which included requests from the healthcare professionals (which were often refused) and attempts to bring the encounters to an end (which often went unrecognised). This analysis also identified strategies that were successful in avoiding these problems.
The results were used to design a training course, which included simulated encounters with actors trained to behave in ways typical of people with dementia. The course was run six times in two hospitals with 45 staff. The course comprised two days, one month apart, and included ‘before and after’ video-recorded encounters and interviews after the course. There was a before and after evaluation of the course with knowledge, attitudes and confidence reported by participants. Participants were also followed up by a survey one month later - response rate was 31/44 (70%).
What did it find?
- Researchers observed from video-recordings that people with dementia were more likely to agree to requests when asked to do something directly, when the healthcare professional making the request made it with authority, and when perceived difficulties associated with the task were minimised. Examples included stating what was going to happen – ‘we’re going to…’ or ‘I need you to…’ and minimising the task using phrases like ‘just,’ or ‘for a minute’.
- Requests were more often refused if the request was made indirectly, or used vague language, or asked people whether they were willing or able to do something – ‘can you…’ or ‘will you…’.
- Closing an encounter was more successful when healthcare professionals made clear statements indicating closure, such as ‘I’m finished now’ or ‘all done and dusted’. Vague promises of return such as ‘see you soon’ confused people, who wanted to know when that would be.
- The training course was scored highly in evaluation feedback, with 98% of participants saying they would recommend the course to others. On a scale of 1 to 10, attendees reported they remembered the course skills (mean score 8.6), were using the skills in practice (8.2) and found them helpful (9.6). Attendees also improved on a dementia knowledge quiz, from 7.2 out of 10 to 8.8 out of 10, and improved their confidence in dealing with people with dementia.
- The participants were surveyed again one month later and said they continued to remember, use and find the skills learned useful.
- The evaluation does not state the cost of the training course, but says the ‘length and intensity of the course were similar to other reported effective interventions', and the cost was ‘not high in commercial training terms'. However, they add, ‘cost may present a barrier for staff and services with little access to training funding.'
What does current guidance say on this issue?
NICE issued a guideline in 2018 about assessment, management and support of people living with dementia. The guideline says: ‘Care providers should provide additional face-to-face training and mentoring to staff who deliver care and support to people living with dementia,’ including ‘adapting communication styles’ as appropriate. The guideline does not specify which types of communication training are appropriate or preferred.
What are the implications?
The study demonstrates the feasibility of delivering a training programme to help healthcare professionals learn skills designed to improve communication with people living with dementia.
The evaluation showed that the programme was valued by attendees, who found it practically useful. However, the training programme has not been tested for its effect on subsequent interactions between healthcare professionals and people with dementia, or outcomes relating to clinical care.
Because of limitations of testing, the programme is likely to need further evaluation in situations other than acute general hospitals. If successful, it may also be appropriate to community and primary care settings.
Citation and Funding
Harwood RH, O’Brien R, Goldberg SE et al. A staff training intervention to improve communication between people living with dementia and health-care professionals in hospital: the VOICE mixed-methods development and evaluation study. Health Serv Deliv Res. 2018;6(41).
The study was funded by the National Institute for Health Research Health Services and Delivery Research programme (project number 13/114/93).
NICE. Dementia: assessment, management and support for people living with dementia and their carers. NG87. London: National Institute for Health and Care Excellence; 2018.
Communication between people living with dementia and healthcare professionals in hospitals has been highlighted as a significant problem. The development of effective and sustainable communication methods with these people is challenging as the pressures on staff time increase exponentially.
This important research that focused on equipping staff in acute care with the skills for communicating with people with dementia marks a significant step in addressing this agenda. The focus on ‘requests’ and ‘closings’ in communication is smart, as these are often the most challenging aspects of communication with people living with dementia, and shape the quality of subsequent engagements. It is particularly significant that the staff who undertook the training were able to continue the practices one month after the training – this bodes well for future practice development.
As staff turnover is a significant challenge in acute care settings, the real test will be ensuring the scalability of the practice to all healthcare professionals working in acute care settings.
Professor Brendan McCormack, Head of the Divisions of Nursing, Occupational Therapy & Arts Therapies; Associate Director, Centre for Person-Centred Practice Research, Queen Margaret University, Edinburgh
The commentator declares no conflicting interests