The senior staff perspective
dementia
POSITIVE
The senior staff perspective on the implementation was explored in mid-way review meetings and through telephone interviews with six steering group members from five organisations conducted after the end of the intervention delivery period; five interviewees were senior clinicians in leadership roles, and one was a research manager. One of the clinicians also contributed as a CR practitioner. They represented organisations with varying degrees of success in achieving implementation targets (#4, #8, #9, #11 and #14; see Table Outcomes of introducing CR – the perceived benefits for people with dementia, carers and staff teams.Implementation processes – the organisational challenges that made it hard to implement the intervention effectively despite high levels of enthusiasm and good will.Prospects for sustainability – uncertainty over whether it would be possible to continue delivering the intervention in the future.All the senior staff interviewed described positive impacts for their organisations. CR was thought to encourage a more person-centred and creative approach in planning and delivering interventions, leading to better outcomes for people with dementia and carers, and improved morale and confidence among staff. Positive features of the intervention included the flexibility to accommodate individual needs and preferences, and the legitimacy resulting from the perceived strength and quality of the evidence-base.Despite these positive views, all senior staff interviewed acknowledged that the implementation outcomes could have been better. Most of the barriers identified and discussed in the senior staff interviews were organisational. The primary external influence was local health service commissioning, which did not always support provision of psychosocial interventions. Within organisations, contextual factors related to culture, structure, leadership, organisational change and resources. In organisations where nihilistic views about dementia were prevalent or there was strong adherence to a medical model, it was difficult to secure resources and referrals for psychosocial interventions. Across all organisations, dementia care focused primarily on complex needs and responding to crises, and preventive or rehabilitative work was not part of practitioner remits. Senior managers often did not provide sufficient leadership to support a change in approach. In those cases where motivated managers and committed staff champions ensured that CR was kept on the agenda in their organisations and informed managers and colleagues about it, for example by giving presentations at meetings and using case examples, this helped to gain support and stimulate referrals. Across all services, there were high levels of staff absence and job vacancies, and instances of organisational change disrupting referral pathways. This meant that, contrary to the agreed implementation plans, practitioners were required to deliver CR on top of their usual caseload, and hence had limited opportunity to develop confidence in providing the intervention.All six senior staff were keen for their organisation to continue providing CR and were trying to make plans for taking the work forward. However, there was uncertainty about support from senior managers and concern that service priorities specified by commissioners might preclude the potential to offer CR in the future.