Staff Perceptions of an Online Training Programme for the Management of Behaviours That Challenge in Dementia: A Qualitative Assessment of CAIT

Abstract

Background/Objectives: Behaviours that challenge (BtC) are common in people with dementia. International guidelines recommend using non-pharmacological interventions (NPIs) as first-line treatments. A promising training package that provides a framework for delivering NPIs is “Communication and Interaction Training” (CAIT); this programme has received national recognition within the UK. Our study aimed to explore staff’s perceptions of the effect of CAIT on their understanding and responses to the behaviours and emotions of people with dementia. The study also sought to further understand how CAIT worked and the conditions which help implement it. Methods: Reflexive thematic analysis was used to analyse interviews with 11 staff who had been trained in the use of CAIT and then attempted to implement the contents of the training in clinical settings. Results: Six main themes emerged regarding the impact of the training: enhancing understanding, transforming interactions, skills development, accessible and flexible, socio-cultural change enablers, and obstacles in training. CAIT was viewed positively by the participants and was perceived to improve their knowledge, attitudes and skills. Conclusions: The positive findings are consistent with previous studies on CAIT and its current use in guiding training programmes in the UK. Implications for the delivery of CAIT are discussed, as well as suggestions for further trials of the programme.

1. Introduction

Behavioural and psychological features of dementia, such as sleep disturbances, agitation, anxiety, depression, apathy, disinhibition, and hallucinations, are common [1]. Their frequency increases with the severity of the dementia, and these actions are typically referred to as behaviours that challenge (BtC) [2,3]. Other terms such as BPSD (biological and psychological symptoms of dementia) and challenging behaviour are also commonly used in the literature [4]. An informative review of 14 popular terms in current usage was undertaken by Wolverson and colleagues [5]. BtC can be distressing for the individuals exhibiting them and the people supporting them [6,7]. These behaviours are frequently managed using medication; however, there is an international consensus that non-pharmacological interventions (NPIs) should be implemented prior to employing medication [8,9]. This is because medications, such as antipsychotics, have major negative side effects, including vascular complications, falls, and increased mortality [10].

Dyer and colleagues’ major review of non-pharmacological approaches showed that while atypical antipsychotics showed the best effect sizes, some non-drug interventions achieved only marginally lower effect sizes compared to pharmacological approaches, but with a lower risk of adverse events. The NPIs with the greatest evidence base are known as functional analysis-based interventions [11], and they involve a structured biopsychosocial method of gathering information to detect the unmet need and potential cause(s) of behaviour. Livingston and colleagues [12] examined the training requirements of effective NPIs and observed that person-centred care and supervised communication skills training were associated with good outcomes, but only for those living in care homes. Subsequent empirical work highlighted the importance of training with intensive input from experienced and/or qualified staff in these areas [13]. The mechanisms through which “good” carer communication skills lead to reductions in agitation have been a major focus of investigation in recent years [14]. Hence, some important requirements of NPI training programmes are to:

• Deliver effective person-centred care, utilising biopsychosocial frameworks.
• Teach evidence-based communication skills that meet the needs of people with dementia.
• Be effective in all dementia settings: care homes, inpatient units, and patients’ own homes.
• Have multiple modes of delivery to meet the needs of the carers (face to face, online, and written formats).

According to Surr and colleagues, who conducted a major review of this area, effective training needs to be comprehensive and practical, be developed by experienced trainers, involve active participation, employ a structured tool/manual to assist with the application of learning, and should involve ongoing supervision/coaching [15]. Training programmes have been developed worldwide to be in line with such requirements. For example, Teepa Snow’s Positive Approach to Care (PAC [16]) employs practical techniques based on occupational therapy theory. A further example of a training programme is DICE, which is an evidence-based programme for family carers [17]. Notably, a systematic review of training for family/non-paid carers was undertaken recently by Felstead and colleagues [18]. In Australia, clinical researchers have developed BtC educational programmes that incorporate modifications to facilitate better communication with people referred to as Australia’s first peoples (i.e., Aboriginal and Torres Strait Islander communities) [19]. In relation to the current study, we were mindful to develop a programme that could be used across all settings (inpatient, care facilities and family homes) and that focused on the use of verbal and nonverbal skills as the main therapeutic mechanism of change. With such notions in mind, we developed the programme CAIT [2]. Over the last ten years, CAIT has been assessed and revised periodically to keep pace with emerging evidence [20,21]. In relation to CAIT, the term BtC has been defined within a Positive Behavioural Support framework (PBS, ref. [22]). The triggering of BtC indicates that an individual has transitioned from a state of relative wellbeing to a state of illbeing. Illbeing is characterised by at least four heightened phases of behavioural and emotional activity (triggering, escalation, high distress, and calming), prior to returning to a state of wellbeing. Typically, the illbeing phases are perceived as the “BtC”. For the individual engaging in BtC, the phases are experienced in terms of physical sensations, thoughts, behaviours and emotions [2]. Using this cognitive therapy (CBT) rationale, it is evident that BtCs can therefore be expressed via emotional states (depression, anger, fear, etc.) as well as through actions (hitting out, shouting, seeking assistance, etc.). Defining BtC in this way clarifies the goals of the NPIs needed in each of the phases, which include the following: (i) to maintain wellbeing states for as long as possible through preventative therapies such as cognitive stimulation therapy, reminiscence, and music therapy [22]; (ii) to anticipate and prevent the triggering of distress using knowledge of the person, and through the delivery of good care during intimate care activities, etc. [22]; (iii) to develop carer confidence and competence in the use of de-escalation techniques [23] and also in the use of person-centred restraint [22]. CAIT employs both the PBS and CBT frameworks as useful templates. Such templates provide information about when and where specific NPIs should be used, and they also inform the training requirements needed by carers to deal with all the phases of illness (from “maintenance of wellbeing” to the “containing of extreme distress”). The current national British Psychological Society’s guidance on BtC has been greatly informed by the CAIT programme [22]. CAIT is concerned with understanding the micro-skills of delivering good dementia care and managing BtC [23] by helping carers become aware of their good communication skills and supporting them as they work to improve their skills further. CAIT borrows materials from other disciplines that rely on strong customer care skills, such as the retail sector and police force [2]. Their training materials were adapted by the developers of CAIT to accommodate the differing needs of people with dementia, such as changes in memory, problem-solving deficits, and sensory difficulties. The developers created a series of 18 engaging animations on topics such as non-drug therapies, sensory changes, distraction, and behaviours that challenge [24]. The CAIT programme is composed of six sections: description of dementia; description of behaviours that challenge and CAIT; core communication skills (customer care skills, Module 1); adaptations for communicating with people living with dementia (Module 2); communicating around intimate care tasks (Module 3); and use of care plans and delivery of complex care (Module 4). A thread running through CAIT is the unmet needs perspective (i.e., the eight needs framework). This suggests that BtC can be conceptualised as reactions to people not having one or more of their eight needs met (safety, control, dignity, esteem, fun, meaningful touch, etc. [20]. The unmet needs perspective is based on the work of Algase [25] and Cohen-Mansfield [26], who hypothesised that BtC could be understood as people’s attempts to meet their needs (e.g., kicking a door to exit a building), or as ways of signalling their distress/anger at not having their needs met. Such a perspective is valuable because it implies that people living with dementia have positive agency, rather than merely being aggressive and troublesome. CAIT incorporates work from many dementia experts, including Kitwood [27] and Teepa Snow [16]. It applies a “magpie” approach by incorporating the core values of person-centred, relationship-centred, and emotion-focused care. It does this by fostering the notion of “theory of mind” with respect to the carers [28], thereby encouraging the carers to place themselves in the position of the person with dementia mentally, emotionally, socially and experientially. CAIT also contains several strategies that were specifically developed “in-house”, such as RAM (reduce emotion, assess need, meet need). This is a de-escalation technique that recommends targeting an individual’s distress and emotional thinking prior to engaging in any form of problem-solving approach. It suggests using calm, non-confrontational interpersonal approaches to reduce levels of cortisol and to reset the person’s executive functioning abilities. Once the person is calmer, there is a greater chance that a therapeutic relationship can be established between the person and the carer. Other techniques taught within CAIT have been borrowed from professions who have specific expertise in “de-escalation”. For example, CAIT adopted George Thompson’s method, which is known as Verbal Judo, from the US police force [2]. This approach raises “de-escalators’” awareness of the verbal phrases that typically produce greater resistance (e.g., Stop that!, Calm down, I’m not going to tell you again!). The method helps people to become aware of the impact of such problematic phrases and then helps people to generate suitable substitutes that achieve better responses and improved compliance. CAIT was originally designed for staff of all disciplines working in care homes and inpatient wards. It has since been used in acute hospitals and by staff working in the community. In summary, CAIT is seen as a compendium of evidence-based tools and materials drawn from experts working inside and outside of the world of dementia care.

To date, a number of empirical studies have examined CAIT [20,29,30], with measures such as the Confidence in Dementia Scale, Knowledge in Dementia Scale, Compassionate Competence Scale and brief qualitative feedback [20,30]. Thus far, evaluations of CAIT have identified increases in carer self-efficacy; however, the current authors argue that a deeper understanding of the processes that happen during CAIT could add to or refine the programme’s efficacy. Therefore, the current qualitative study explores staff’s perceptions of the impact of CAIT on their day-to-day management of people with dementia’s emotions and behaviours. Further, this study aims to understand how CAIT works and the conditions which facilitate its implementation. The study’s specific research questions were whether CAIT improves carers’ knowledge, attitudes, and skills relating to dementia and BtC, and whether the CAIT programme enhances the use of non-pharmacological interventions.

2. Materials and Methods

Design: Semi-structured interviews were conducted within a qualitative design, utilising a critical realist position [31]. Braun and Clarke’s [32] reflexive thematic analysis was used to analyse the interview data. Inductive coding at both the semantic and latent level was undertaken [32]. All participants consented to having their data analysed and used for publication. Ethical approval was provided by the University of Canterbury, UK.

Participants: Eleven participants were recruited through purposive sampling by contacting previous CAIT trainees who agreed to be part of CAIT research. Eligible candidates had received CAIT consisting of the online programme purchased by their NHS Trust or organisation and an additional two days of face-to-face training (12 h) in its use. To be eligible, the staff had to have used CAIT materials subsequently in their clinical roles. Recruits were given a £20 voucher for participating. Ten of the recruited participants were female and one was male; all were white British. The age range was 35 to 64. There were seven psychologists, three nurses and one occupational therapist. The majority had over 10 years of experience working in dementia care; two had less than four years of experience. Five participants were from the North East of England, four from the South East, and two from the North West of England.

Intervention: All participants had previously been taught CAIT using a face-to-face classroom training format. The CAIT materials are contained within an online package, which is accessed during the training. The teaching was interactive and included in-depth discussions, quizzes, surveys and roleplays. The face-to-face training was delivered over two days with each of the main modules taking three hours to complete. A further four hours of supervision was provided in the following months, utilising material contained in a 35-page workbook (which is available from the corresponding author on request). The workbook follows the modular structure of the training and includes key references supporting the contents of the programme. Following the training, the participants had full access to all the online materials. A train-the-trainer model was used, whereby the CAIT participants were required to offer training to their colleagues. The CAIT materials comprised information slides, media clips and animations. The contents of the teaching modules have been described previously in the introduction. CAIT is supported by a manual, case study and supportive materials which can be accessed within the online program. A YouTube animation channel was developed for CAIT, providing a convenient way of accessing CAIT content [24]. There is a textbook [2] which can be purchased separately.

Data Analysis: NVivo 12 software was used to aid the coding and theme development process of the recorded interviews; they lasted 27 min on average. Transcripts were coded relevant to the research questions (perceptions and understanding of the mechanisms of change in CAIT). To reduce single-coder biases, two coded transcripts and a list of initial codes were shared between the first author and a co-author to allow for collaborative discussions to refine and deepen their understanding of the data.

3. Results

The study explored staff’s perceptions regarding CAIT in relation to their day-to-day management of the emotions and behaviours of people with dementia. The analysis produced six themes and fifteen subthemes (Table 1). Table 1 also provides details of which participant (participants 1 to 11) endorsed each theme and subtheme.

Table 1. Themes and subthemes identified in the thematic analysis.

Theme	Subtheme (Participants Endorsing Theme)
3.1. Enhancing understanding	1a. Improvements in understanding dementia (1, 2, 3, 4, 6, 7 and 9)
	1b. Remembering the person behind the illness (2, 3, 4, 5 and 7)
	1c. Understanding needs (1, 2, 3, 6, 7, 9, 10 and 11)
3.2. Transforming team interactions	2a. Using a different language (1, 3, 4, 6, 7, 8, 9, 10 and 11)
	2b. Changes to team practice (1, 3, 4, 5, 6, 7, 8, 9, 10 and 11)
3.3. Skills development	3a. Validating the work (2, 3, 6, 7, 8, 9, 10 and 11)
	3b. Greater understanding of practical skills for BtC (1, 2, 4, 5, 6, 7, 8, 9, 10 and 11)
	3c. Recognising and refining skills (1, 2, 3, 4, 5, 7, 8, 9, 10 and 11)
3.4. Accessible and flexible	4a. Shorthand for carers (4, 6, 7, 8, 9 and 11)
	4b. Online training provides on-demand accessibility (1, 5, 6 and 7)
	4c. One for all (1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11)
3.5. Socio-cultural change enablers	5a. Cultural conditions for change (1, 2, 4, 6, 8, 8 10 and 11)
	5b. Leaders and drivers (3, 7, 8, 9 and 10)
3.6. Obstacles in training	6a. Barriers to training (1, 2, 4, 5, 6, 8, 9, 10 and 11)
	6b. Information-heavy (1, 5, 6, 7, 8, 9 and 10)

3.1. Theme 1—Enhancing Understanding

This domain captured participants’ views on how CAIT improved attendees’ understanding of dementia and provided them with practical skills and advice regarding the management of BtC. Participants valued CAIT’s emphasis on meeting people’s needs and were particularly supportive of how the “eight needs” framework could be used practically in the management of behaviour.

1a. Improvements in understanding dementia

Participants reported improvements in their understanding of dementia and BtC. For example, CAIT increased awareness of sensory changes in dementia; participant 7 said, “That’s what the CAIT course kind of gave us… there was stuff around the changes in sensation and how people experience or process the sensory world in relation to their dementia.” There was an understanding that more time was needed in the form of giving people “more time to process information” (participant 3), and spending time as a way of preventing the escalation of behaviour. For example, participant 2 said, “If you can just spend a bit of time, even if it’s 10 min that might well save you several hours later on if behaviours going to escalate potentially into a bigger incident.”

1b. Remembering the person behind the illness

CAIT helped some participants to remember the human element of patient care. Reflecting on why CAIT was important to have in their NHS Trust, participant 5 said, “Because everybody’s so busy we’re missing out the point that we’re treating people.” This sense of “getting to know people is really, really important,” (participant 3). Participant 4 described enhancing their understanding of the person through the training, “CAIT provides lots of ways, tons of different ways, really trying to help people empathise and get and live in the shoes of the person with dementia.”

The inclusion of roleplay exercises was approved of by participant 5, who said, “I’ve actually never thought how that may feel.” CAIT helped staff “stay grounded in that compassionate approach, which isn’t always easy to do” (participant 2).

1c. Understanding needs

CAIT’s notion that everyone, including people with dementia and their carers, has eight discrete fundamental needs was viewed positively. CAIT’s checklist approach was seen as helpful. For example, participant 1 said, “These are your [8] fundamental needs. If people are presenting with challenging behaviour, are we ticking off the fact that all needs are being met?” It was reported that the needs framework was used widely and enabled staff to predict behavioural reactions—as commented by participant 10 and 3, respectively: “Unmet needs checklist, that’s something good…my colleagues will use it as well”; “It helped understand how somebody is likely to react, and why they’re reacting.” The programme also highlighted the idiosyncratic nature of needs (i.e., “Needs have different weightings for different people.”—participant 1).

3.2. Theme 2—Transforming Team Interactions

CAIT was credited with positively transforming interactions between professionals and people living with dementia. Participants spoke about being more conscious of their communication within the multidisciplinary teams (MDTs) and how they collaborated with colleagues. This awareness changed their practice.

2a. Using a different language

CAIT raised awareness of staff posture and nonverbal skills, as noted by participant 3, “must get to somebody’s eye level and give non-verbal cues to the individual.” Nonverbal cues were more easily identified as an enabler of care: “It’s that approach, it’s the fact that I smiled at the patient as I walked up to them” (participant 7). A better understanding of the effect of communication and one’s approach helped one participant feel “more confident to work with people with kind of a moderate to late-stage dementia where communication can be difficult” (participant 1). Participants reported starting to instruct colleagues to communicate better, by “speaking slower, not using too many words you know, not arguing,” (participant 6). When employing such communication techniques, participants reported witnessing “people’s challenging behaviour go down, people being more willing to accept personal care, and less aggression” (participant 1).

2b. Changes to team practice

CAIT was credited as changing practices: “It really changed my practice” (participant 1). The impact of training was witnessed on a service level by some, allowing for a “much more multidisciplinary team (MDT) approach,” (participant 8). More collaborative working around care planning and the use of assessment tools, such as the implementation of the Pool Activity Level (PAL, ref. [33]) were noted. For example, following the CAIT, participant 8 consulted with their occupational therapy colleagues asking, “Any chance of a PAL assessment?,.. They were like ‘oh yeah we’ll get back into that.” PAL, which is a system for assessing an individual’s strength and deficits in ADLs (activities of daily living), was particularly well-liked, in part, because it was supported by an animation that provided a helpful theoretical description, as well as case material.

Participants recognised that they had a better awareness of people’s surroundings and looked at “environments differently” (participant 3) and had a greater understanding of their impact. “We’ve got a lady that we’re working with in a care home at the moment. And it’s like medication’s not going to change her symptoms. It’s the environment, she’s in a really, really socially deprived care home environment, it’s probably just exacerbating all of her negative symptoms” (participant 7).

CAIT was credited with providing space for participants to “pause and think about interventions used” (participant 6), and “to break that down [the processes] a little bit more” (participant 11). This space to reflect helped “highlight the importance of person-centred care” (participant 7) and assisted the participants in working out “what works for that person” (participant 9).

3.3. Theme 3—Skills Development

CAIT helped participants be more insightful about their skills, giving them the knowledge to support their actions. With increasing awareness of their existing skills, it was suggested that staff could go on to refining their competencies further.

3a. Validating the work

CAIT provided staff with a rationale for their work. Staff felt more comfortable advocating for NPIs and more confident about the research and scholarship that supported these non-drug interventions, as noted by participant 3, who said, “People are seeing my job more as a science now, rather than a just sort of reassurance of elderly people within the environment.” and participant 9, who stated, “I definitely feel more empowered personally”. The self-assurance helped staff feel more confident in promoting NPIs and “why that should be done first, before we introduce some of the drugs” (participant 7).

3b. Greater understanding of practical skills for BtC

CAIT provided practitioners with practical skills for managing BtC. For example, respondents appreciated how CAIT provided advice for tasks such as “dealing with repetitive questions” (participant 7). CAIT also gave practical guidance in relation to specific clinical situations, as noted by participant 6, “There’s a bit where you click on, responding to time shifting and personal care, you know that gives the advice. But the advice is given in relation to that particular thing. I think it’s really good.” Some of the techniques in CAIT that were appropriated from other disciplines (e.g., armed services, police, retail workers) were highly valued, as noted by participant 2, “RAM and verbal judo and things, these just really helped to provide a framework.” Participants liked that CAIT addressed “real- world” problems that they could relate to as carers. For example, CAIT contained a section on the use of “therapeutic lying”, which considers whether untruths should be used to reduce people’s distress (e.g., not informing a person that their husband has died when the person is asking to see their spouse [2]). Participant 6 liked that CAIT addressed the topic. “I mean the therapeutic lies stuff I thought was really good because I think that that’s a quite a contentious, tricky one for people to get their heads around”. The raising of such topics also led to greater communication and encouraged carers to think of the implications of using such techniques. “Things like therapeutic lying, I think, has been really interesting as a way of getting care staff to think about actually care planning it in a bit more detail. It gives them something that’s a bit more tangible to be able to explain an approach and say why we might take that approach” (participant 7). The participants were also aware that the developers of CAIT had published widely on these topics, and thus could be regarded as experts and up to date with the relevant literature relating to deception [2,34].

Participants spoke of how the CAIT framework assisted their “care planning” (participant 11) by allowing staff to be “really specific about what to do in relation to particular behaviours” (participant 2). CAIT was also described as a useful refresher for staff who had perhaps “been working in the same way for quite a chunk of time” (participant 4) and it helped take them “get back to basics” (participant 5). CAIT also facilitated the way the participants trained other staff (participant 3) and informal carers and families: “We can try and educate families around how it is that they can understand what’s going on for their loved ones” (participant 4).

3c. Recognising and refining skills

One learning outcome of CAIT is to help carers be more aware of the skills they already possess. This effect was observed in participants’ responses with statements such as, “It was those micro skills that I didn’t actually realise I was doing. So, the kind of smiling, the non-threatening stuff, the taking time I was kind of doing a lot of that but not quite realising why it was so important,” (participant 1). Staff also gained greater awareness of their actions, stating, “I’m aware of why I’m doing things, and why I’m saying things” (participant 3). This also led staff to feel they had “more options…as a practitioner” (participant 9), to “have a bit more in my toolbox” (participant 9) and “feel better equipped” (participant 8). These “tools” were often referred to by name (e.g., the RAM technique).

3.4. Theme 4—Accessible and Flexible

Participants felt CAIT was accessible both in terms of the material presented and by virtue of using an “online training” format. It is suggested that such features permitted trainees from various backgrounds to benefit from its content—in this sense, CAIT was referred to as a “one-for-all” training package.

4a. A shorthand for carers

CAIT was viewed as accessible, with “Video links and accessible stuff…info broken down into quite an easy to digest way for carers,” (participant 7). The training being partitioned into modules and topics was commented on frequently, with participant 6 saying, “It can be delivered in bite sized chunks as well.” The notion of having bite-sized information was seen as “a really good, good element to it” (participant 6). Further, the large suite of videos produced for CAIT was seen as beneficial. The fact the videos were accessible on YouTube was also found to be helpful. This idea of the development of a shared language was also highlighted by many of the practitioners. For example, one of the participants stated, “I think that the terms and the language enables you to bring consistency to that” (participant 4). The ability to have a shorthand for dementia care “increases efficiency” in their day-to-day roles (participant 6).

4b. Online training provides on-demand accessibility

Participants working in organisations that had the online training package liked “that they have access to it anytime” and that was a “game-changer” as it meant staff could “prepare themselves for being on the ward” (participant 5). The flexibility of the online package meant that those who missed training were able to complete it later in their own time, and “[this is] absolutely brilliant because it means you can get night staff in particular, which was always a challenge we could never get round” (participant 1).

4c. One for all

A quality of CAIT that was reported by participants was that learners could “really identify with the information that’s provided” (participant 1) and that it “made so much sense” (participant 9). Staff also felt that “there is very much something for everybody there” (participant 3) due to CAIT’s “vast compendium of kind of different ideas” (participant 10) and that there were “different levels of it. So, you could, you know, parts of it would potentially be better for certain staff” (participant 6).

3.5. Theme 5—Socio-Cultural Change Enablers

This theme examined the social and cultural receptiveness of the setting to use the CAIT material, and their willingness to embrace change. The importance of good leadership was also highlighted, along with the requirement for “drivers” that provided sufficient motivation to overcome cultural inertia.

5a. Cultural conditions for change

Participants spoke of the benefit of having CAIT principles modelled by “more senior members of the team” (participant 10). A participant stated they had a “doctor who is…very CAIT savvy. So, it kind of runs through our conversations in our daily reviews” (participant 6). Being able to access support to embed learning was viewed positively, as noted by participant 1: “People were trained, but you then had regular supervision of how to use it.”. Similarly, participants spoke of being eager to implement CAIT in care homes but thought that without “supervision to embed, you can’t” (participant 8). In contrast, being in a setting in which numerous staff had been trained was viewed positively, as described by participant 10. “It was really important, I think to be there also with your colleagues and with people that you’re working with and receiving that training. It kind of made it much more easy to kind of think about how to implement it.”

5b. Leaders and drivers

The sense of needing a good leader to push CAIT was highlighted by a number of interviewees. Participants suggested that a cultural shift was required because, “It is a really a medical world still I think, even within like mental health. There is such a reliance on just pharmacological approaches, particularly in the acute settings.” (participant 7).

With regards to prescribing medication for BtC, one staff member advised “that’s what we’re expected to do and I don’t really want to do that” (participant 9). This difficulty was also expressed by participant 3 who said, “Changing that culture within the wards is a very difficult thing to do! But we are, we’re getting there.” Participants reported that to achieve a “cultural shift, you need a buy-in and the right drivers,” (participant 8) particularly from senior team members “discussing it all the time in meetings, formulations, etcetera” (participant 1).

3.6. Theme 6—Obstacles in Training

This theme describes barriers to the use of CAIT. It contains responses on barriers to training in healthcare as well as perceived barriers around the use of CAIT.

6a. Barriers to training

There was an acknowledgement that accessing and delivering training in healthcare settings was challenging because of high turnover and the high number of staff requiring training. Such concerns were raised by participant 1 and 2, respectively: “We’ve struggled a bit with turnover recently, which has made it harder. Use of agency staff, and then staff leaving.” “It can be hard to really to embed CAIT, because we don’t have that many care homes where the vast majority of staff have been trained.” An unpredictable turnover of staff was discussed by several interviewees. Another barrier that affected implementation of the CAIT was insufficient time. Participant 8 noted that the training was costly in terms of finances and resources, particularly if staff were then unable to make use of the training due to being too busy. “It’s costly and they (care homes) have to be able to do it.”

6b. Information-heavy

The main concern regarding CAIT was that it was “vast” (participant 10), containing “so much information” (participant 9). Staff recognised that the content was important, but daunting. “My only criticism of it is it’s just so much information and I don’t have no solution to that… there’s nothing that I’d take out of it.” (participant 1).

4. Discussion

CAIT was developed to be a comprehensive, accessible package, providing access to evidence-based materials from within and outside of the traditional areas of dementia; it was envisaged to be a “compendium of good practice”. While its eclectic nature (i.e., accessing material from the retail sector, police, etc.) was somewhat unique, further information about CAIT’s impact was required. Hence, this study explored participants’ perceptions regarding CAIT, how CAIT worked and the conditions that helped with its implementation.

Six main themes were found: “Enhancing understanding, Transforming interactions, Skills development, Accessible and flexible, Socio-cultural change enablers, Obstacles in training.” The results will be discussed in relation to the participants’ perceived improvements in terms of their knowledge, attitudes and skills. We will then address the interviewees’ views on the programme’s accessibility, and finally the requirements and barriers in relation to the implementation of CAIT.

The first two themes, “Enhancing understanding and Transforming team interactions,” provide good evidence of increases in knowledge, attitudes and skills. CAIT enabled participants to become more aware of key elements of dementia care, and they also gained a greater awareness of the importance of communication skills. The subtheme “Remembering the person behind the illness” captured changes in participants’ attitudes, such as empathy and compassion. This increase in positive attitudes towards people with dementia was facilitated through CAIT’s promotion of person-centred perspectives via experiential exercises (e.g., roleplays) and empathic animations. Previous research assessed post-CAIT responses on the Compassionate Competence Scale [35] and found significant increases in the subscales related to insight, sensitivity and communication [20]. The use of animations was viewed as particularly helpful for imparting knowledge in an accessible manner. Participants were also impressed by the breadth of topics dealt with in the cartoons: sensory changes, communication skills, de-escalation, and the “unmet” need perspective. Interviewees suggested that CAIT deepened the notion of unmet needs in particular (see subtheme: Understanding needs), and reported that they had gained a higher level of understanding of how to identify “unmet” needs and address these when working with people with dementia. This was illustrated through using tools such as the unmet needs checklist and finding creative ways to meet people’s needs. The latter work concurred with recommendations from NICE and guidelines by the British Psychological Society (BPS) about the importance of addressing unmet needs [22]. Promoting this approach over a medical model was described as depending on leadership buy-in. Some respondents felt that without this, the medical model was difficult to challenge, despite the evidence supporting NPIs [36]. Improvement in participants’ skills was evident in the themes of “Transforming team interactions and Skill development”. Participants described themselves as becoming better communicators within teams and with people living with dementia. In a similar manner to other researchers [14,37], CAIT suggests that communication skills are the key mechanism of change with respect to the de-escalation and management of distress and aggression.

The theme “Skills development” also highlights gains in the participants’ clinical competencies. Indeed, participants reported tangible changes to the way they delivered NPIs due to attending CAIT. The three subthemes of “Validating the work, Greater understanding of practical skills, and Recognising and refining skills” provide examples of these improvements. Within these subthemes, the participants talked about specific de-escalation strategies they had learned (e.g., RAM, Veral Judo, therapeutic lying), and they valued the scholarly research that supported their use. The interviewees thought they had an improved “set of tools” as alternatives to medication and felt more confident in the use of NPIs. The participants thought the tools could be used across all settings beyond care homes and wards. A further feature highlighted by participants was improved awareness of existing skills. Nevertheless, by the end of the training they were clearer about the actual skills they possessed and they were able to articulate their skills more clearly, giving them a greater sense of confidence, competence and ability to share this knowledge.

In addition to the improvement in knowledge, attitude and skills, participants were positive about the multi-format approach offered by the CAIT program. The evidence for this perspective is found in the theme “Accessible and flexible”. The participants liked that the programme is online and interactive, and is supported by animations, case studies, written material, etc., thus allowing multiple access points and learning styles [15]. The study revealed that the participants gained a greater understanding of both the requirements and barriers to establishing change in dementia settings [36]. For example, under the theme “socio-cultural change enablers” participants mentioned the importance of having good role models, effective leadership and ongoing supervision [15]. The participants highlighted getting cultural “buy-in”, and the importance of collaboration. It was implied that there needed to be a critical number of colleagues jointly trained in CAIT to achieve sufficient traction and to embed meaningful change.

The barriers to change were highlighted under the theme of “Obstacles in training”. Within the subthemes (“Barriers to training” and “Information-heavy”), the participants talked about both the generic difficulties of implementing training in care settings, as well as some of the specific difficulties associated with CAIT. Issues associated with releasing staff for training, maintaining a trained workforce and having access to supervision following training were mentioned [12]. These barriers were also identified in a recent report on dementia training, which mentioned a lack of time, competing demands, staff turnover and lack of management support [38]. Participants also noted that while there was value in the CAIT programme being so comprehensive, this also made it difficult to navigate and potentially daunting to use.

Finally, with regard to the limitations of the study, all participants were white and British. A recent scoping review on diversity and NPIs found that most studies, including those on carer training, recruited white participants, with a third of studies not disclosing the ethnicity of participants [39]. Therefore, further research is required with more diverse and minoritised groups. Another limitation was that the participants were all professional graduates, and the project did not sample “unqualified” support workers. This is clearly a sampling bias that needs to be rectified in any future investigations. As noted above, some participants felt that the information contained in CAIT was overwhelming due to the breadth and depth of the contents. In the future, such issues could be addressed by providing greater support and supervision regarding the delivery of the material. This could include top-up training sessions, practical coaching sessions, and greater levels of mentorship. Specific training sessions could also be provided for particular forms of BtC that are currently occurring within care settings (e.g., for the treatment of a person continually asking for a deceased relative, or for an ex-miner who is repeatedly asking to go to work).

The current study is the fourth in a series of projects on CAIT. It is now timely to consider exploring the impact of the programme via more robust methodologies, including trials sampling quantitative and qualitative information from families, non-qualified nursing assistants, and members of other professions, including psychiatrists. As such, quasi-experimental mixed-method studies would be appropriate as next steps. Ideally, such projects would involve the setting up of steering groups composed of people living with dementia, carers, and other relevant stakeholders, as well as researchers and clinicians.

5. Conclusions

CAIT is an online training package aiming to help carers provide an evidence-based alternative to medication in the treatment of BtC. It is supported by literature and animations that are designed to make the materials highly accessible to carers. It is built on key modules, providing a compendium of psychosocial tools for the management of distress and agitation in people living with dementia. This study sought to explore staff’s perceptions of the impact of CAIT on their day-to-day management of people with dementia’s emotions and behaviours. The results suggest that CAIT positively impacts staff’s planning and delivery of NPIs. Staff who had previously received CAIT were able to articulate marked changes in their knowledge, attitudes and skills in relation to dementia and BtC. Further, CAIT was found to be sufficiently flexible and accessible to bring about meaningful person-centred change. However, it is now time for these effects of the programme to be assessed across a greater range of stakeholders and settings.