Enriching opportunities for people living with dementia: The ...

Aging & Mental Health, July 2007; 11(4): 371–383ORIGINAL ARTICLEEnriching opportunities for people living with dementia: Thedevelopment of a blueprint for a sustainable activity-based modelDAWN J. BROOKER & ROSEMARY J. WOOLLEYUniversity of Bradford, UK(Received 22 December 2005; revised 12 June 2006; accepted 25 July 2006)AbstractThe aim of this paper is to describe the process of building a multi-level intervention called the Enriched OpportunitiesProgramme, the objective of which is to provide a sustainable activity-based model for people with dementia living inlong-term care. It is hypothesised that five key elements need to work together to bring about a sustainable activity-basedmodel of care. These elements are specialist expertise – the staff role of Locksmith was developed as part of this programme;individualised assessment and case work; an activity and occupation programme; staff training; and managementand leadership. These elements working together are known as the Enriched Opportunities Programme. This paper reportson the processes undertaken to develop Enriched Opportunities from its inception to the present, and focuses on lessonslearnt from the literature, an expert working group and action research in four UK study sites. A blueprint for evaluationin other long-term care facilities is described.IntroductionMany practitioners in the dementia care fieldsee activity and occupation as central to promotingwell-being for people with dementia. Activities forpeople with dementia can be therapeutic, enhancequality of life, arrest mental decline, and generateand maintain self-esteem (Marshall & Hutchinson,2001). Activities can also create immediate pleasure,re-establish dignity, provide meaningful tasks,restore roles and enable friendships. The NationalMinimum Care Standards for Care Homes for OlderPeople (Department of Health, 2001) states thatservice users, particularly those with dementia,should have opportunities for stimulation throughleisure and recreational activities which suit theirneeds, preferences and capacities.Nevertheless, the practical issues of working withpeople with dementia in nursing homes and extra carehousing in a way that promotes activity, achievementand well-being, remain unclear and improvementsare difficult to sustain over time. Although there isgrowing consensus that individually based and multifacetedinterventions are likely to be most efficacious(e.g. Cohen-Mansfield, 2005; Margallo-Lana et al.,2001; Moniz-Cook, Woods, Gardiner, Silver, &Agar, 2001), there is little guidance for how thesemight work as part of regular care.Members of our research and developmentteam have worked together with a care providerorganisation since 1998, initially on staff trainingissues and assessment and on the evaluation ofinnovative practice. The starting point for theEnriched Opportunities Programme was whether itwas possible to achieve the elevated levels ofwell-being that we had seen during a small scaleevaluation (Brooker, 2001) for people with dementiaas part of regular nursing home care. The past threeyears has seen a process of research and developmentto build the Enriched Opportunities Programme intoa practical working model. There were a number ofprocesses that we used, including:1. a review of the published literature2. an Expert Working Group3. action research in four practice developmentsites. The Enriched Opportunities Programmewas subjected to a within-subjects repeatedmeasures evaluation in three specialist nursinghomes and one extra care housing scheme, theoutcomes of which are reported elsewhere(Brooker et al., in press). This paper reports onthe process of the development and the resultingblueprint for long-term care facilities.Correspondence: Professor Dawn Brooker, Bradford Dementia Group, School of Health Studies, University ofBradford, Unity Building, 25 Trinity Road, Bradford. BD5 0BB, UK. Tel: 01274 235726. Fax: 01274 236395.E-mail: d.j.brooker@bradford.ac.ukISSN 1360-7863 print/ISSN 1364-6915 online/07/040371–383 ß 2007 Taylor & FrancisDOI: 10.1080/13607860600963687

372 D. J. Brooker & R. J. WoolleyMethodsThe literature reviewThe published literature was reviewed throughoutthe development of the programme. Searches weremade of relevant databases such as Medline,CINAHL and Cochrane with regard to key termssuch as dementia, activity/occupation, therapy, andlong-term care/homes. Similarly, key journals werehand searched. Further references were followed upfrom articles obtained.The Expert Working Group (EWG)This group guided the development of the EnrichedOpportunities Programme. It was a four-way forumfor discussion and action between the research team,the practitioners (key operational staff) in the fourpractice development sites, family carers and a groupof thirty experts from a variety of professional,therapy and training perspectives in dementia care.Collectively, this forum was known as the ExpertWorking Group (EWG). All members were invitedto use their expertise from practice and research inorder to shape the Enriched OpportunitiesProgramme from a theoretical ideal into a usableintervention within long-term care. An initial twodayresidential meeting of the Expert WorkingGroup was held and the recordings of presentationsand ensuing discussions of this first meeting weretranscribed to help guide the project (Brooker &Woolley, 2003). A further five EWG meetings wereheld in this advisory capacity over the course of thedevelopment. All meetings were recorded and notesmade for analysis. Between times, individual membersof the EWG provided training and mentorshipto the four practice development sites.Action researchThe remit of the research was to capture theprocesses and outcomes of the EnrichedOpportunities Programme on people with dementia,their family carers and staff in the four study sites.The evaluation adopted a case study design(Robson, 1993) combining qualitative and quantitativeresearch methods and action research. Thecase in this evaluation can broadly be viewed as theinnovation i.e. the development of the EnrichedOpportunities Programme. Action research wasintegral to the case study approach, as the innovationrequired action with collaboration between theresearchers and practitioners and the EWG inorder to achieve both the developmental andresearch objectives.Four practice development sites participated;three dementia specialist nursing homes and oneextra care housing scheme. All three nursing homeswere registered EMI homes. In total, 127 peopleresiding within these nursing homes participatedin the programme. The extra care housing schemepractice development site had apartments for86 tenants with 18 tenants participating in theprogramme. A fuller description of the facilitiesand outcomes of the intervention in the nursinghomes are reported in a companion paper (Brookeret al., 2007).A series of focus groups were held for staff,relatives and volunteers. Thirty staff focus groups,seven relatives groups and six volunteer groups wereheld in all, ranging in size from 3 to 12 participants.In addition to obtaining general feedback, the aimof the groups was to help draw out ideas that hadbeen effective in promoting well-being and toexplore remaining obstacles to change. Notes werewritten afterwards, and each focus group meetingwas recorded then transcribed for analysis.‘Locksmiths’ and practice development sitemanagers were interviewed individually at threepoints to help capture the processes and enhanceunderstanding of their roles. A semi-structuredinterview schedule was followed so that similarquestions were asked at each site at parallel researchstages, but issues specific to each could be followedup. The interviews were recorded and subsequentlytranscribed for analysis purposes.In addition, in-depth case studies were completedon five residents in each of the nursing homes.In the extra care housing scheme, in-depth casestudies were undertaken on all of the tenants whohad participated. The Locksmith, staff members,relatives and wherever possible the participantthemselves were involved individually in this process.The transcripts from the focus groups andinterviews were read and re-read on a number ofoccasions by the authors. These were analysed toidentify the perceptions around four broad themesand to develop sub-themes from these:1. how people felt about the EnrichedOpportunities Project2. what life was like for residents/tenants3. what were identified as barriers to leading anenriched life4. what was identified as facilitating leading anenriched lifeThe qualitative data was analysed as a whole anddifferences and similarities between the study siteswere explored. The results were then discussed withthe project team and the EWG. Two in-depthreports were produced to set out the experience asa whole – one focusing on the nursing home sitesand one on the extra care housing scheme.ResultsEnriched Opportunities for People with Dementiahad as its premise that elevated well-being for peoplewith dementia is desirable and, that given the rightconditions, is obtainable and sustainable. It was

Enriching opportunities for people living with dementia 373hypothesized that five key elements needed to worktogether to bring about a sustainable activity-basedmodel of care for people with dementia living inlong-term care. These elements, described in detailbelow, working together were known as the EnrichedOpportunities Programme. The quotes used in thissection are illustrative.Element 1 Specialist expertise: the LocksmithSpecialist expertise can improve staff managementof problem behaviours (Moniz-Cook et al., 1998,2001; Opie, Doyle, & O’Connor, 2002; Chung &Lai, 2002), levels of resident depression andcognitive impairment (Proctor et al., 1999), generalclinical practice (Hoek, Ribbe, Hertogh, & Van DerVleuten, 2003; Rantz et al., 2001), and in reduceduse of medication (Ballard, O’Brien, Reichelt, &Perry, 2002; Rovner et al., 1996).As part of the Enriched Opportunities Programmeit was decided to develop a senior staff role calleda Locksmith who was internal to the team, whoseraison d’être was to ensure residents and tenants reachtheir potential for well-being. The title ‘Locksmith’was chosen to reflect their central responsibility indiscovering and developing keys that would unlockthe potential for well-being in individuals withdementia. Locksmiths also required the authority totake a lead in staff training and mentoring with regardto the Enriched Opportunities Programme. AllLocksmiths were employed full-time as part of thesenior team and as such had authority to lead staff andto challenge decisions. (The Locksmith personspecification is available from the author on request.)The Locksmith was pivotal in bringing the EnrichedOpportunities Programme to life. The staff teamcommented on the usefulness of having someone theycould use as a resource and someone to offerleadership.‘‘Having the Locksmith, it’s somebody who, youknow if you can’t think of an activity somebodycan come back to you with a different idea, so youcan try that to get a bit more of a variety and if it’ssomething you’re not sure about, either it’s nicehaving the Locksmith there you can go down tosee him and that makes a big difference.’’‘‘She tries to get us motivated more as well doesn’tshe? She will come into the lounge, you know, youcan do, get it done, you know kind of thing andshe’s, she’s not forceful but she’s practical atgetting things working ...’’Through the project, a number of themes developedabout the Locksmith role. This job would not havebeen possible without an absolute commitment tothe belief that people with dementia are entitled toand able to, enjoy life. One Locksmith commented:‘‘I really believe in it. I mean, I really, reallypassionately believe in kind of valuing the lives ofpeople with dementia and doing what we can tokind of ...to improve people’s lives, I suppose.’’Having specialist knowledge of the needs of peoplewith dementia was important for the Locksmithsboth for their own confidence and in order for themto be a role-model and resource for other staff.Comments from the Locksmiths included:‘‘You’ve got to go in there and you’ve got to leadit. Show them that it’s not a myth and you know,nothing. We’re not asking them to do wonderfulthings getting them leaping up and down thecorridors singing and dancing.’’The Locksmiths also highlighted communicationand person-centredness. Locksmiths needed strongorganisational skills. They needed to have a handleon a wide variety of knowledge – knowing theirresidents, staff, assessments, making and sustaininglinks with the local community – there was a hugeamount of information to process on all these levels.Locksmiths needed to be able to motivate themselves– they were the only person in the establishmentemployed in this role and they needed to bestrong enough to withstand the pressure of thespecialist role being eroded.‘‘Cos if I was the kind of person who justaccepted ...if I was the kind of person who didwhat they were told and accepted what they weretold and did what I was supposed to be doing,according to whoever, then I wouldn’t have gotto the point where I am now.’’The management staff saw the Locksmith as apivotal figure and particularly commented on theirability to challenge. A manager commented:‘‘I do feel very strongly that they have to beassertive, they have to be pushy. Not just in theirlinks with me, but in how they relate to othermembers of staff as well, who are busy andperhaps haven’t got the time and all this sort ofstuff. So they really have to be assertive characters,I think, and pretty thick-skinned characters aswell, solid characters.’’Element 2: Individualised assessment and case workThe needs of people in long-term care are manyand varied. Individualised assessment and analysissets a basis from which interventions can bedesigned, for both enhancing well-being byappropriately matching activity and occupationto persons with dementia, or reducing disturbedmood or behaviour (Cheston, 1998; Verkaik, VanWeert, & Francke, 2005) and for determiningindividualised care plans (Turner, 2005). Theaim was to identify types of occupation and activitythat were the most likely keys to unlock the potentialfor well-being. The core elements of the assessmentare described in Table I.

374 D. J. Brooker & R. J. WoolleyTable I. Summary of the Enriched Opportunities Programme assessment process.What is the Locksmithlooking for? Questions that are asked Why is this important? Tools that were helpful How was this used?Cognitive ability andengagement capacityHow does this person think? How do theycommunicate? How do they relate tothe world? How do they relate toobjects?Life history What are experiences from the personspast that could hold clues to improvingand maintaining well-being now?Personality What is this person like? What motivatesthem? What influences their mood?Current interests What happens in the home that bringsthis person to life? What delightsthem?This helps in planning the level that aperson can engage with activities andwhat type of support they will need.This provides clues as to what activitieswill be familiar and enjoyed. Also whatobjects could trigger positive memoriesand actions.This provides clues as to what the personenjoys and doesn’t enjoy.This provides the establishment ofeveryday opportunities that can bringreal joy.Milestones Assessment of capacity forengagement and cognitive ability.(May & Edwards, in press)Filled out through observation of theresident in every day situations.Life story books and life boxes. Completed with person themselves orsometimes family members. Readingand sifting through existinginformation.Well- and Ill-being Profile likes anddislikes and routines checklist.Completed by Locksmiths’ own observationsand by discussion with keyworker and family.Magic moment cards key cards These were developed as part of theprogramme and completed by staffand Locksmiths.

Enriching opportunities for people living with dementia 375The assessment process was low-key andnon-stressful for participants. It involved theLocksmith reviewing existing information, observingthe participants in many situations, talking toparticipants, families and staff. None of theLocksmiths carried out formalised pen and paperassessments directly with the residents – although allhad some of these in mind when making theirassessments. This process was individualised andcontinuous. The Locksmiths commented on seeingthings from the point of view of the service user asthis quote illustrates:‘‘I think my whole understanding and my practice,my skills, have vastly changed from this idea thatwe really want people with dementia doing whatwe’re doing ...or stuff that looks good for us. Andsaying, ‘Well, okay, what we really, really needto do, the real nitty-gritty, is to get alongsidepeople, really understand where they’re comingfrom and then try to work round that. Andconnect with that.’’‘Magic moment cards’ were used by all staff if theyspotted an activity or a trigger that appeared toenhance the well-being of an individual to asignificant extent. These triggers could then beinvestigated further by the Locksmith, to see if theycould be turned into a ‘key-card’. Key cards wereideas that had been found to work in a consistentway to bring pleasure to individuals.There were many staff comments on how usefulaspects of the assessments had been for individualsand how the findings were incorporated into everydayactivities:‘‘Just having those (magic moment) cards, Imean in lounge four the other day the gentlemanthat does a lot of shouting he was looking througha magazine and he sort of came out with twowords you know, and I though oh my gosh,you know, I’ve never heard him speak like thatbefore, you know, so you write that down on amagic moment card, you know, but it’s one ofthose things.’’There had been a well established practice of LifeStory work in most of the nursing home sites. Theidea of developing these into ‘Life-Boxes’ whichcontained objects and pictures that had meaning toparticipants, that staff could use to help maintain apositive identity for the participant, developed aspart of the programme. One member of staffcommented:‘‘The Life Boxes help don’t they because they’veall got something in their life box? So we’velearned new stuff where they’ve got ...and that’sgood if you’re on a different House Group andresidents you’re not familiar with.’’Element 3: Activities and occupationThere are an increasing number of structured ortherapeutic activity-based interventions that havebeen utilised with people with dementia, on bothgroup and individual bases, with a wide range ofaims. These include reality orientation (Spectoret al., 2000a, 2000b); cognitive stimulation therapy(Orrell, Spector, Thorgrimsen, & Woods, 2005);reminiscence and life review (Woods et al., 2005;McKee et al., 2005); music therapy (Aldridge, 2000;Sherratt, Thornton, & Hatton, 2004a); art, writing,dance and movement (Allan & Killick, 2000;Coaten, 2001); drama (Batson, 1998; Chaudhury,2003); aromatherapy and sensory stimulation(Ballard et al., 2002; Holmes et al., 2002;Smallwood, Brown, Coulter, Irvine, & Copland,2001); Multi-Sensory gentle stimulation (Snoezelen)(Baker et al., 2003); intergenerational programmes(Jarrott & Bruno, 2003); Montessori-based methods(Camp & Skrajner 2004); doll therapy (James et al.,2005); the SPECAL approach (Garner, 2004);emotion-oriented care (Finnema, Dröes, Ribbe, &Van Tilburg, 2000; Finnema et al., 2005); horticulturaltherapy (Gigliotti, Jarrott, & Yorgason, 2004)and woodlands therapy (Pulsford, Rushforth, &Connor, 2000). The research evidence for most ofthese activities appears weak (see reviews by Beck,2001; Cohen-Mansfield, 2005; Gitlin, Liebman, &Winter, 2003; Marshall & Hutchinson 2001;Sherratt, Thornton, & Hatton, 2004b;Thorgrimsen, Spector, Wiles, & Orrell, 2004;Verkaik et al., 2005). Nonetheless, from a practiceperspective, seeing someone light up with delightwhen engaged in an activity that has meaning forthem, indicates that this is a worthwhile endeavour.It is applying occupation and activity as part ofregular care practice that poses the real challenge.The EWG identified that the programme ofactivity should be rich, integrated with the localcommunity, variable, flexible and practical toprovide opportunity for vulnerable individualsto experience optimum well-being. There wasconsensus that the provision of activities andoccupation were the responsibility of the wholestaff team not just the Locksmith. The keycomponents and the different roles of the team areshown in Table II.Staff remarked on the difference that knowingmore about their residents helped with theireveryday interactions, that their care was moreperson-centred than task centred.‘‘If you can empathise with the resident and putyourself in that resident’s shoes – how must theybe feeling? They have been sat in that chair all day,they have not moved. How do they feel? Howwould I feel if I’d been there? If you can putyourself in their position then you can do the jobproperly.’’

376 D. J. Brooker & R. J. WoolleyTable II. Core components of the enriched activity programme.Core component Function Locksmith role Staff role Management roleGeneral good qualityperson-centred careIndividualised simpleand fun activity andoccupation that canoccur everydayCommunal spaceand equipmentMeets psychological needs of vulnerablepeople. Overcomes exclusion.Maintains well-being on a day to daybasis.To support the individual and groupactivities.Getting out of the facility Maintains feeling part of the world,empowers to continue everyday activities,fresh air, excitement and fun.Models this in all interaction, can explainits importance to all.Assesses what works with whom. Deviseskey cards. Communicates to all team.Monitors its implementation.To assess what is needed, to maintain itsuse, safety and security.Organises and liases with appropriateplaces and people. Assesses suitability.Positive attitude towards and empathywith residents/tenants. Low number ofpersonal detractions.Carries this out on a one-to-one withidentified tenants/residents or in smallgroups.To use equipment and props imaginativelyand safely on a day to day basis.Provide one-on-ones where necessary.Risk aware.Recognition and reinforcement ofperson-centred care practice.To give priority to this in workloadplanning and scheduling.To provide resources and space.Provide staff resources and planningsupport.

Enriching opportunities for people living with dementia 377‘‘...even though they can’t talk you can tell. Theireyes are fixed on you and they’ll smile or they’ll befar more relaxed when you’re doing something.But to be honest, even the most impaired we getsome kind of feedback from them.’’The Locksmith needed to work out everydayactivities that would maintain and sustain well-beingfor each individual participant. This needed to besomething that staff could work on with participantsas part of the everyday routine.‘‘We have one woman that spends a lot of times inthe rooms, and we know from her family that sheused to listen to classical music. Now becausewe’re playing that a lot, this lady, we’re getting somuch more response. She’s smiling, she’s happy,she’s laughing. And we haven’t had that for a longtime – and it’s lovely. It’s really lovely.’’‘‘We’ve actually got a bottle of Tia Maria, andsherry, so she’s having a tipple with her meals, andit’s lovely – she enjoys it. And her chocolate. Soeven though we’re not doing a LOT with herdown here in the main lounge, she is getting moreone-to-one attention. She’s getting something shelikes listening to, she likes a drink, and a lot oftouchy-feely.’’‘‘It is the simple things, it is like last week they hada snowball and put it in front of Bill (resident) andhe picked it up and was passing it round, that is anactivity. It is sensory, it’s ...whereas if somebodycomes in and says, ‘‘you bake a cake’’, whatreaction are you going to get?’’‘‘With Elsie who’s so difficult to engage ...with theballoons, she loves knocking balloons around.I mean she’s just like plus 5, plus 5, plus 5(exceptional well-being). And once you stopknocking it around she’ll kind of hold on to aballoon and use it in a sensory way, so it’s brilliant.’’All Locksmiths used a lot of objects in their work.These were either reminiscence-type objects thatpeople enjoyed handling or using, or objects like theballoons that people could have fun with. There wasalso the more specialist equipment such as massagecushions or craft material that some people foundbeneficial. A member of staff described using variousprops to help one of her residents:‘‘I mean Bob, he can’t communicate, he justshouts; he can’t say any words at all. But if he likesan activity that we’re doing with him he usuallygrins at you. So, you sort of read his body languagethat way. He likes hats. Different hats just keepchanging the hats. Or he likes reading gardeningbooks, sports. So we know really by his bodylanguage. We read his body language that he’senjoying the activity that he’s doing.’’The main groups of people that were important toengage with the Enriched Opportunities Programmeare summarised in Table III. Staff commented onthe interest generated by outside therapists andentertainers.‘‘On St Patrick’s Day we had two Irish Dance girlsin and the reaction from some of the residents waslovely. And we did a proper Irish meal and oh itwas really nice. The relatives came in and theyenjoyed it – the residents enjoyed it. They love liveaction stuff – close stuff.’’Working with local community mental healthteams was well established already in the practicedevelopment sites. Had this not been the case, thiswould have been a bigger role for the Locksmith. Interms of specialist expertise, the Locksmith is ideallyplaced to engage with specialists outside the facility,whilst also being able to implement and monitoradvice and suggestions.Element 4: Staff trainingLack of staff knowledge or skills is often highlightedas a reason for interventions not achieving positiveresults (e.g. Ballard et al., 2002: Turner, 2005). Thevalue systems, knowledge and skills of staff arefundamental to providing good quality care forpeople with dementia. There is evidence that shortfocused training courses (1–5 days) increases careteams’ confidence and knowledge in working witholder people (Lintern, Woods, & Phair, 2000a;Mayall, Oathamshaw, & Pusey, 2004; Moniz-Cooket al., 1998). Although all these studies showed apositive impact on staff knowledge, none of themmanaged to demonstrate a significant impact on theclients that the staff were caring for. The EWGemphasised that all staff, particularly those withgreatest participant contact, needed to have thenecessary skills to support the EnrichedOpportunities Programme. There was no prescribedtraining at the commencement of the EnrichedOpportunities Programme. Part of the Locksmithand managers’ role was to use the Expert WorkingGroup to assess what training would help themdeliver the programme.From the interviews and focus groups, all agreedthat training had to change hearts and minds andprovide the skills and attitude necessary to deliverthe Enriched Opportunities Programme. Trainingshould be accessible, fun, practical, and based onexamples from practice with the client group. Therewas a strong commitment that the whole of the staffteam should be trained in the core approach and thatthis staff training should also act as a team buildingexercise. The core content of training for all directcare staff should include:. Mental health awareness – Knowledge andawareness about mental health and cognitiveimpairment in later life and how it affects people.. Person-centred approach – Valuing all people andunderstanding their perspective, team building.

378 D. J. Brooker & R. J. WoolleyTable III. Involving others in the Enriched Activity Programme.Core people & agencies Function Locksmith role Staff role Management roleOutside therapistsand entertainersMaintains feeling part of the world andexcitement. Brings in expertise that isnot present in the staff group e.g.dancing, aromatherapy.Working with volunteers Brings in time and expertise that mightnot otherwise be available.Working with families To ensure key relationships are maintainedand that family expertise is fullyutilised.Involvement with localmental health team orspecialist statutoryservicesTo ensure that health and well-beingis maintained at the optimal level.Organises and liases with appropriateplaces and people. Assesses suitability.Organises roles for volunteers, supervisionand support.Forms relationship with key familymembers to facilitate life story workand ensure personal preferences areknown.Liaison with health and social careprofessionals if problems with significantdeterioration.Ensure tenants/residents are preparedbeforehand and supported to get themost out of the therapy orentertainment.Ensure volunteers are welcome and beclear of their role.Be welcoming of family carers and sharecare where possible.To be alert to worsening confusion ordepression.Provide staff resources and planningsupport.Oversee the engagement and supervisionof volunteers in the home.To model and facilitate the involvementof family carers in the general life ofthe home.To facilitate good relationships with localteams.

Enriching opportunities for people living with dementia 379. Communication – Effective communication witheach other and with residents, observation skillsof non-verbal communication.It was recommended that selected direct care staffshould receive training on specific activities andcreative therapies to enable them to participate morefreely in fun activities with residents.The following comments on training illustrateits power to create a new way of looking at theirwork even for staff who had been employed formany years:‘‘It gives you more confidence as well andyou looked at it in a different way. You mayhave looked at it in that way before but it feelsdifferent now.’’One of the study practice development sites tooka different approach to training and invested in two3-day training courses with their mentor from theExpert Working Group on Essential LifestylePlanning (Smull & Sanderson, 2005). This wasan intensive experiential course, with its rootsin learning disabilities services, that all staffattended. Initial feedback was extremely positiveand, at the final focus groups and interviews, theimpact the training had had on staff was in no doubt.Staff commented:‘‘You couldn’t not be affected by the course itselfbecause the course was very emotional. We allcame out of it feeling totally changed towardseverybody, you know, you see everybody, even thechildren and your own relations, people on thestreet, I see them totally different now to whatI did before. You know, so it was very powerful initself, wasn’t it?’’Element 5: Management and leadershipThe organisational, professional and managementcontext is particularly influential on dementia careand is crucial to effecting and sustaining change(Cody, Beck, & Svarstad, 2002; Lintern, Woods,& Phair, 2000b). However, there is little researchto tell us about managers in dementia care or onthe specific leadership qualities and managementskills that will have a positive impact on the livesof people with dementia (Cantley, 2001). Poorleadership has consequences for staff in terms ofdemoralisation, burnout and stress, lower worksatisfaction or job clarity, lower psychological wellbeingand high workforce turnover (Cole, Scott, &Skelton-Robinson, 2000; Moniz-Cook et al., 1997,2001). Staff burnout has been shown to beassociated with less willingness to help residents,low optimism and negative emotional responses totheir behaviour (Todd & Watts, 2005). Withmany care environments still emphasising primaryfulfilment of a custodial function, it is unsurprisingthat staff often feel unable to provide therapeuticactivities for their residents (e.g. Pulsford, 1997).By its nature, management is a dynamic processand it is this area more than any other whereit is difficult to be prescriptive. Themes thatemerged from the EWG and the focus groupsand interviews were:. Change management – taking the whole organisationfrom task-focused to Enriched OpportunitiesProgramme-based care.. Ownership at the highest level – given the list ofcompeting demands this would have to beprioritised at Executive Board level and at localmanagement levels if it were to become embeddedpractice. This programme had, leadership fromthe highest level within the organisation and aclear directive that it should be a priority area to bedeveloped.. Open and inclusive management style – thisenables front-line staff to be responsive tochanging needs of residents. Both Locksmith andcare staff need to feel that they contribute todecision-making and to productive work withthe residents.. Seniority and authority of Locksmith – this wasessential for giving the programme status andenabling Locksmiths to fulfil a leadership andmentorship role. The leadership function of theLocksmith was acknowledged from the start withthe Locksmith being employed as one of the seniorteam with a salary commensurate with thatposition.. Supervision and mentoring for Locksmith – fromits inception the EWG was very active in itssupport and guidance. All Locksmiths valuedhaving support and mentorship from the ExpertWorking Group. This ‘arms length’ supervisionelement was important for Locksmiths and issomething that may need to be in place given thecomplex nature of the work. Locksmiths also hadto have the skill at seeking out and using thissupport.All Locksmiths reported a dual need both to feelsupported by the manager of the facility but also tohave the authority of being a senior member of staff.This presented a challenge for management. Onemanager commented:‘‘On the one hand you’re trying to drive theproject forward, keep the profile, all the rest of it.You’re trying to encourage support, the perceptionthat the Locksmith is senior and all the rest ofit. But you’re trying to encourage the Locksmithto get in at a very low level, very basic level, handsonlevel, you know, not to become elitist, not to beseen just as another activity organiser, not to beseen as just an extra member of staff in the socialclub. So yeah, you’ve ‘gotta guard against all thosedangers as you go along. And that’s not easysometimes. Not easy.’’

380 D. J. Brooker & R. J. WoolleyAnother manager of one of the homes emphasisedthe necessity for regular communication betweenthe Locksmith and the manager:‘‘I think there needs to be a structured periodof ...supervision. You need to have that importantlinking together, whether it be just for an hour oran afternoon together to work on something. Butinvaluable I would say, keep your Locksmithonboard, keep you onboard, work together at theteam ...’’Part of the reason that the Enriched OpportunitiesProgramme remained high on the managementagenda was the fact that it was a research projectand that a lot of attention was focused on the results.The challenge is how Enriched Opportunitiesmaintains management focus without this. Theidea of having a senior coach specifically identifiedwithin the organisation who could mentor theprocess at a management level and provide someof the arms length supervision to the Locksmithwas seen as a possible solution to keeping thefocus on this programme once the research phasehas ended.By and large there was recognition at finalmeasures that the management and organisation ofcare meant that staff felt proud to part of a cuttingedgeorganisation. This is a positive spin-off formanagement who want to improve job satisfactionand retain staff. One member of staff said:‘‘Compared to other places I’ve worked theresidents seem more happy here than anywhereelse I’ve worked. And the staff seem to knowthem better as well; they know them asindividuals and not as a resident or a problem,or whatever.’’The EWG thought there needed to be anexternal recognition through the inspection processof the impact of this work on the lives of veryvulnerable residents, if it were to be maintainedin the long term. It has already achieved positivespin offs for inspections, particularly in onenursing home when the manager was describingtheir latest inspection:‘‘It was absolutely fantastic, she said, yeah. She’dmet with the residents, she met with the staff,she met with the volunteers, she’d looked atour paperwork and she just couldn’t believehow good it was. She just said, ‘‘What I’m actuallymeasuring now for my documentation is justso trivial.’’ You know, she said, ‘‘I don’t reallythink that this is probably going to be appropriatefor here.’’ChallengesThere are a number of challenges that remainabout the Enriched Opportunities Programme.Involving family carers in the process of EnrichedOpportunities was something that was seen asan important aspect from the outset andsomething that requires further development. Aswith engaging family members, working withvolunteers was an aspect of the programme thatrequired further work. There was a wish for morevolunteers to spend more one-on-one time withpeople with dementia.There was a theme about ensuring that managementand staff teams shared the same vision for theprogramme. There were still concerns at the end ofthe intervention that the emphasis on activity meantthat some of those with more advanced dementiamight be given inappropriate things to do.One of the challenges in the extra carehousing scheme was ensuring that those on theEnriched Opportunities Programme were not stigmatised.This quote from the Locksmith about howtenants viewed her, suggests this was achievedalthough the mechanisms for this need clarifying.‘‘They just see me as a staff member, it’s, I have tosay I’m amazed at the amount of people thathaven’t actually said, ‘‘What do you do?’’ BecauseI think that’s all to do with the approach I had atthe beginning, that I worked with the staff team, Iwent on the floor as a carer. They see me as anoffice person, because I’ve been in the office doingpaperwork and stuff, so nobody’s quite sure,I don’t think. And they’ve never tackled me as‘‘Why, why are you here? Why you do the thingswith us?’’ I just say, ‘‘I’m here and I’m doing allthe fun things.’’ And I have made it fun.’’The manager commented on how it appeared tovisitors:‘‘We’ve had some visitors here this morning andwe’ve been down there. And the one visitor didask about dementia and how we cope, you know,but he wasn’t aware that there was anybody in thatgroup who was part of a project group who hadbeen, who’d got dementia or, you know, just atotal integration, merger, nothing stood out. Andit wasn’t introduced as anything special, youknow, this is an ordinary Thursday at MapleCourt and this is an ordinary range of activitiesthat are going on.’’One of the major challenges was in helping the teamdeal with competing priorities on their time. Staffwere aware of competing demands and sometimesfelt unclear about their priorities. Lack of staff timewas mentioned at all stages of the project and inevery facility as being a barrier to achieving fulfilledlives for people with dementia.It is a long day, it is a long day, there are notenough hours in that day to try and fit everythingin that you would like because it is just a routineisn’t it?

Enriching opportunities for people living with dementia 381DiscussionDuring this research and development we identifiedan evidence base for all of the elements of theEnriched Opportunities Programme. Many lessonshave been learnt from the literature, the expertworking group and the action research about theprovision of the Enriched OpportunitiesProgramme. As a result of this work we now havea much clearer idea of what the different elements ofthe Enriched Opportunities Programme look like inpractice. It has moved from a theoretical ideal to apractical working model. We have a clear idea ofthe assessment process, the provision of activityand occupation, the person specification andjob description of the Locksmith, the role andresponsibilities of the Locksmith, the staff teamand the management team, staff training needs andissues to do with management and leadership.The strength of The Enriched OpportunitiesProgramme lies in the triangulation of evidence foreach element of the programme from the publishedliterature, expert opinion and from feedback frompractice. Its limitations lie in its possible narrownessof focus – in that it could be argued that eachevidence base was significantly contaminated by theother. The other major weakness is the enormousHawthorne effect in this type of research. It could beargued that had any care provider found themselvesunder such scrutiny from the EWG, that this in itselfwould have radically changed practice.This evaluation was carried out with a careprovider that already has in place a number ofelements that would be seen as markers of goodpractice. Whether this model is transportable toother providers with more variable standards of careis a question that requires further research. Researchmethodologies for understanding the impact ofmulti-level interventions such as this are notstraightforward. There are many variables to dowith the micro-environment of a care facility thatcan strongly affect outcomes in this area. One of theproblems with researching a multi-level interventionis being able to ensure that it is carried out in astandardised and uniform manner. 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