Role of occupational therapy in person‐centred dementia care: Exploring family member and clinician perceptions

This study aimed to explore the role of occupational therapy in dementia facilities using a person‐centred model of care, from the perspective of family members, occupational therapists and multidisciplinary health professionals.

models of dementia care are growing in Australia, driven by recognition of the benefits of holistic approaches that provide quality care. 4Person-centred dementia care values the perspectives and preferences of people with dementia and ensures these are meaningfully included in therapy, enabling engagement and partnership.
Person-centred care has evolved over the years 5 and is founded on principles of empowerment, 6 enhanced knowledge 7 and active participation 8 of the service user within the delivery of health services. 9This is contingent on a multidisciplinary approach including family members, 10 each voicing their expertise, aimed at strengthening relationships between all key stakeholders.This humanistic approach serves to centre the person in the health-care setting rather than the disease itself. 11The interpretations, perception and execution of person-centred care across different settings and stakeholders can vary. 5However, when supported by adaptive leadership, 12 person-centred care provides residents with better control over their environment and emotions, leading to decreased adverse behaviours, improved physical function and independence. 2his can enhance the quality of life for the resident, family members and staff as well as improved safety and costeffectiveness 13 within the service.
Occupational therapists have long been employed in residential aged care facilities and the discipline's unique philosophical and theoretical foundation aligns closely with the values and strategies of person-centred dementia care. 2 Occupational therapists utilise their expertise of understanding the complex relationship between person, environment and occupation to adopt a person-centred approach. 14Their scope of practice includes assessing personal skills, evaluating occupational characteristics and modifying environmental contexts to enable optimal engagement and occupational balance in daily life. 15,16pecifically, strategies such as daily living retraining, memory and interest eliciting stimuli (possessions, photographs or music), strength-promoting environments (such as activity stations with wood-working or child-rearing equipment) and the development of small, homelike residential care environments 17,18 are used.
A systematic review of multisensory environments provided by occupational therapists in residential care led to decreased behavioural and psychosocial symptoms for people with dementia, 19 while a randomised controlled trial identified distinctive benefits from group and individual occupational therapy. 20Group therapy appeared to yield improvements in well-being and sense of selfefficacy whereas individual therapy yielded improvements in environmental mastery. 20Significant improvements in activity of daily living (ADL) function, staff distress, social connection, sleep and medication need 21,22 have also been identified in studies incorporating occupational therapy as part of multicomponent interventions.However, other studies targeting quality of life, global cognition and behaviour symptoms have found no significant improvements from the introduction of occupational therapy. 2,23ccupational therapists have reported challenges to implementing person-centred dementia care in residential aged care facilities. 24Aged care funding arrangements designed to provide more funding for residents with greater disability discourage interventions which maximise occupational opportunities for residents. 24Australian studies by Rahja et al. 3 and Calderone et al. 24 confirm occupational therapists in residential aged care are prompted to focus on assessing or identifying deficits rather than promoting occupation through intervention and can feel pressured to employ non-evidence-based interventions such as pain massage and fall prevention programs.Preconceived expectations of passivity and frailty for residents by staff, limited resource availability and inadequate staff training are barriers 11 to person-centred care in residential aged care facilities. 25,26ccupational therapists also report a lack of selfperceived confidence or competence when working with people with dementia. 27While evidence is emerging to support the role of occupational therapy in these settings, the evidence base is not established or coherent enough to support the development of discipline-specific clinical practice guidelines. 27This is a barrier to the execution of quality person-centred care.The recently approved Australian Clinical Practice Guidelines and Principles of Care of people with dementia identified a single study that examined the efficacy of occupational therapy in this setting with nil improved outcomes 23 suggesting that there was insufficient evidence to support formulating a recommendation for persons living with dementia in a residential facility. 27As such, it may be some time before sufficient evidence becomes available to support evidence-informed

Policy Impact
This study found that key stakeholders in a dementia facility had conflicting views on the role of occupational therapy yet recognised that they facilitated positive social intervention and present-orientated occupational engagement with residents.

Practice Impact
There is an opportunity to enhance the utilisation of occupational therapy services to improve the health and well-being of residents.approaches, suggesting that existing occupational therapy expertise may be underutilised to the detriment of residents. 3,24A better understanding of the occupational therapy role in person-centred dementia residential facilities could inform ongoing development and maximise the profession's potential impact on residents.
This study aimed to explore the role of occupational therapy in dementia facilities using a person-centred model of care, from the perspective of family members, occupational therapists and multidisciplinary health professionals.

| METHODS
Ethics approval was sought and received from Deakin University (HEAG-H_117_2014).A descriptive qualitative approach was adopted due to its focus on the personal experience and meaning, ability to include contextual influences and factors and its relevance to topics about which little is currently known. 28

| Study context
Multidisciplinary and family participants were recruited from a small (10-bed) person-centred dementia facility focused on cultivating a personal and interactive care environment.The rural facility located on a two-hectare site has an indoor environment comprised of a double-sided fireplace dividing the communal areas, a glass conservatory, an artist's studio and kitchen to support the socialisation of residents and staff.The outdoor environment provides access to a machinery shed, a stockyard with animals and walking trails.Residents varied within the disease process, levels of function and/or mobility and remained at the facility for extended periods of time.

| Sampling and recruitment
Participants were recruited purposively for their direct experience of the occupational therapy role in residential aged care settings.Participants included (1) Multidisciplinary health professionals within the facility, (2) family members of residents within the facility; and (3) occupational therapists with experience of person-centred and other models of dementia care within Australia.All participants were aged over 18 years and could participate in the study without interpreter support.A hard copy or email invitation to participate was distributed to all staff and family members by the facility administration, to uphold their right to decide whether to disclose their contact details to the research team.All potential participants received a detailed plain language statement that emphasised their participation was voluntary.After returning their written consent form, the second author made phone contact to screen for eligibility, collect demographics, and schedule and complete an interview.
Occupational therapy participants employed within the facility were employed 2 days per week with nil overlap and engaged with residents at least two times per week (either in a group or individually).There were no exclusionary criteria around experiences.The facility regularly had occupational therapy students undertake their placements within.
Occupational therapy participants from outside the facility were recruited to provide a contrast with the broader practice context in Australia.An advertisement was emailed to members of the Occupational Therapy Australia Victoria Division including a link to the plain language statement and consent form.Recipients were encouraged to snowball the email to others.Following an online version of the plain language consent form, participants were advised that submission of responses via Survey Monkey would constitute implied consent.Participants were then able access the survey and complete their responses.

| Data collection
Bespoke data collection instruments were developed as there were no suitable existing measures.The semistructured interview schedule for family members comprised four open-ended questions about their perceptions and experience of occupational therapy with their family member at the facility (Appendix S1).The staff member schedule included five open-ended questions about their professional role, perceptions of the occupational therapy role, the influence of different service settings on the occupational therapy role, their observations of residents engaged in occupational therapy and perceptions of subsequent change (Appendix S1).Both schedules were piloted with occupational therapy students for clarity, and no changes were suggested.Interviews were conducted in person by the second author in a mutually agreed quiet and private location and lasted approximately 30 min each.Audio recordings of the interviews were transcribed verbatim and returned to participants by email for member checking.The data collection spanned a 4-month period.Participants had 1 week to provide additional feedback or comments, and no transcripts were returned for amendment.
Occupational therapists were posed five questions via the anonymous online survey, which explored their perceptions of the role of the occupational therapist in aged and dementia care, and the interventions used within this population.The survey was piloted with occupational therapy academics, found to take approximately 20 min to complete and no changes were deemed necessary.The survey remained open for 4 weeks, after which responses were exported into an Excel spreadsheet for data analysis.

| Data analysis
A reflexive thematic approach was used to identify, analyse, and report themes within the study, 29 with no a priori coding or theme identification.The first two authors initially familiarised themselves with the interview and survey data, by reading and re-reading the transcripts.Initial codes were then generated highlighting meaningful and relevant data from the transcript, particularly around the perceived role of occupational therapy and experiences relating to its implementation in person-centred dementia residential aged care services.These researchers then compared their codes, resolved any disagreements through discussion and collaboratively determined initial themes based on the shared meaning interpreted from the data.The third author reviewed these themes in relation to the overall analysis of the data and research aims and provided feedback around conceptualisation and defining each theme.The first and third authors then redefined and finalised the themes and selected participants' quotes to illustrate their essential meaning.Finally, an analytic narrative was constructed to report the study findings.
Trustworthiness refers to confidence in the data, analysis and methods employed in qualitative research-essential to evaluating the rigour of qualitative research. 30he four aspects of this phenomenon are credibility, transferability, dependability and confirmability, 31 and several strategies were incorporated.Researcher triangulation was enabled by the involvement of several team members in analysis, which supports credibility by ensuring themes are collaboratively identified.Peer debriefing and iterative discussion during the data analysis process contributed to the quality of this study.The dependability of the study is indicated by the detailed description of the analytical method.Member checking is a recognised strategy for confirmability which provides an opportunity for participants to confirm their responses and ensure their accuracy.Transferability is the extent to which the study's findings can be applied to other contexts. 31While the sample size has the potential to approach saturation, the diversity of service settings and levels of implementation for person-centred care in dementia facilities suggests some perspectives and contexts are under-represented in this study.We therefore make no claim that these findings are broadly generalisable.

| RESULTS
There were 17 participants in this study; eight family members, five multidisciplinary staff members and four occupational therapists employed externally.Seven female and one male family interviewees (mean age 61 years) identified as spouses, siblings, children or in-laws of residents.Staff interviewees were all female (mean age 41 years) and employed as occupational therapists, registered nurses, patient care assistants and lifestyle/leisure workers.The four occupational therapists working outside the facility (mean age 48 years) in mostly rural locations were employed in diverse workplaces including aged and dementia residential care facilities, acute and sub-acute hospital settings, and in-home care services.Gender-aligning pseudonyms were used for participant privacy.
Two key themes around perceptions of occupational therapy in person-centred dementia care were identified: (1) poorly understood contribution of occupational therapy and (2) perceived features of the occupational therapy role.

| Poorly understood contributions of occupational therapy
Family members described the occupational therapy role in person-centred dementia care as focussed on skill maintenance; 'Work with a client just to help them maybe with their skills or movement' (Lorna, daughter); 'Practice the skills that patients have so that they don't lose them but also to enhance their sort of quality of life…' (Karly, daughter).
Or providing mental and/or physical stimulation (individual or group): 'He's been, you know, entertained' (Sonia, daughter); 'Sometimes, I see the [OT] doing things with them.Like they do games or tests with them on the computer …to help their brain work' (Keely, spouse).
Or in the context of function: Enables people to function in a day-to-day environment.By either making changes to their environment or making changes to what they do…to help the residents cope with their lives they're building … (Chris, son) Multidisciplinary colleagues generally described the role as promoting independence and active participation via equipment provision: 'I thought the role of an occupational therapist would be assessing ADLs and maximising inde-pendence…' (Holly, nurse); 'Getting equipment to help them out and also get them into activities' (Krista, personal care assistant).Or to provide, embed and facilitate education opportunities with or for staff: 'Educate staff, and families in managing behaviours associated with dementia… I'd love to see the OT's to be able to get in there, work with the staff…' (Holly, nurse).
These opportunities for collaboration, sharing of skills and practices-coupled with organisational support of student placements, were perceived to enable workforce capacity building; 'We are aware of what the OTs are doing so we pick up on some of their skills and… become better trained ourselves' (Jade, lifestyle/leisure).
Occupational therapists employed within and external to the facility emphasised engaging residents in meaningful occupations more prominently; 'Getting ideas of each resident of how to be able to help them' (Katie, occupational therapist).They identified a broader range of potential occupations than family members including crafts, music, bowls and community outings; and interventions suitable for people with dementia, including reminiscence therapy, validation therapy, multisensory strategies, assessment of physical, cognitive and psychosocial abilities, ADL retraining, education and equipment/aid provision.
Family members appeared to envision the role to be engaging the resident to do 'something' and to build a relationship with them, whereas staff saw the role as pivotal to enhancing independence, education and collaboration.Both perspectives were captured by the practising occupational therapists within and external to the facility.Overall, while perceived to be beneficial, the therapeutic intent and embedded complex reasoning still appeared unclear rather, occupational therapy was perceived as providing a diversion.

| Perceived features of the occupational therapy role
Participants suggested the occupational therapy role fostered positive interactions and social inclusion-through structuring social interactions around topics of personal interest; 'Whether it's bingo… word games or putting golf or cooking, things like that, trying to get them to interact' (Lou, sister); 'Well dad will join in what they are doing rather than sitting in front of the tv all day.[…]It is different because where he was, he did not interact with the other residents as much' (Grace, daughter).This appeared to facilitate solidifying relationships with family, staff and other residents.
Both participant groups suggested the occupational therapy role appeared to influence residents' behaviours: 'It's a lot more quiet… relaxed and comfortable.There's nowhere near as much agitation within the residents them-selves… it's more settled' (Jade, lifestyle/ leisure).
Dad is a bit happier and seems more stable, so it is probably attributed to occupational therapy …just someone spending time with him and doing things just with him.In other facilities, I think he was probably more bewildered, and sort of wandering.
(Sonia, daughter) Overall, participants in both groups suggested that residents were happier, more settled, less agitated, slept better and more motivated to engage in activities (either actively or passively).However, this was not always the case-and likely linked to the limitations of the disease itself; 'Mum's health has actually deteriorated -so it is a bit of a roller coaster now, I don't know if occupational therapy would have had an effect on her or not' (Lorna, daughter).Despite the disease progression, and the fact that residents may engage but then forget, staff members and external occupational therapists highlighted the presentfocused nature of practice in person-centred dementia facilities, in comparison with their work elsewhere: [In other settings] the focus is on the future for the client.[…] Whereas here, it's really present moment.It's how we can engage them right now (Katie, occupational therapist); It's [the role of OT] not to do with independence; it's to do with reminiscence and joy.

| DISCUSSION
Family and staff members appeared to have a different understanding of the role of occupational therapy in this setting than members of the profession.Family members indicated that occupational therapy aims to maintain skills or movement and characterised interventions as diversional or keeping residents busy.Staff members suggested that the occupational therapy role was to educate (family and multidisciplinary staff), increase independence and build rapport with the residents to better understand their needs.Both family and staff members recognised the holistic nature of the occupational therapy role but links to quality of life, empowerment and active engagement of the resident were not always clear.
While the contributing role of occupational therapy was somewhat limited, both family and staff members were able to identify person-centred features of the occupational therapy role.Specifically, both staff and family members described the occupational therapy involvement facilitated positive interactions between residents and staff, which collectively led to positive changes in mood, sleep, decreased irritability and increased willingness to engage or participate.These positive interactions were seen as a precursor to developing rapport and increasing understanding of the residents' idiosyncratic nature.There were assumptions that this would lead to greater quality of life however it was also recognised that engagement was limited by disease aetiology.
The lack of clarity around the role of occupational therapy and the impact of that role could lead to underutilisation of occupational therapy services, which has been raised as a potential risk in this service setting for some years. 32In a multidisciplinary setting such as residential aged care, the boundaries of the occupational therapy scope may be blurred in some areas.However, there is a clear need for a national scope of practice statement to support practice consistency and raise awareness of potentially untapped potential benefits for residents.
The staff and family member participants in this study perceived the role of occupational therapy as keeping residents busy and occupied in the present.In contrast, occupational therapists emphasised the therapeutic potential of engaging the residents in meaningful occupations on the basis that meaningful occupations are goal-directed pursuits. 33A focus on occupation 'in the moment' could be considered appropriate considering the profound cognitive challenges faced by people with dementia; Du Toit et al. note this disregards the residents need for ongoing growth as an occupational being, which could promote occupational injustice and poorer outcomes for residents.Re-ablement strategies for people with dementia have emerged in recent years which aim to maximise function, but they are yet to become a common feature of Australian dementia care.However, the enablement of social inclusion for residents was identified as a current practise feature of occupational therapy by participants, which could also counteract the loss of autonomy, decreased selfconfidence, anxiety and depression often experienced by people with dementia. 34rom the organisational perspective, participants also identified capacity building with multidisciplinary colleagues within the occupational therapy scope of practice.Recent studies indicate that training led by occupational therapy can enhance the problem-solving capabilities of a multidisciplinary team when addressing real-life challenges. 35However, these activities also run the risk of diverting occupational therapists from the deployment of their specialist skills.Any scope of practice statement developed must therefore address the influence of professional philosophy and values, practise regarding specific assessment and interventions, the impact of multiple environmental factors (i.e., built, social and policy) and the relationship of the discipline's role with those of multidisciplinary colleagues.
This study has several limitations, beginning with the relatively small size and rural location of the facility associated with most of the participants.Any benefits observed for residents cannot only be solely attributed to occupational therapy, as multiple other factors and interventions are being provided simultaneously.The range of employees interviewed did not include management, who may have additional insights into the culture of care at the facility and its impact on the occupational therapy role.Finally, this study did not include the perceptions of residents themselves, which are key informants about the impact of occupational therapy on their health and well-being.

| CONCLUSIONS
This study explored the role of occupational therapy in a dementia facility using a person-centred model of care, from the perspective of family members, occupational therapists and multidisciplinary health professionals.While the perceptions and experiences of participants varied, the scope of this role is currently poorly defined.Occupational therapists in this setting commonly facilitate positive social interaction and present-oriented occupational engagement with residents and are also recognised as building workforce capacity with multidisciplinary colleagues.This is the first study of the role of occupational therapy in Australian person-centred dementia care, and more local research is urgently required to support practice development in this service setting.Future studies must include the perceptions of residents and should seek to gather data from a wider range of services and disciplinary groups.Additional evidence is also needed around the effectiveness and clinical impact of occupational therapy on the health and well-being of people with dementia in residential aged care services.

ACKNO WLE DGE MENTS
Open access publishing facilitated by Deakin University, as part of the Wiley -Deakin University agreement via the Council of Australian University Librarians.

CONFLICT OF INTEREST STATEMENT
No conflicts of interest declared.