Cognitive Stimulation Therapy (CST): Exploring Perspectives of Trained Practitioners on the Barriers and Facilitators to the Implementation of CST for People Living with Dementia

Abstract

Dementia is recognised as a disability under the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). People with disabilities like dementia have the right to access specialised health and social care services, including interventions that support independence and community participation. Cognitive Stimulation Therapy (CST) is an evidence-based psychosocial intervention that improves cognition, communication, confidence, and quality of life for people living with dementia, but an implementation gap means that CST is often not available. This study examines whether trained CST practitioners implemented CST, their perceptions of the acceptability and efficacy of CST, whether the perceived acceptability and efficacy of CST predicted implementation, and practitioners’ opinions on the barriers and facilitators to CST implementation. A mixed-methods approach was used, with 62 participants (91.9% female). Although 95% of participants were trained to deliver CST, 45.2% did not facilitate CST groups. Statistical analysis showed that perceived efficacy significantly predicted both the likelihood of running CST groups (p = 0.006) and the number of groups delivered (p = 0.01). Thematic analysis of qualitative data identified the three key themes of ‘resources’, ‘awareness and education’, and ‘acceptability of CST’. Overall, the results show that while CST is acceptable and deemed highly effective, resources and staffing often impede implementation. The results are discussed in the context of prioritising the rights of people with disabilities and recommendations are made on improving access to evidence-based support.

1. Introduction

Dementia is a condition that affects the brain, leading to difficulties with memory, thinking, language, and daily tasks [1]. It is recognised as a disability under equality laws, including in Ireland and by the United Nations Convention on the Rights of Persons with Disabilities [2,3]. Cognitive Stimulation Therapy (CST) is a well-established psychosocial intervention that improves language [4], cognition, and quality of life [5] for people with mild to moderate dementia [6]. CST has been recommended by the National Institute for Health and Care Excellence (NICE) Guidelines in 2006 [7] and 2018 [8], the World Alzheimer Report [9], the Centre for Economic and Social Research in Dementia [10], and the Health Service Executive (HSE) Model of Care for Dementia [11]. CST is also cost effective [12,13] and is consistently reported as enjoyable and impactful by people with dementia and their families [14].

There are four different versions of CST. The original 14 session programme is designed to be delivered to groups of approximately 5–8 participants twice per week for seven weeks [4]. Maintenance CST includes an additional 24 themed sessions designed to be delivered once per week after the original 14 sessions [15]. Individual CST (iCST) was subsequently developed to facilitate CST to be delivered on a 1:1 basis [16] and virtual CST (vCST) was developed to meet the demand for CST during lockdown [17]. Practitioners who deliver CST are usually health or social care professionals that have completed a 1 day training course designed by Prof Aimee Spector and colleagues at the CST-International centre at University College London. CST is now offered in more than 38 countries, and there are approximately 48 accredited international trainers from 13 countries who train practitioners to deliver CST (https://www.ucl.ac.uk/international-cognitive-stimulation-therapy/international-cst-training, accessed on 2 December 2024).

As CST was developed and evaluated in the UK back in 2003 [4], it is perhaps unsurprising that CST is widely implemented in memory clinics [18] and other community-based services in the UK (www.ageuk.org.uk, accessed on 12 May 2024) [19]. Although CST was also offered in Ireland as far back as 2011 [20], the pace of implementation is much slower than in the UK. Currently we estimate that there are approximately 450 people trained to deliver CST in Ireland (based on figures provided by Engaging Dementia who offer training CST for practitioners), yet CST is not routinely offered in memory clinics [21] or other memory services across the country (www.Alzheimer.ie, accessed on 20 November 2024). There is a clear implementation gap where those trained often do not deliver CST [22]. Issues with the implementation of evidence-based psychosocial supports are more common in low and middle-income countries (LMICs) [23], but it is not clear why this treatment gap is arising in an Irish context. We aim to build on the implementation by CST-International [23,24] LMICs. Stoner and colleagues provide a template for CST implementation studies. Stoner et al. [24] stipulate that exploring the barriers and facilitators to implementation is an important initial step. We are especially interested in the perspectives of trained facilitators to examine why the interest in CST and the access to training does not translate to widespread routine delivery.

The dementia literature suggests that the implementation of interventions or supports may be impacted by factors such as stigma [25], public awareness [26,27], the level of training or education of carers or healthcare practitioners [28] or their opinions about the overall acceptability [29,30] and the perceived efficacy of an intervention [31]. A growing body of implementation science highlights that perceived efficacy is a determinant of whether interventions are adopted into practice. Perceived efficacy reflects practitioners’ confidence in an intervention’s ability to achieve the desired outcomes, which can motivate adoption and sustained implementation [30]. For CST, prior research has shown that observing participant benefits firsthand reinforces its perceived effectiveness and encourages group delivery [4,14]. This study builds on these findings by examining whether practitioners’ perceived efficacy predicts their likelihood of running CST groups and the frequency of delivery. This focus addresses an identified gap in understanding the factors that drive CST implementation. Similar challenges have been identified in the context of assessment and diagnosis [32], with Bernstein et al. reiterating the necessity to examine such factors with a view to strengthening dementia care initiatives.

The aim of this study is to examine the characteristics, experiences, and opinions of practitioners who have attended CST training or have delivered CST to people with dementia. We hope that by gathering information from trained practitioners, we can further elucidate possible facilitators and barriers to CST implementation after training. We hope to clarify the conditions under which CST is most likely to be offered after training and provide insights into how barriers may be overcome. Overall, we hope to contribute to a knowledge base which can ultimately facilitate greater availability of evidence-based psychosocial support for people with dementia. Our study may also serve as a guide for countries experiencing similar implementation issues.

We used a mixed-methods survey design to examine the following research questions (RQs): (1) what are the demographic characteristics of practitioners who were trained in CST and/or delivered CST to people with dementia; (2) what is the level of engagement with CST training and implementation of CST by participants; (3) do participants perceive CST to be an acceptable and effective intervention; (4) do participants’ opinions about the acceptability and perceived efficacy of CST predict whether or not they ran CST groups; and (5) what are the participant’s opinions on the barriers and facilitators to the implementation of CST, and how might identified barriers be overcome.

2. Materials and Methods

2.1. Participants

Recruitment was conducted via social media (Twitter and LinkedIn) and was supported by two voluntary organisations who shared the study information in their newsletters. Inclusion criteria stipulated that participants must be over the age of 18, have been previously or are currently working with people with dementia, and have either: (i) attended CST training; or (ii) learned how to deliver CST by working with a colleague who has attended CST training or by using the CST manuals; or (iii) delivered CST to groups of people with dementia. G*Power was used to calculate the required sample size to ensure statistical power for the inferential analysis. For a regression with one predictor (RQ4), a minimum sample size of 55 was required for a statistical power of at least 0.80 with a medium effect size (f² = 0.15) and an alpha level of 0.05. Medium effect sizes are commonly observed in exploratory studies examining intervention implementation behaviours (e.g., [4]), providing a meaningful yet realistic threshold for identifying practical relationships. A total of 70 participants (‘CST practitioners’) completed the online survey but data from eight participants were excluded as they did not meet the inclusion criteria. The final sample of n = 62 participants included 57 females (91.9%), 4 males (6.5%) and 1 other (1.6%). Additional demographic information is presented in

Table 1. Demographics table showing the gender, occupation, and role description of participants.

Gender	N	Frequency
Female	57	91.9%
Male	4	6.5%
Other	1	1.6%
Occupation	N	Frequency
Dementia Advisor/Dementia Specialist	27	43.5%
Speech and Language Therapist (SLT)/Occupational Therapist (OT)	15	24.2%
Care Assistant/Home Care Coordinator	6	9.7%
Psychologist	4	6.5%
Nurse	2	3.2%
Geriatrician/Psychiatrist	1	1.6%
Other (incl. health care coordinator for religious service; family member; training facilitator; principal of a primary school; assistant coordinator of services; activities assistant; advocate and former primary carer for people with dementia)	7	11.3%
Role Description	N	Frequency
Work directly with people with dementia on a daily or weekly basis	42	67.7%
Work more with carers and families than with people with dementia	15	24.2%
Assessment, training and intervention via staff teams	1	1.6%
Staff training	1	1.6%
Work both with people with dementia and families	1	1.6%
Community awareness and advocate for supports	1	1.6%
Principal, family carer	1	1.6%

.

2.2. Design

The study was designed as mixed-methods, cross-sectional research. RQ1 and RQ2 included a within-participants quantitative design and were assessed using descriptive statistics. RQ3 included a within-participants correlational design with two continuous predictor variables (acceptability and perceived efficacy of CST) and two categorical criterion variables (whether participants ran CST groups, and the number of CST groups run). RQ4 and RQ5 included a qualitative survey design [33] with data examined using a thematic analysis [34].

2.3. Materials/Measures

The survey was presented on Google Forms and was divided into five sections. Section 1 included three demographic questions with multiple choice response options, including “what is your current occupation?”, “tick the description that best describes your role”, and “what is your gender?”.

Section 2 included seven questions with multiple choice response options to assess the participant’s level of engagement with CST training (four questions) and the implementation of CST groups (three questions). For the level of engagement with CST training, the first question asked whether participants had attended training in Ireland, outside of Ireland, or had not attended any formal training; the second question asked if those who had attended CST training had been trained by an accredited trainer; the third question asked how long ago the training was for those who had attended training; and the fourth question asked if those who did not attend training were trained to deliver CST by a colleague or by following the CST manual. For the implementation of CST groups, questions included “have you ever facilitated or co-facilitated any CST groups in Ireland” (Yes/No), “if yes how many CST groups have you facilitated/co-facilitated”, and “If you have run CST groups, approximately how many people (in total) have you delivered CST to”.

Section 3 measured the acceptability of CST using the Theoretical Framework of Acceptability (TFA) questionnaire [35]. Prior research shows that the TFA is a reliable and valid measure of intervention acceptability [36]. The TFA included eight questions and sample TFA items are as follows: “CST is an acceptable intervention for people with dementia” and “CST is likely to improve patient care/likely to improve the lives of those with dementia”. Responses were measured on a 5-point Likert scale from 1—strongly disagree to 5—strongly agree. Items 3, 4, and 6 were reverse scored. The minimum possible total score was 8 and the maximum was 40. Higher scores indicated a greater level of acceptability of CST.

Section 4 of the survey examined the perceived efficacy of CST. This section included six questions measuring participants’ opinions on whether CST improved the cognition, confidence, interest/engagement, communication, enjoyment, and mood of their service-users. The questionnaire was adapted from the “Monitoring Progress Form” of the official CST manual, titled Making a Difference 2 [37], and included key outcomes identified in a systematic review of qualitative CST studies [14]. Sample questions included “As a result of CST, participant’s Confidence levels were generally…” and “As a result of CST, participant’s Interest/Engagement was generally…”. Responses were measured on a 5-point Likert scale ranging from 1—not improved to 5—significantly improved. The minimum possible total score was 6 and the maximum was 30. Higher scores indicated greater perceived efficacy. Participants only completed this section if they had run CST groups. If they had not run groups, they skipped to the final section.

Section 5 included three open ended qualitative questions that asked participants “what do you think are the key barriers to running CST groups?”, “in your opinion, how might these barriers be overcome?”, and “what are the most important factors that make CST easy to run—either in the community or to embed within a service?”

2.4. Procedure

Ethical approval was granted by Research Ethics Committee at the National College of Ireland on 10 February 2023 (Approval Number 1002202303). Participants accessed the survey via Google Forms and all participated online. Once participants clicked on the link to take part, a separate browser opened, and they were presented with the study information sheet. Once the study information was read, participants clicked ‘Next’ and were presented with the consent form. If participants consented to participate in the study, they clicked ‘Next’ to access the survey. Participation took approximately 15 min. There was no time limit for completion of the survey and participants could end participation at any point by exiting their browser. Once the survey was complete, participants were presented with the debriefing form.

2.5. Analytic Approach

Descriptive statistics of continuous and categorical variables provided an overview of participants’ responses to address RQs 1 and 2. Inferential analysis included two binary logistic regression analyses to address RQ 3 and 4. For RQ5, qualitative survey data were analysed using a thematic analysis [38]. The first and second authors analysed the data, and we took a realist approach to examine the entire dataset. An inductive, data-driven approach was suitable as we had no pre-existing coding frame and aimed to understand the participants’ responses at face value. Responses were read multiple times, and coding and analysis followed the recommendations of Braun and Clarke [38]. Analysis incorporated both semantic and latent themes, focusing both on the meaning of what participants wrote while also identifying underlying ideas and assumptions that informed the semantic content of the data. Like Braun et al. [34], we applied initial codes to all data using general/broad coding such as “time” and “suitability of participants”. We subsequently collapsed code-names that were similar (e.g., “staffing” and “availability of staff”) and expanded those remaining codes to be more explanatory. Those expanded codes were collated in a meaningful way to contribute to potential themes. The final two steps involved identifying and refining themes to provide a concise yet informative account of the data.

3. Results

Demographic information provided insights into the characteristics of participants who were trained in CST and/or delivered CST to people with dementia (RQ1). Variables included gender, occupation, and role description. The final sample of n = 62 participants included 57 females (91.9%), 4 males (6.5%), and 1 person with another gender identity (1.6%). Most participants were either dementia advisors/dementia specialists (n = 27) or SLTs/OTs (n = 15). Other occupations included care assistants/home care coordinators, psychologists, and nurses (see Table 1). Participants predominantly worked with people with dementia on a daily or weekly basis (n = 42) or worked with carers/families (n = 15). Other participants worked with both people with dementia and families, conducted staff training, engaged in advocacy, or cared for a family member with dementia.

Descriptive statistics in

Table 2. Frequency table showing participants responses to questions on the level of engagement with Cognitive Stimulation Therapy (CST) training and the implementation of CST groups.

Level of Engagement with CST Training	N	Frequency
Did you attend CST training in Ireland or elsewhere?
Attended in Ireland	57	91.9%
Attended outside of Ireland	2	3.2%
Never attended CST training	3	4.8%
If attended CST training, was training delivered by an accredited/approved CST Trainer? *
Yes	54	87.1%
No	1	1.6%
I don’t know/Prefer not to say	5	8.1%
If attended CST training, how long ago did you attend?
1–6 months ago	9	14.5%
7–12 months ago	17	27.4%
1–2 years ago	18	29.0%
2+ years ago	15	24.2%
Not Applicable (N/A)	3	4.8%
If you did not attend CST training, were you trained to deliver CST by a colleague who had attended training OR by following the CST manual?
Trained to deliver CST by a colleague who had attended training	5	8.1%
Trained to deliver CST by following the official CST manual	15	24.2%
I have never received any training in CST or used the CST manual	1	1.6%
NA/Attended training	41	66%
Implementation of CST Groups	N	Frequency
Have you ever facilitated/co-facilitated CST groups in Ireland?
Yes	34	54.8%
No	28	45.2%
Number of Groups
1–2	16	25.8%
3–4	1	1.6%
5–6	3	4.8%
7+	14	22.6%
NA—I have not run any CST groups and am unlikely to do so	10	16.1%
NA—I have not run any CST groups yet but aim to do so in future	18	29.0%
Approximately how many participants have you delivered CST to?
None	29	46.8%
4–10	16	25.8%
12–20	7	11.2%
35–50	4	6.4%
56–75	3	4.8%
80–100	2	3.2%
150	1	1.6%

* Two participants left this question blank.

show the level of engagement with CST training and the implementation of CST by participants (RQ2). Most participants (95.1%) attended CST training and most of the training courses were delivered by accredited trainers (87.1%). Although 95% of participants were trained to deliver CST, 45.2% of participants reported that they had not facilitated or co-facilitated any CST groups. Regarding intentions for future CST groups, 16.1% of participants reported that they did not intend to deliver CST at any point in future while 29% stated that although they had not yet delivered CST, that they intended to do so in future. The number of CST groups delivered varied, with 25.8% of participants reported having facilitated or co-facilitated one to two groups, followed by 22.6% who led more than seven groups. The data illustrate that while CST groups are being implemented, availability is not dependent on training.

Descriptive statistics on continuous outcomes demonstrated the extent to which CST facilitators perceive CST to be an acceptable and effective intervention for individuals with dementia (RQ3). The acceptability of CST was measured by the TFA, which demonstrated moderate internal consistency for this sample (Cronbach’s alpha = 0.636). Although this alpha value is slightly below the conventional threshold for reliability, it aligns with prior research using the TFA in exploratory studies. The perceived efficacy measure showed high internal consistency (Cronbach’s alpha = 0.886), indicating strong reliability for this scale. In terms of acceptability as measured by the TFA, participants (n = 62) responded with primarily positive ratings (TFA mean total = 3.99, SD = 0.471 on a Likert scale of 1–5 with higher scores indicating greater acceptability), with the highest ratings on questions such as “CST is an acceptable intervention for people with dementia” (mean rating = 4.66, SD = 0.54) and “CST is likely to improve patient care/likely to improve the lives of those with dementia” (mean rating = 4.47, SD = 0.67). Interestingly, the questions that participants scored lower on acceptability were those querying how CST might impact day-to-day duties. Responses were more negative for the questions “it required or would require effort for me to deliver CST” (mean rating = 2.19, SD = 1.05) and “delivering CST interfered with (or would interfere with) my other priorities” (mean rating = 3.19, SD = 1.25). This indicates that participants agreed that CST is an acceptable, interesting, and beneficial intervention, but they had concerns about their capacity to be able to deliver it alongside their existing workload.

For perceived efficacy, as questions pertained to observations of behavioural change during CST, participants that did not run CST groups did not respond to those survey items. Participants who had run CST groups and responded to those survey items (n = 34) had high Likert scale ratings when asked about the perceived efficacy of CST (perceived efficacy total, mean rating = 4.27, SD = 0.51 on a Likert scale of 1–5 with higher scores being more positive). The highest mean score was for the item “overall I found CST to be an effective intervention at making a difference” (mean rating = 4.56, SD = 0.59). See

Table 3. Descriptive statistics for the scores on the individual questions for measures assessing the acceptability (TFA) and perceived efficacy of CST.

Acceptability (TFA)	Mean	SD	N	Min Score	Max Score
CST is an acceptable intervention for dementia	4.66	0.54	62	3	5
CST was (or would be) interesting to deliver	4.66	0.60	62	3	5
It required (or would require) effort for me to deliver CST *	2.19	1.05	62	1	5
There are negative moral or ethical consequences to the delivery of CST *	4.13	1.05	62	1	5
CST is likely to improve patient care/likely to improve the lives of those with dementia	4.47	0.67	62	2	5
Delivering CST interfered with (or would interfere with) my other priorities *	3.19	1.25	62	1	5
I am confident that I can perform the necessary steps to deliver CST effectively	4.06	1.02	62	1	5
It makes sense to me how CST would result in improved patient care/improved outcomes for those with dementia	4.56	0.61	62	3	5
TFA Total	3.99	0.47	62	1	5
Perceived Efficacy	Mean	SD	N	Min Score	Max Score
As a result of CST participants confidence levels were generally	4.13	0.73	39	2	5
As a result of CST participants interest/engagement was generally	4.13	0.57	39	3	5
As a result of CST participants communication ability was generally	3.95	0.69	39	3	5
As a result of CST participants level of enjoyment was generally	4.49	0.64	39	3	5
As a result of CST participants mood was generally	4.34	0.63	38	3	5
Overall I found CST to be an effective intervention at Making a Difference	4.56	0.59	39	3	5
Efficacy Total	4.28	0.52	38	2	5

* Items were reverse scored.

for the full data.

3.1. Inferential Analysis

Univariate logistic regression models were employed due to the exploratory nature of the study and the focus on specific predictors, namely, acceptability and perceived efficacy. By isolating the effects of these predictors, the models provided clarify on their independent contributions to CST implementation in Ireland. Given the small sample size (n = 62), univariate models were deemed appropriate to minimise the risk of overfitting and to ensure interpretability. A binary logistic regression was conducted to examine whether the acceptability of CST (predictor variable, PV) predicted the likelihood that participants had implemented CST groups (RQ4). The criterion variable (CV), implementation of CST, was measured based on whether participants had ever facilitated or co-facilitated a CST group (Yes, n = 34; No, n = 28). The model was statistically significant X² (1) = 9.165, p = 0.002; it explained 18% of the variance (Nagelkerke R²) in CST implementation; and correctly classified 66.1% of cases. Higher levels of acceptability were associated with an increased likelihood of implementing CST (Wald = 7.65, p = 0.006). The odds ratio for the acceptability of CST was 1.25, suggesting that for each one-unit increase in acceptability, the odds of implementing CST increased by a factor of 1.25.

To facilitate the regression analysis and to determine whether perceived efficacy (PV) predicted implementation of CST for those that ran groups (n = 34), the number of groups run (CV) was recoded as a binary categorical variable where participants either ran 1–4 CST groups (n = 17) or 5–7+ CST groups (n = 17). A binary logistic regression demonstrated that higher levels of perceived efficacy were associated with an increased likelihood of running a greater number of CST groups (Wald = 6.716, p = 0.010). The model overall was statistically significant X² (1) = 9.164, p = 0.002; it explained 31.5% of the variance (Nagelkerke R²) in the CV; and correctly classified 76.5% of cases. The odds ratio for the perceived efficacy was 1.676, suggesting that for each one-unit increase in acceptability, the odds of running a greater number of CST groups (5–7+ compared to 1–4) increased by a factor of 1.676.

3.2. Qualitative Thematic Analysis

Data from the survey included 186 excerpts of text. Initial codes were generated by the first and third authors. Data from question one was coded independently with data from subsequent questions coded collaboratively. When initial similar codes were collapsed, a set of sixteen codes remained which we expanded to improve informativeness (e.g., “time” became “time to deliver the intervention with an already busy schedule”). We initially identified eight emergent themes and subthemes which were then refined to the final set of three themes including resources, awareness and education, and the acceptability of CST (

Table 4. Table showing emergent and refined themes identified from the qualitative survey data.

Emergent Themes/Subthemes	Refined Themes
Workloads and capacity of staff	Resources
Funding (increased staffing and other tangible resources)
Logistics
Accessible venue at a suitable location with transport provided
Accessing suitable participants	Awareness and Education
Awareness, education and buy-in for CST translating to supported delivery
Communication within and amongst stakeholders
Acceptability of CST	Acceptability of CST

). After analysing the entire dataset, we further analysed the qualitative responses that supported interpretation of selected quantitative data. For this subgroup analysis, we were interested in responses from: (i) participants with lower overall TFA scores (we defined ‘lower’ as a total TFA score of 30 or less), as they may provide a unique context-driven explanation for less acceptability of CST (n = 29); (ii) participants who attended CST training but did not run CST groups, as they might identify important barriers compared to those who went on to run CST, like key factors that prevent implementation (n = 28); and (iii) participants who co-facilitated CST groups and rated CST as highly effective (total score of 24 or above on the perceived efficacy scale), as they could provide unique perspectives on the most important factors that make CST successful (n = 29).

3.3. Theme 1: Resources

Participants described resources as barriers or facilitators to the implementation of CST, including staff time, funding, suitable venues, and transport. In relation to staffing, participants suggested that due to already busy schedules, they may not have time to deliver CST, and that the capacity to fit CST into current workloads was a key barrier. For example, responses to question 1 (“what do you think are the key barriers to running CST groups”) included “Limitations on people’s time who might be expected to deliver this training i.e., daycare managers, DAs etc.”; “It would be extra work and I have a full workload”; “… the main barriers were being short staffed and having to cancel the group at short notice… not having a helper… and finding time to prepare for the groups, most of the preparation was done in my own time.” Participants identified the need for local services and management to prioritise CST and ensure protected time to deliver groups and plan appropriately. “Time and resources that the planning and setting up of the group requires”; “space, time, caseload demands”; “support from managers”; “support from other services; “Support from other health professionals”. Some stated that additional trained staff were required to support greater capacity and alleviate workload to facilitate CST “Not enough CST Trainers in the country; “Sufficient staff trained in CST”. In the subgroup analysis, participants with lower TFA scores and those that had attended training but not run CST groups most commonly identified time constraints and the need for more trained staff barriers; and time for preparation, delivery, and follow-up was deemed essential. They mentioned “competing clinical priorities” and a lack of support for other tasks associated with running groups like managing logistics and administrative work (e.g., contacting participants). Also, reiterated was the point that managers should “prioritise and schedule in time” for CST and ensure staff availability.

Across all data, funding was described as a necessity, not only to hire additional staff but also to resource the running of groups “No funding for materials/supplies—only able to plan sessions within our resources”; “lack of resources, both financial and personnel to run a CST group”, while other logistical resources like adequate space, an accessible venue, and providing transport for participants were also seen as priorities “Space, finding an appropriate location. Transport… rural Ireland, no public transport available”. “Lack of transport for those who don’t drive, families can’t consistently take them, or they can’t safely navigate public transport”.

To overcome barriers, participants suggested that coordination with other multi-disciplinary teams as well as support from managers would be crucial. Some also suggested that having a network or team of CST facilitators would be helpful in planning/managing groups. Staff considerations included staff numbers/time but also having a set service or team that would deliver CST; and having CST as part of defined staff roles. To support this, participants suggested that CST should be offered as a standard or stand-alone service “CST could be delivered through MTRR, memory clinics”, “HSE funded as a standard service using a national coordinated approach”, and that CST might be considered as a community-based service “HSE funded and not diluted by other services (e.g., not taken out of day room in day care service) but proper community locations identified”; “CST not only in health environment setting but run in the community by groups with support/assistance from health care professional”. Participants identified the need to identify and link-in with already existing community initiatives around the country to support the implementation of CST, such as community volunteers “I have facilitated a successful CST group for 15 months. We are in a local Community Centre with local people as Volunteers. There is no reason why we shouldn’t have CST in every town in Ireland” or local transport initiatives “linking in with local council services to see if flexibus can accommodate any people living with dementia (PLwD) to attend the group”.

In addition to the suggestions above (management support, staff time, use local volunteers, and accessible community-based settings), the subgroup of participants who co-facilitated CST groups and rated CST as highly effective also suggested that practitioners should come from diverse backgrounds like “OT, SLT, psychology”, and be motivated and good communicators. They indicated that co-facilitation and mentoring from experienced CST practitioners would be important, especially for those starting out. Another important point highlighted by this group, but not others, was that practitioners should use the “Making a Difference” manual; this was seen as important for guiding session-planning “the Making a Difference manual provides an excellent framework to guide and plan each session and [ensure]…benefits to those attending CST”. Finally, this subgroup emphasised that while some programs have been successful with minimal funding, securing consistent financial support would ensure long-term sustainability.

3.4. Theme 2: Awareness and Education

Participants wrote about a “lack of awareness of CST in general and potential benefits” as a barrier to implementation, and that education and awareness raising would be key facilitators. This was echoed in the data from participants with lower TFA scores. Some suggested that access to suitable participants might be a barrier to CST implementation, but if PLwD and their families were informed about the benefits of CST, e.g., “Communication to families with a diagnosis of dementia the importance of CST”; “Inform and support both clients and family members”, this might encourage greater participation when CST is available. Responses highlighted the necessity for appropriate/informed referral processes to ensure that suitable participants are recruited, and that knowledge of CST could support appropriate referrals, “Access to the right cohort of patients is ideal—we gain referrals from our outpatient care of the older persons team which all of 3 of us running the [CST] groups work in, so we can target the right population for the group.” Interestingly in the subgroup of participants who did not run CST groups and those with lower TFA scores, recruitment of people with dementia was more consistently identified as a barrier. They felt that delays in diagnosis and long waiting lists were preventing people from accessing CST in a timely manner “CST is a valuable resource for people with dementia and a service we have missed to offer people as an early intervention”, and that delays also impeded creating a group with participants at similar stages in their dementia journey. Overall, there was a desire to educate PLwD and their families, as well as health and social care professionals about what CST is, its benefits, and the evidence base.

The data also showed that awareness raising for healthcare professionals should include good communication within and between teams about what CST is, the evidence base, what is required to run groups, and ideally a roadmap for standardised implementation. Many participants suggested that increased awareness about CST could contribute to overcoming barriers and promote greater implementation and buy-in: “Increased promotion of CST as an evidence-based intervention for dementia care to facilitate OTs to prioritize this work and facilitate protected time … CST” and “Better understanding of value of CST by Management …will then filter down and help get CST programs prioritized, and funding/staff/, etc., made available to run the programs”. At times, participants described how they took the responsibility to inform and educate others—and how helpful information provision was “After I did the flyer and explained to everyone what the group entailed things were much better. I contacted relatives and told them about CST and would they have any objections to their family member being involved. I spoke with my manager and told them I needed to commit to two weekly sessions for eight weeks at a time and things went really well then”. The subgroup of participants who co-facilitated CST groups and rated CST as highly effective also emphasised the importance of public awareness of CST and its benefits, emphasising people’s personal experiences “Understanding how it helps people with dementia, not necessarily quantitative evidence but more qualitative, how it impacts patients and families.” Overall, raising awareness of CST was seen as important, and the inclusion of CST as a recommended post diagnostic support in the HSE Model of Care for Dementia is seen as very beneficial in this regard.

3.5. Theme 3: Acceptability of CST

Response to all three open-ended questions on the survey demonstrated that participants have positive opinions about CST and indicate that CST is a valued and highly acceptable intervention. Participants wrote about their positive experiences of implementing CST and its impact on PLwD and families: “Lots of family members commented on the change in mood and more communication from their relatives and I could definitely see the benefits”; “It’s simple and easy to run and very enjoyable and its rewarding to see enjoyment residents got from CST”; “it can be a very cost efficient service but one that gives hope to so many people, particularly newly diagnosed and early onset when so little suitable supports are on offer”. Also highlighted was the acceptability of CST across disciplines “It is fun, so people enjoying coming and it makes the group a positive event…. The consultants and multidisciplinary teams I have worked with in psychiatry and neurology are positive and supportive of me providing this intervention.”

Participants described the ease at which they felt CST could be incorporated into the current service provision, the cost-effectiveness of CST, and how useful the CST manuals are “The making a difference manual provides an excellent framework to guide and plan each session, and the outcomes/benefits to those attending CST”; “It is a fun group; manual is clear; flexibility within manual allows bespoke adaptations to match the needs of the people taking part in the group”; “Once you have the equipment and the manual makes everything easy! I found there was very little expense and a lot of materials I used were donated. I had access to the same room for eight weeks, some residents used to comment on entering that they had been there before, and they really liked the room which to me was great to hear because they enjoyed being there”.

Where participants did not have an opportunity to offer CST, they wrote about their disappointment that CST was not available “CST is a valuable resource for PLwD and a service we have missed to offer people as an early intervention”; “These groups need to be out in the community” or about their desire to do whatever possible to support implementation “It was hoped that [an existing dementia service] would deliver CST. The service is currently not operating and there is difficulty around recruitment of staff, etc which makes delivery of CST extremely difficult. As DAs [dementia advisors] we would be willing to assist in any way we can.” Even participants with lower TFA scores suggested that CST is a cost-effective intervention that can “give hope to so many people” in the early stages of dementia. Overall, the data clearly demonstrate high levels of acceptability for CST, and aside from concerns around the resource implications of running CST, there was no negative feedback about CST identified across any of the data.

4. Discussion

4.1. Summary of Key Findings

The aim of this study was to examine the characteristics, experiences, and opinions of practitioners who have been trained to deliver CST to people with dementia in Ireland. Despite attending training, many participants did not facilitate or co-facilitate CST after training, indicating a considerable implementation gap. Responses on individual TFA items showed that while most participants either agreed or strongly agreed that “CST is an acceptable intervention for dementia”, overall TFA scores tended to be lowered by responses to questions 3 “It required (or would require) effort for me to deliver CST” and 6 “Delivering CST interfered with (or would interfere with) my other priorities.” As the lower TFA scores were driven primarily by questions 3 and 6, this suggests that participants evaluated the intervention as acceptable but not feasible to implement without adequate staff or resourcing. Other challenges to the successful adoption of CST included concerns around conflicting priorities and workload, in accordance with prior findings [39]. The qualitative data and subgroup analysis supplemented the TFA scores by further explaining that barriers to the implementation of CST related to resource constraints. Practitioners with lower TFA scores and those who did not run CST groups after training highlighted the need for more trained staff, additional staff time, greater capacity, and relevant expertise. Analysis of the entire dataset supported these findings—practitioners frequently mentioned the shortage of time, funding, a suitable venue, and staffing as substantial barriers. These results align with previous research indicating that lack of resources is a common barrier to the implementation of psychosocial interventions in dementia care [23]. The data underscore the pivotal role of resources and organisational support in the implementation of CST. To alleviate these barriers, participants advised that services and management should prioritise CST by guaranteeing staff time to organise and plan CST sessions. Moreover, the need for investment to hire extra staff and provide resources for conducting CST groups was highlighted. The qualitative data also suggest that awareness and understanding of CST, the recruitment of suitable participants for CST, and logistical difficulties are barriers faced by practitioners in the implementation of CST in community settings.

Participants not only reported that CST was acceptable (TFA) but also that it was deemed effective (perceived efficacy scale). Specifically, participants reported that PLwD were likely to experience positive outcomes through engaging with CST across multiple domains, with high mean scores for improvements in confidence, self-esteem, communication ability, quality of life, and mood, consistent with prior research findings [5]. The qualitative data further support that CST is perceived as a valuable and acceptable intervention (theme 3). In the qualitative subgroup analysis, participants who co-facilitated CST groups and rated CST as highly effective provided unique insights about the successful implementation of CST. They described the necessity for multidisciplinary collaboration, co-facilitation and mentoring from experienced CST practitioners, support from local volunteers and running CST in accessible community-based settings, the importance of using the “Making a Difference” manual, and the need for public awareness of CSTs benefits through accounts of personal experiences. This information should be prioritised when drawing up implementation plans and for wider dissemination.

The logistic regression analysis revealed that practitioners perceived acceptability of CST was a predictor of whether they facilitated or co-facilitated CST groups and that higher levels of perceived efficacy were significantly associated with an increased likelihood of running a greater number of CST groups. These findings are consistent with the existing literature, which has shown that the perceived value and appropriateness of an intervention can significantly influence its adoption into routine practice [30]. This also strengthens the idea that when practitioners perceive an intervention to be effective, they may be more motivated for its integration into care plans [5,23]. Although we consider perceived efficacy as a driver of CST implementation, due to the cross-sectional nature of the study, reverse causality (i.e., running more groups predicting a higher perceived efficacy) cannot be ruled out. Future research should examine whether perceived efficacy has a causal influence on initiating groups, or whether the perception of efficacy rises after group implementation. Future studies could focus on exploring specific factors that contribute to high levels of acceptability of CST by practitioners, such as format, content, or facilitator characteristics. Additionally, investigating how these factors may impact the successful implementation of CST in specific settings or diverse populations could provide valuable insights into intervention outcomes [29]. Given identified barriers related to resource constraints, future research could focus on strategies to overcome implementation gaps in low-resourced settings [23].

Despite strong perceived acceptability and efficacy of CST among practitioners, the broader implementation of CST is hindered by a significant lack of awareness and education about the intervention among healthcare professionals, PLwD, and their families or companions. This lack of awareness can have a direct effect in limiting appropriate referrals and the uptake of CST. Participants noted the importance of educating all stakeholders about the benefits and scientific evidence supporting CST. This is in accordance with the literature, which reports that increasing knowledge and awareness of dementia interventions is a facilitating factor in adoption and implementation [26]. To address this gap and enhance the awareness and understanding of CST, future studies could identify the barriers to public and professional awareness of CST to further understand why CST is not widely known among healthcare professionals and families of PLwD in Ireland. Developing and assessing the impact of public awareness campaigns for increasing the knowledge and acceptance of CST among healthcare professionals, PLwD, and their families is another important avenue of future research.

4.2. Implications for Practice and Policy

The findings of this study suggest that improving awareness of the efficacy of CST among practitioners may help to bridge the implementation gap. Providing opportunities for practitioners to observe the benefits of CST firsthand and offering ongoing support could enhance their confidence in its efficacy and encourage sustained delivery. Establishing a network or team of CST facilitators could improve collaboration and resource sharing. In addition, embedding CST training as a standard part of the professional development of those working in dementia care could enable more practitioners to be prepared to deliver CST. Policy initiatives should prioritise funding and support for the standardised implementation of CST, recognising it as an important evidence-based service within dementia care. The inclusion of CST in the HSE Model of Care for Dementia is a positive step, but further work is needed to secure dedicated funding and resources. A coordinated national approach to the implementation of CST could ensure more consistent availability across different regions. The mobilisation of community resources and volunteers can also play a vital role in the delivery of CST implementation, particularly in rural areas where access to services is limited. Local councils and community organisations should be encouraged to support CST initiatives, possibly by providing additional venues, transport, and volunteers.

Beyond CST, the findings of this study offer broader insights into the implementation of psychosocial interventions. Common barriers such as limited resources, insufficient awareness, and the need for perceived acceptability align with challenges observed across various evidence-based interventions. For instance, research on psychosocial care integration in diverse healthcare settings highlights that organisational alignment, stakeholder buy-in, and interdisciplinary collaboration are essential for successful implementation [40]. Similarly, reviews of third-sector organisations implementing evidence-based programs underscore that addressing logistical constraints such as the lack of financial and staff resources, as well as fostering professional education, can improve adoption rates [41]. The strategies proposed here, such as embedding training within professional development frameworks and ensuring dedicated funding, could be adapted to enhance the implementation of psychosocial interventions in other contexts. By bridging these gaps, our findings advocate for systemic solutions that support equitable access to effective psychosocial care.

4.3. Limitations and Future Research

Recruitment was difficult, and although over 450 people are trained to deliver CST, only 70 responded to the survey. This is likely suggestive of the limited time staff have to engage in research on top of busy workloads; but may also suggest that our recruitment efforts did not reach all trained facilitators. Although our final sample of n = 62 met the minimum requirements as per the power analysis, the sampling ratio (sample size to population size) was only 28%. Our data were not fully representative of the experiences of the full population of trained CST practitioners, thereby impacting the external validity of the research [42]. Research suggests that employees who are more dissatisfied are more likely to respond or provide comments on survey items than their more satisfied peers [43], suggesting that barriers to CST implementation may be overrepresented and facilitators underrepresented in this study.

Despite the lower-than-expected sample size, targeted sampling meant that we did access a variety of relevant professionals trained to deliver CST, and those participants provided valuable insights into CST implementation in Ireland. However, the univariate model did not account for potential confounding or explanatory variables such as demographic factors (i.e., time since training) or organisational contexts (e.g., resource availability). These factors are likely to influence CST implementation outcomes and could moderate the relationships identified in this study. Thus, the current findings represent an initial step in understanding the factors influencing CST implementation. The current study utilised the TFA to assess acceptability; while the TFA questionnaire is useful for understanding the acceptability of healthcare interventions, future studies should use it in conjunction with other methods to gain a more comprehensive understanding of the acceptability of CST. That said, we considered response effort and aimed to keep this low, with a view to reducing the burden and increasing engagement for busy staff. Balancing response effort and informativeness is always a consideration for this type of research.

Despite limitations, a key strength of this study is the mixed-methods approach. The benefit of using mixed methods in implementation research is well recognised [44,45]. Palinkas and colleagues explain that while quantitative methods can test hypotheses regarding predictors of successful implementation, qualitative methods provide additional important insights into specific reasons for implementation gaps in evidence-based care [44]. The combination of both approaches provides a superior exploration of the research topic compared to what either qualitative or quantitative methods can offer in isolation. Although this research is an important first step in analysing the barriers and facilitators to CST implementation, the data only represents the views of one group of stakeholders. Stoner et al. [24] outlined a more comprehensive three-phase methodology, based on the Consolidated Framework for Implementation Research (CFIR), which resulted in standardised plans to successfully translate CST research to practice. An important next step for our research team is to examine diverse stakeholder perspectives as suggested by Stoner et al., and to use the methodological template provided by CST-International to advance implementation efforts in Ireland.

5. Conclusions

Overall, participants affirmed their positive perceptions of CST and indicated a strong collective belief in its sustainability as an intervention for individuals affected by dementia in Ireland. CST is a valued intervention among practitioners, and this study has positively demonstrated its treatment acceptability and implementation. Staff, time, and capacity were inextricably interlinked as staff need structured and defined time to be able to deliver CST and require workload balance and training to ensure capacity to offer CST. Addressing these barriers through enhanced training, funding, and community involvement can facilitate the wider adoption of CST, ensuring support for people with hidden disabilities such as dementia so they can have equitable access to evidence-based interventions. Future research should seek input from other relevant stakeholder groups on the barriers and facilitators to CST implementation and should refer to the CFIR and the ongoing implementation research by the CST-International group. Our collective research endeavours should not only improve the quality of care for people with dementia but may also serve as a model for other countries facing similar challenges in offering evidence-based support.