‘There's something they can do’: Educating aged care staff about the trajectory of dementia, palliative care and the Namaste Care™ program: A mixed methods study

To evaluate outcomes of education about the dementia illness trajectory and Namaste Care™ program on aged care staff's knowledge, attitudes, self‐perceived skills and competence.

and complex health care. 1 As people with advanced dementia have a reduced ability to actively participate in usual leisure or memory care activities, they are also at high risk of social isolation and loneliness. 2 Quality dementia care at the end of life is best supported by comprehensive education about the dementia trajectory as well as multicomponent interventions to address quality of life in the context of palliative care. 3A palliative approach improves quality of life through the relief of serious health-related suffering and can be integrated across all health services and at all levels, not just when a person is imminently dying. 4,5esidential aged care staff have been found to have only moderate knowledge of advanced dementia 6,7 and inadequate knowledge of dementia-related complications such as delirium, dysphagia, lack of mobility and pain assessment, 8 hydration and nutritional needs. 9Up to three quarters of a sample of aged care clinicians, including nurses, care aides, and medical and allied health professionals, reported learning needs in dementia palliative care, 9 with knowledge and attitude deficits found to be higher in care staff who have not received training in palliative care and dementia care. 6Education and training are variable, 10 most often provided as in-service education by on-site nursing staff and, as such, are not well regulated or required to be evidence based. 7Nor do education and training typically promote non-pharmacological approaches that staff can use to improve quality of care. 11amaste Care™ is a multicomponent, psychosocial intervention for improving quality of life for people living with advanced dementia which can be offered until the end of life. 2 This structured, person-centred program, underpinned by a palliative approach, provides tailored, sensory activities to meaningfully connect with the person and offer comfort and pleasure. 12It has been shown to improve communication, social engagement and connection with caregivers 12,13 and reduce changed behaviours, including agitation and rejection of care. 14t also offers a way to show people living with dementia and their families that they are cared for and valued. 13Key activities of Namaste Care™ include gentle personal care activities such as face washing and traditional-style shaving, 15 hand and foot massage, range of motion exercises, reminiscence activities, interaction with seasonal scents, and other activities tailored to individual recipient preferences.Assessment of pain and continuous offerings of refreshment are important to promote comfort.Family carers are invited to be involved in activities with their family member. 16o date, there has been little research conducted in the Australian context on workforce education and training to assess Namaste Care™ in improving staff's capacity to provide quality dementia care within a palliative approach.Enhancing the capability and confidence of staff in caring for people with advanced dementia aligns with the principles of the Australian National Palliative Care Strategy 17 and is also mandated by Aged Care Quality Standards. 18his paper presents the qualitative findings and integrated conclusions from a mixed methods study, which aimed to evaluate the effectiveness of a Namaste Care™ training workshop on aged care staff's knowledge, attitudes, self-perceived skills and competence towards end-of-life dementia care.Quantitative results of the evaluation are already published 19 enabling comparison with the qualitative findings presented here to better understand the effects of the training.The quantitative findings showed small, statistically significant improvements in knowledge of and attitudes towards palliative care for advanced dementia (p < 0.01) using the Questionnaire on Palliative Care for Advanced Dementia (qPAD), and in self-reported care skills (p < 0.05) using the Palliative Approach for Nursing Assistants (PANA) Skills Questionnaire after the workshops described below.There was also a small increase in one subscale: Building Relationships from the Sense of Competence in Dementia Care Staff (SCIDS).

| Design
The study adopted a mixed methods convergent design in which both the quantitative and qualitative data were collected concurrently and analysed separately comparing the two sets of results.Integration occurred in the interpretation and discussion.This methodology is underpinned by the epistemological approach of pragmatism which values objective and subjective data equally. 20Three validated survey instruments (Table 2) were used to collect quantitative data pretest and post-test. 19Semistructured interviews or a focus group with key staff collected qualitative data to interrogate staff learning following an education

Practice Impact
This research shows the value of dementia education using the Namaste Care™ program as a vehicle for practice change and the program's potential as an in-house model of palliative care for people living and dying of advanced dementia in residential aged care facilities.intervention comprising intensive workshop sessions conducted over 3 days.Quantitative data were analysed first followed by a thematic analysis applied inductively to the qualitative data to explore convergences and divergences in the quantitative results.Integration of the data occurred during the interpretation and discussion phase.The study is reported with the Consolidated criteria for Reporting Qualitative research (COREQ) checklist.

| Setting and participants
Staff from a large non-profit organisation, who worked within a residential aged care facility (RACF) in Northern Tasmania, agreed to take part in this mixed methods research.The education program was delivered by an academic in palliative care nursing and an academic in dementia care.

| Ethics approval
Ethics approval was granted by the University of Tasmania Human Research Ethics Committee (HREC): Project ID 20016.

| Recruitment
Selection criteria and recruitment for the education program targeted the residential services care manager or equivalent and all staff who provide direct care: registered nurses (RN), enrolled nurses (EN), personal care assistants (PCAs) and staff who provide psychosocial support to residents: allied health worker, recreational activities officer (RAO)/leisure and lifestyle personnel and volunteers.
The RACF manager organised staff attendance at the education workshops as part of the facility's staff education program.A researcher who was not involved in the education workshop provided information about the research arm of the educational intervention and invited participants to complete consent forms if they agreed to participate in the anonymous pre-and post-test surveys.At the completion of the education workshop, staff who provide direct care or psychosocial support to residents were offered the opportunity to attend a focus group and all management-level staff who attended the education were offered the chance to participate in an interview, also with collection of consent.
While participants of the interviews and focus groups may also have completed surveys, the anonymous nature of the surveys precluded linking the two data sets directly.

| Education and Namaste Care™ program training intervention
The education learning outcomes were related to knowledge of the dementia illness trajectory, pain and symptom management in advanced dementia and communication with the person living with dementia and with family carers.Assessment of residents for comfort using a validated pain assessment tool (Pain Assessment for Seniors with limited ability to communicate (PACSLAC_II) was included. 21he Namaste Care™ program training component of the intervention used existing resources 22 and included experiential activities to promote the principles and philosophy of Namaste Care™ and simulate sensory experiences.Importantly, the simulation emphasised the two pillars of the Namaste Care™ program: a calm environment in which people are brought together to prevent them being socially isolated and a 'loving' touch approach. 15Simple touch that is provided in a meaningful way is recognised as a means of communication and of conveying the essence of caring. 23

| Data collection and analysis
Demographic items were included in the pre-and postworkshop surveys.For further details and quantitative data analysis methods, see Kochovska et al. 3 Interviews and a focus group used semistructured question guides which explored participants' knowledge of the dementia illness trajectory, and attitudes towards dementia care provision, including the Namaste Care™ program.Focus group participants (n = 5): volunteers, personal care assistants and a recreation and leisure officer (RLO) were provided with a vignette on a resident who displays symptoms consistent with advanced dementia (Appendix S1) that participants had learned about in the workshop and whose care experience precipitates responsive behaviours.The case was used to investigate learning from the education workshops.
The interviews and focus groups (Appendix S2) were recorded and transcribed verbatim.A six-step thematic inductive analysis 24 was followed based on the reflexive thematic approach by Braun and Clarke, which included familiarisation with the data through close reading of the transcripts, generating initial codes across the whole data set, developing and reviewing themes from the codes and considering what each theme contributes to the overall analysis, and writing the thematic analysis to tell the story. 24One of the researchers (SK) who conducted the training and data analysis had previous experience with Namaste Care™ and is a representative for the program in Australia, though has no financial interest in the program.The previous experience with the Namaste Care™ program and representation at a National level for Author SK was consciously considered when designing this research.To account for the potential influence of the position, values and/or beliefs of Author SK, a researcher not involved in the training (CE) conducted the interviews, and the third researcher (MA) co-conducted the focus group with Author SK.Additionally, to ensure the trustworthiness of the qualitative data and findings, the accuracy of the transcripts was checked by Authors SK and MA.Coding schemas were developed individually by Authors SK and MA and then reviewed together for agreement.The third researcher (CE) reviewed and confirmed the identified themes.
Results of the inferential statistical tests on the quantitative data (improved scores and statistical significance) were compared with the themes of the qualitative findings for evidence of convergence.This analysis is shown in Table 2.

| RESULTS
Demographics of the participants of the education workshops have not previously been described and are presented in Table 1.Thirty-five participants undertook the education and 32 consented to participate in surveys.Most were in their twenties, were female (81%) and were employed as assistants in nursing (AIN) or personal care workers (PCAs).Most participants spoke English at home and nearly a third (31%) held a vocational qualification; the highest level of education was at the master's degree level.More than a third of participants had personally cared from someone living with dementia.

| Qualitative subsample
The qualitative subsample comprised eight participants following the education intervention.Focus group participants (n = 5) were volunteers, personal care assistants and a recreation and leisure officer (RLO).Interview participants were the quality administration officer of the service, a lifestyle coordinator and a volunteer who had missed the earlier focus group.

| Qualitative findings
Three main themes were identified from the interviews and focus group (1) dementia-related education and knowledge changes; (2) recognising benefits of the program; and (3) importance of changing practice.

Variable Count (%)
Age (years) including confusion, anxiety, aggression, withdrawal, not eating or drinking, wandering and finding it hard to sit still.One participant offered a solution to the case which showed a responsiveness to the needs of the person to prevent this negative outcome: I've felt that their approach, the staff's approach to this lady, could've been a lot more gentler and encouraging and helping her to understand where she was at, at that time.You probably use her name and some gentle touch and being face-on and down to her level and explaining what they're going to do and how they'd like to help her rather than a statement saying, "We'll take you to the toilet, love."I think the behaviours would change.She would feel more reassured, probably, and more comfortable.Maybe she wouldn't be struggling to get out of the lifting machine like I can tell she does end up doing.
Participants showed an understanding about the link between behaviours and unmet needs, explaining how the education improved their knowledge in anticipating residents' needs, as follows: being able to recognise when somebody is experiencing a behaviour due to an unmet need, I think that you guys really outlined things that they may be missing such as pain or even looking for something when they're unfamiliar in their environment.I think that may trigger something for the staff that they're not having behaviours, that they are trying to get a message across that they actually can't verbally express.I think they're going to be able to recognise that a lot better.
Participants showed good understanding about the impacts of dementia on communication, recognising how their residents were exhibiting symptoms of aphasia, apraxia and agnosia and how they could help address their needs: there's a lot of people that might say, oh, that's rubbish.That's not going to make a difference … They're just acting up, misbehaving.It's like, no, we can actually help them … If we look at why, for some, it may have an effect.Look at the pain first, and how we can keep them comfortable and relaxed.
Participants were able to relate a resident's functional status and perceived benefits to the resident from being involved in the Namaste Care™ program to a score on the seven stages of dementia Global Deterioration Scale T A B L E 2 Joint display of mixed methods results showing convergence of findings.

Qualitative themes Quantitative variables Mixed methods interpretation
Dementia-related education and knowledge changes Knowledge (from qPAD, Questionnaire on Palliative Care for Advanced Dementia subscale) There was an improvement in understanding the link between behaviours and unmet needs after education on the dementia trajectory and common symptoms, shown by improved knowledge in anticipating residents' needs (QUAL), and statistically significant increase in total qPAD knowledge scores and in the qPAD Insight and Intuition subscale scores (QUAN) 19 Recognising benefits of the Namaste Care™ program qPAD Attitude Scale Staff had more positive attitudes towards palliative care after the education and training in Namaste Care™ (increased scores for overall qPAD attitudes and all subscales) that were statistically significant (QUAN). 19 Staff felt better equipped to be able to provide a palliative approach-a small but statistically significant increase in scores of the skills subscale of PANA was shown (QUAN). 19This was also shown by staff understanding and recognition of the need for quality time with residents who were missing out on the most important aspects of care: comfort and connection (QUAL) Adapted from: Creswell and Plano Clark. 20GDS) 25 showing staff had taken 'on board' what they had learnt: I feel that it's actually a really great way to engage residents that have got that 5 to 7 on the dementia scale.
3.2.2| Recognising benefits of the Namaste

Care™ program
The emphasis on quality of life through comfort in a calm environment was acknowledged: we all want that nice environment.We all want to feel comfortable and warm and be touched.Things that we don't give during care, you do the showers, washing, so I think that then it's going to give them more quality of life in that moment while they're experiencing it.
Benefits for residents who would attend the Namaste Care™ program once implemented were also seen to have flow-on effects to other aspects of care: If they're used to having the benefit of the Namaste Care program morning and afternoon, regularly, and I should say that they look forward to that, then all other aspects of their care can then be more pleasurable for them, and then they're feeling better within themselves.
Implementation of the Namaste Care™ program in the service was also seen as an opportunity to upskill staff: I think that Namaste is going to give them the knowledge and skills to be able to connect with that person on what actually is more valuable at the end of their life rather than the tasks.
Another participant expressed how Namaste Care™ will be helpful for enabling staff to build relationships with the residents: As a program in itself, I can say that it's gonna have great benefits, and it's going to be a good way to teach staff new skills … make staff feel more involved and connected with the residents, rather than performing a task, as in a shower, or toileting, or making a bed for them.I feel that it's going to be really helpful for staff to relate to them as people.
This positive opinion was confirmed by a new staff member who commented: From yesterday's workshop, I feel like the touch, and the warm hand is really helpful.You will feel the support.With the warm things, it really feels really good, and it's relaxing.I also think that Namaste Care is also, for me, a really new way.I never thought of it.I also have always had the confusion of what can I do with the people with advanced dementia.I think it's really helpful for me to find a way to help the residents to relief from their pain and anxiety.

| Importance of changing practice
The third theme related to the need for changing practice to allow quality time with residents that staff in aged care currently do not have.Some participants identified the task-oriented nature of care where 'time was the biggest thing' and 'being able to spend time' was a luxury.
I just feel we rush too much.That's the same everywhere.…. unfortunately, there's never enough staff.This is where things need to change in aged care … The likely reluctance of some staff to make this shift was also acknowledged: because it is [a] time management thing … I think some carers won't have any trouble with adapting to it, but others will.
Participants acknowledged that residents were missing out on the most important aspects of care: we're providing good care, but there are things that are being missed, which is really the comfort and connecting with that person, whether they're dying or they're not dying.
Participants stated what they thought a Namaste Care™ program could bring to initiate a change in practice, including an efficient way of using time and a move away from task-focussed care: That will allow them to be able to spend that time with the residents in that Namaste environment without, in the back of their mind, without having that I've got 50 things to do.I think that's going to be the biggest thing that we need to change -just to get out of that mindset.
Participants also acknowledged how they might provide a more pleasurable experience for residents, reduce anxiety and 'actually care for a human [being], not just another dying resident'.The qualitative themes discussed above were compared to the results of the quantitative data for evidence of convergence.This is shown in Table 2.

| DISCUSSION
This mixed methods study demonstrates the value of the learning opportunities in enhancing dementia care afforded by dementia education and training in the Namaste Care™ program simultaneously.Qualitative data were collected to explore participants' perceptions of their learning and their knowledge and self-perceived skills to support practice, such as the use of touch to promote comfort and pleasure and creating a calm environment.Participants showed their increased knowledge about the dementia trajectory by describing deterioration and identifying symptoms such as pain as being one possible cause of a responsive behaviour.Participants also demonstrated positive attitudes towards the importance of quality of life for residents and in their ability to better relate to residents through the Namaste Care™ activities which supports other studies that evaluated staff perceptions and experiences of the program. 26A shift to a more person-centred approach to care and the opportunity to spend quality time is important to improve their overall work experience. 16Our findings also show that staff want to provide 'better' care for residents, that is slower, focussed on comfort and quality (the nice things), instead of feeling rushed and 'ticking off' tasks.They described the difference between task-focussed care and quality care and suggested the Namaste Care™ Program-the creation of the calm environment and the meaningful activitiesmight enable them to do this.
Staff identified Namaste Care™ as a 'simple' way to help people living with dementia and provide a supportive environment for families.The positive attitudes described by staff reflected a greater confidence in being able to connect with the person confirming the improved scores in the Building Relationships subscale of the SCIDs (reference has been redacted for purposes of review).Positive attitudes may have implications for both staff and residents' well-being, as improved relationships with care providers correlate with a decline in residents' responsive behaviours. 27While staff acknowledged the focus on getting tasks done in current practice, the education and training which included experiential elements helped them to see that there was a need for practice change and that the Namaste Care™ program might be one way to achieve this.
Our findings also resonate with previous literature that describes structural barriers in providing optimum palliative care to people living with the most advanced dementia. 28As in our study, barriers to care, such as time pressure, resulted in staff feeling conflicted about spending time with the person as they felt pressure to help other residents and support colleagues completing care. 28Similarly, insufficient staffing and time, an inappropriate physical environment, negative attitudes and poor relationships, as well as staff's lack of education are perceived as barriers in implementing person-centred care. 29All these factors mean that staff often do not have capacity to pay attention to the 'person' when completing required tasks.
Educational interventions that aim to upskill care providers have been found to be a key component in addressing the needs of people living with dementia in long-term care. 3While education and training can support staff, education is not a solution on its own.Education helps when it takes place within the context of work experience: in this case, enabling staff to connect symptoms with observed complex behaviours of the person living with advanced dementia, as well as seeing what can be done to address quality of life.As this research suggests, there is an advantage of incorporating education and skill development within a model of care, such as Namaste Care™, that also embeds a palliative approach in a more proactive and holistic way, such that it becomes 'usual' care.Such a model helps build in-house capacity in palliative and endof-life care and can 'upskill' staff to provide quality care. 30n this way, staff are enabled to put into practice the education and training provided as opposed to training that is marked off as 'complete' and not applied further.While the current research did not assess the translation of the education and training into day-to-day practice, the feedback from staff during the training was overwhelmingly positive including the workshop being engaging and hands on.However, there was divergence in the data showing that for some participants, ongoing practice would revert to business as usual because there are not enough staff to support practice change.
Overall, this mixed methods study shows convergence between the qualitative findings with the quantitative results that confirm the positive impact of the education on participants' knowledge, attitudes and self-perceived skills in providing care to residents with advanced dementia.This research also demonstrates the potential for education to offer tangible benefits to staff in terms of skill development and an opportunity for staff to provide quality care.As such, the Namaste Care™ program is a model of care that enables staff to focus on the holistic needs of residents, specifically those with the most advanced dementia and the highest care needs, to improve quality of life.

| Strengths and limitations
The research design allowed the focus group and semistructured interviews to further explore the quantitative results, providing a richer investigation of the value of education about Namaste Care™ in an RACF.However, the study was conducted in one RACF only in Northern Tasmania which limited the sample size, with only half of eligible participants attending the education workshop.The small number of participants in this qualitative study is a subgroup of the participants who completed the surveys and reflects the diversity of the larger sample.A larger sample would have provided more opportunity for data saturation and transferability of the study findings.
Future research with respect to the implementation and dissemination of the Namaste Care™ program with its potential to engage family care partners using gentle touch and props from home that are meaningful to the person living with dementia 31 would improve the Namaste Care™ experience.Furthermore, family/care partners' direct involvement in the Namaste Care™ intervention may provide a sense of worthiness for family/care partners, particularly at the end of life.The inclusion of family/care partners in future Namaste Care™ education and training research would be advantageous.

| CONCLUSIONS
The study has shown how education delivered to frontline staff can make a difference to knowledge, attitudes, self-perceived skills and competence and the positive contribution that a structured, person-centred, multisensory program for people living with advanced dementia may offer palliative care capacity in the sector.

ACKNO WLE DGE MENTS
Due to the effects of the COVID-19 pandemic on aged care services, we were fortunate that the organisation allowed us to proceed with the research and are very grateful to the organisation and staff for their generous support to deliver the education and conduct this research.Open access publishing facilitated by University of Tasmania, as part of the Wiley -University of Tasmania agreement via the Council of Australian University Librarians.
3.2.1 | Dementia-related education and knowledge changes Participants described a number of behavioural changes that a person with advanced dementia might exhibit T A B L E 1 Demographic characteristics of sample.
This is reflected in staff perceptions that the Namaste Care™ program, once implemented, would have benefits including possible positive flow-on effects to other aspects of care (QUAL)