Care staff and the creative arts: exploring the context of involving care personnel in arts interventions

Arts-based interventions play an important role in the care of people with dementia. Yet, creative arts are seldom implemented as a tool to enhance the care and wellbeing of people with dementia.  We examined the involvement of care staff in creative arts activities in residential care. Aspects of involvement that appear to influence outcomes in people with dementia were identified and analyzed. A broad systematic literature search of MedLine, EMBASE, PsychInfo, CINAHL, ASSIA, SCOPUS, and Web of Science led to the identification of 14 papers. The studies identified through the search process were examined in terms of intervention, context, mechanism and outcome, and the relationships between these aspects.  Training sessions were identified as an opportunity to educate care personnel on useful techniques that are relevant to daily care practice. Evidence from the literature suggests that creative arts programs play a significant role in the way staff and residents interact and as a result influence the care practice of staff. Under certain conditions creative arts programs, that involve and engage staff, facilitate enhanced interactions and improve care strategies, which leads to the recognition and validation of personhood in residents with dementia.  These findings provide a basis for illustrating which elements of care staff involvement in creative arts programs could be implemented in residential care contexts in order to have the upmost benefit.

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title: Dementia Reconsidered: the Person Comes First
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title: The impact of community-based arts and health interventions on cognition in people with dementia: a systematic literature review
abstract: Dementia is a progressive condition, affecting increasing numbers of people, characterised by cognitive decline. The current systematic review aimed to evaluate research pertaining to the impact of arts and health interventions on cognition in people with dementia.  A literature search was conducted utilising PsychInfo, Cochrane Reviews, Web of Science, Medline and British Humanities Index databases. Seventeen studies were included in the review, including those related to literary, performing and visual arts.  The review highlighted this as an emerging area of research with the literature consisting largely of small-scale studies with methodological limitations including lack of control groups and often poorly defined samples. All the studies suggested, however, that arts-based activities had a positive impact on cognitive processes, in particular on attention, stimulation of memories, enhanced communication and engagement with creative activities.  The existent literature suggests that arts activities are helpful interventions within dementia care. A consensus has yet to emerge, however, about the direction for future research including the challenge of measurement and the importance of methodological flexibility. It is suggested that further research address some of these limitations by examining whether the impact of interventions vary depending on cognitive ability and to continue to assess how arts interventions can be of use across the stages of dementia.

title: The benefits of creative therapy for people with dementia.
abstract: To evaluate the use of creative therapy, including dance, drama, music and movement, with people who have dementia attending one NHS organisation that provides day treatment and inpatient services.



A one-day training package in the use of creative therapy in dementia care was commissioned from a dance movement psychotherapist. Creative therapy sessions, including dance, drama, music and movement activities were implemented over an eight-week period, a minimum of three times a week. Observational outcomes of creative self-expression, communication, pleasure and enjoyment, and general engagement were recorded.



Implementation of creative therapy resulted in improvements in creative self-expression, communication, pleasure and enjoyment, and general engagement in people with dementia.



The evaluation has emphasised the positive effects of creative or artistic approaches on dementia care, and supports previous research on the use of such approaches in NHS dementia care services. Further research on the immediate and longer-term outcomes and benefits of creative therapy for people with dementia is recommended to support the routine availability of such therapy in dementia care.

title: The needs of older people with dementia in residential care
abstract: People with dementia often move into care homes as their needs become too complex or expensive for them to remain in their own homes. Little is known about how well their needs are met within care homes.

title: Assessing the outcomes of participatory research: protocol for identifying, selecting, appraising and synthesizing the literature for realist review
abstract: BackgroundParticipatory Research (PR) entails the co-governance of research by academic researchers and end-users. End-users are those who are affected by issues under study (e.g., community groups or populations affected by illness), or those positioned to act on the knowledge generated by research (e.g., clinicians, community leaders, health managers, patients, and policy makers). Systematic reviews assessing the generalizable benefits of PR must address: the diversity of research topics, methods, and intervention designs that involve a PR approach; varying degrees of end-user involvement in research co-governance, both within and between projects; and the complexity of outcomes arising from long-term partnerships.MethodsWe addressed the above mentioned challenges by adapting realist review methodology to PR assessment, specifically by developing inductively-driven identification, selection, appraisal, and synthesis procedures. This approach allowed us to address the non-uniformity and complexity of the PR literature. Each stage of the review involved two independent reviewers and followed a reproducible, systematic coding and retention procedure. Retained studies were completed participatory health interventions, demonstrated high levels of participation by non-academic stakeholders (i.e., excluding studies in which end-users were not involved in co-governing throughout the stages of research) and contained detailed descriptions of the participatory process and context. Retained sets are being mapped and analyzed using realist review methods.ResultsThe librarian-guided search string yielded 7,167 citations. A total of 594 citations were retained after the identification process. Eighty-three papers remained after selection. Principle Investigators (PIs) were contacted to solicit all companion papers. Twenty-three sets of papers (23 PR studies), comprising 276 publications, passed appraisal and are being synthesized using realist review methods.DiscussionThe systematic and stage-based procedure addressed challenges to PR assessment and generated our robust understanding of complex and heterogeneous PR practices. To date, realist reviews have focussed on evaluations of relatively uniform interventions. In contrast our PR search yielded a wide diversity of partnerships and research topics. We therefore developed tools to achieve conceptual clarity on the PR field, as a beneficial precursor to our theoretically-driven synthesis using realist methods. Findings from the ongoing review will be provided in forthcoming publications.

title: RAMESES publication standards: realist syntheses.
abstract: There is growing interest in realist synthesis as an alternative systematic review method. This approach offers the potential to expand the knowledge base in policy-relevant areas - for example, by explaining the success, failure or mixed fortunes of complex interventions. No previous publication standards exist for reporting realist syntheses. This standard was developed as part of the RAMESES (Realist And MEta-narrative Evidence Syntheses: Evolving Standards) project. The project's aim is to produce preliminary publication standards for realist systematic reviews.



A mixed method study synthesising data between 2011-2012 from a literature review, online Delphi panel and feedback from training, workshops and email list.



We: (a) collated and summarized existing literature on the principles of good practice in realist syntheses; (b) considered the extent to which these principles had been followed by published syntheses, thereby identifying how rigour may be lost and how existing methods could be improved; (c) used a three-round online Delphi method with an interdisciplinary panel of national and international experts in evidence synthesis, realist research, policy and/or publishing to produce and iteratively refine a draft set of methodological steps and publication standards; (d) provided real-time support to ongoing realist syntheses and the open-access RAMESES online discussion list to capture problems and questions as they arose; and (e) synthesized expert input, evidence syntheses and real-time problem analysis into a definitive set of standards.



We identified 35 published realist syntheses, provided real-time support to 9 ongoing syntheses and captured questions raised in the RAMESES discussion list. Through analysis and discussion within the project team, we summarized the published literature and common questions and challenges into briefing materials for the Delphi panel, comprising 37 members. Within 3 rounds this panel had reached consensus on 19 key publication standards, with an overall response rate of 91%.



This project used multiple sources to develop and draw together evidence and expertise in realist synthesis. For each item we have included an explanation for why it is important and guidance on how it might be reported. Realist synthesis is a relatively new method for evidence synthesis and as experience and methodological developments occur, we anticipate that these standards will evolve to reflect further methodological developments. We hope that these standards will act as a resource that will contribute to improving the reporting of realist syntheses.

title: What carers and family said about music therapy on behaviours of older people with dementia in residential aged care.
abstract: This study sought to evaluate the effectiveness of group music therapy (MT) intervention on behaviours of older people with dementia.



Reported here are qualitative data from five, semi-structured focus groups; two comprising a total of seven family members and three comprising a total of 23 staff members.



A number of core themes emerged: temporality, effect and policy with a number of subthemes. The MT effect is tempered by the temporality of (i) the older person's dementia state, (ii) the session and (iii) the psychosomatic effect on the older person. Music therapy is perceived to (i) evoke memories and facilitate reminiscence, (ii) act as a diversion (has an instrumental value) and it is contentious to discount the (iii) dichotomy between music and therapist in terms of the overall effect. Finally, policymakers need to know that MT is (i) highly prized and more, not less, MT is recommended.



Findings from this study illustrate that the timing of the MT session has consequences for the workflow in the residential aged care facility; MT has a psychosomatic effect and participants here evaluate this as temporal. Care providers and family members acknowledge the instrumental value of MT and its helping with cognition and exercise. They have mixed views about the effects of the music and the effect on the older person by the therapist but most definitely want policymakers to ensure more, not less, planned and better funded MT is part of ongoing care in the residential aged care context. Areas for future research and policy are also highlighted.



These views on group MT in residential aged care can initiate critical reflection on current practices and systems. Research is needed exploring the timing and scheduling of MT sessions at different times in the day for older person with dementia exhibiting negative behaviours.

title: Introducing a Latin ballroom dance class to people with dementia living in care homes, benefits and concerns: A pilot study
abstract: The objective of the study was to investigate the effect of introducing a dance-based psychomotor intervention using Danzón (Latin ballroom) for people with dementia in care homes. This was a grounded theory qualitative study. Thirteen of the 22 participants had dementia and were care-home residents. The remaining participants were care staff and facilitators of the dance sessions. Interviews were undertaken with seven people with dementia and nine staff, resulting in two separate sets of grounded theory methodologies. Two conceptual models, outlining positive outcomes and negative concerns of the use of Danzón were developed, depicting the experiences of people with dementia and care staff respectively. Danzón psychomotor intervention was found to enhance positive emotional states and general levels of satisfaction for both people with dementia and care staff. The details of these findings have been used to design a quantitative study.

title: A literature-based intervention for older people living with dementia
abstract: While several studies have explored the impact of literature and reading on mental health, there has been relatively little work done on how a literature-based intervention might impact on the behaviours of those living with dementia. The present report addresses the effect that a specific literature-based intervention – Get into Reading, designed and practised by national charity The Reader Organisation – might have on the health and well-being of people living with dementia.  This present study arises out of a service evaluation that specifically assessed to what extent the shared-reading intervention impacted upon behaviours symptomatic of dementia. Its aims were: (1) to understand the influence that reading has on older adults with dementia in different health-care environments; (2) to identify staff perceptions of the influence that engagement in a reading group has on older adults living with dementia; and (3) to investigate any changes in dementia symptoms of older adults participating in a reading group.  The study employed a mixed-method design conducted within three health-care environments: three care homes, two hospital wards and one day centre. The Neuropsychiatric Inventory Questionnaire (NPI-Q) assessed staff views of any changes in dementia symptom severity for participants in reading groups conducted in the care homes. Semi-structured qualitative interviews were then conducted with staff who attended the reading groups and/or had extensive knowledge of service users involved in all of the health-care settings. Responses to questions were recorded verbatim and then subject to thematic analysis.  61 service users and 20 staff members took part in the overall project. The NPI-Q results indicate that symptom scores were lower during the reading group period than at baseline. These findings were supported by the qualitative interviews, which suggested that three themes were perceived to be important to effective engagement with the reading groups: (1) the components of the reading group intervention; (2) enjoyment, authenticity, meaningfulness and renewed sense of personal identity; and (3) enhancement of listening, memory and attention.  In light of quantifiable data of limited but indicative status, together with strongly corroborative qualitative evidence, engagement in reading-group activity appeared to produce a significant reduction in dementia symptom severity. Staff interviews indicated the contribution of reading groups to well-being.

title: Using poetry to improve the quality of life and care for people with dementia: A qualitative analysis of the Try to Remember programme
abstract: This study explores the impact of a poetry intervention at one care home and one day centre in England. It seeks to bolster the growing body of literature assessing the extent to which the arts and reminiscence can improve the quality of life and care for people with dementia (PWD).  Six care staff were interviewed about their experiences of the project. The data were analysed using interpretative phenomenological analysis.  Six themes were elicited: exploring and preserving memories, communicating with service users, humanizing dementia sufferers, co-authorship of poems, continuity and the broader care context. These tell of an intervention which was valued by staff as having a positive impact on clients and their families.  The research suggests that reminiscence-based poetry activities can improve the quality of life and care for PWD, helping to restore their “personhood” in the eyes of those who care for them.

title: Impact of TimeSlips, a creative expression intervention program, on nursing home residents with dementia and their caregivers.
abstract: Creative expression (CE) programs are emerging interventions to improve the quality of care and life of persons with dementia (PWDs) in long-term care settings. However, limited empirical evidence exists to support the effectiveness of these programs. Here, we report the findings from an assessment of the impact of TimeSlips (TS), a group storytelling program that encourages CE among PWDs and those who care for them.



Instruction in TS was provided through a 10-week on-site training. An observational study using an experimental design was conducted in 20 nursing home facilities in 2 states, 10 of which were randomly selected to implement TS. Two weeks after the implementation of TS at the intervention sites, we conducted 4 days of direct observation, using a time-sampling approach, of residents and staff in each facility. Using surveys, we also assessed staff job satisfaction, attitudes toward residents, and burnout.



Compared with residents in the control facilities, those in the TS facilities were more engaged and more alert. In TS facilities, there were more frequent staff-resident interactions, social interactions, and social engagement. Also, staff who participated in the TS program had more positive views of residents with dementia and devalued residents less than did the control group staff. There were no differences in staff job satisfaction and burnout among staff in the TS and non-TS facilities.



Implementing the TS program in nursing facilities improves the care environment for PWDs. However, additional studies are needed to offer further insights into the mechanisms by which TS improves both staff and resident outcomes.

title: “I’m a Storyteller!”
abstract: TimeSlips creative storytelling program is beneficial for persons with dementia and caregivers, but no studies have qualitatively explored participant experience.  Ten residents in a skilled nursing care unit participated in 2-hour-long TimeSlips sessions per week, for 6 weeks. Semistructured interviews of participants and staff members were conducted to elicit perceptions of TimeSlips. Thematic analysis was used to evaluate qualitative data.  There were specific benefits for residents (increased creativity, improved quality of life, positively altered behavior, and involvement in meaningful activity), staff members (learning new practices, developing a deeper understanding of residents, involvement in meaningful activity, and thinking creatively around programmatic challenges), and the nursing home community (nurturing relationships and improved atmosphere).  Involvement in TimeSlips can engender benefits for residents, staff, and nursing home communities. Future research is needed to quantitatively assess whether the benefits noted in this study can longitudinally improve quality and lower cost of long-term care.

title: Emotional response to social dencing and walks in persons with dementia
abstract: The emotional response to social dancing and walks in persons with dementia was studied to better understand the feasibility, popularity, and meaning of these activities from the perspective of the patient. Social dance events and walks were videotaped and analyzed using Husserl's philosophy as a basis for the analysis. Six persons with dementia participated in the study. The results are described in terms of four interrelated themes: 1) the engaged body; 2) the caregivers' understanding, encouragement, and response to patients during the activity; 3) mutual tenderness and communion; and 4) environmental conditions. Results were then synthesized into a general assessment of the emotional states observed and reported in relation to the activities.

title: The importance of music for people with dementia: the perspectives of people with dementia, family carers, staff and music therapists
abstract: Despite the popularity of music-based interventions in dementia care, there is a limited knowledge of how and why people with dementia find music beneficial for their well-being. A qualitative study was conducted to develop further insights into the musical experiences of people with dementia and explore the meaning of music in their lives. Separate focus groups and interviews with (1) care home residents with dementia and their families, (2) day hospital clients with dementia, (3) care home staff, and (4) music therapists, were conducted. The findings of the thematic analysis were investigated further in the light of psychosocial factors with the aim of developing a theoretical model on music in dementia. Six key themes were identified. The accessibility of music for people at all stages of dementia, close links between music, personal identity and life events, the importance of relationship-building through music making were particularly highlighted as valuable. The psychosocial model of music in dementia was developed. The model revealed the importance of music to support the personal psychology of people with dementia and the social psychology of the care home environment. The effects of music go beyond the reduction of behavioural and psychological symptoms. Individual preference of music is preserved throughout the process of dementia. Sustaining musical and interpersonal connectedness would help value who the person is and maintain the quality of their life.

title: Dementia Care Mapping (DCM): initial validation of DCM 8 in UK field trials
abstract: This paper describes DCM 8 and reports on the initial validation study of DCM 8.

title: Re-imagining the care home: a spatially responsive approach to arts practice with older people in residential care
abstract: This paper considers some of the spatial challenges of doing arts projects with older people in care homes, including those living with dementia. It reflects on the author's own experience of running a performance project with residents with at a care home in North London. Drawing on Lefebvre's concept of socially produced space, it argues that repetitive and task-oriented nature of caregiving can create particular challenges for artists who are bringing new activities in. However, rather than seeing the routine practices of a care home as a hindrance to creative activity, this paper suggests that an aesthetic engagement with the space itself can support artists and residents to re-imagine care homes as creative spaces in their own right. This argument is illustrated through an analysis of a sound project that took place in a care home dining room. In describing how the author worked with residents to explore the acoustic properties of the space, it suggests some ways in which artists may find inspiration from the care home environment. In particular, it considers the significance of atmosphere when doing arts practice in care homes as something which can create a shared sense of place. The paper concludes by considering the particular contribution of the artist to the culture of care in light of emerging concepts of relationship-centred care. It suggests that an aesthetic engagement with care homes can draw attention to the relational nature of caregiving, and the wider network of spaces that make up a care home environment.

title: Prevalence and pharmacological management of behavioural and psychological symptoms amongst dementia sufferers living in care environments
abstract: Behavioural and psychological symptoms in dementia (BPSD) are a common reason for placement in long term care and are often associated with indiscriminate prescription of psychotropic medication.

title: Person-Centred Dementia Care
abstract: Person-centered care is most successful when caregivers are able to be flexible around meals and activities of daily living. Consistent care providers are crucial to build trust and a sense of safety. A person-centred environment is characterized by emotional connectedness and emotional security, respect, optimization of the person’s self-worth and strengths, and support of autonomy, privacy and dignity.