Identifying personal beliefs of nursing staff about encouraging psychogeriatric nursing home residents in daily activities: A qualitative study

Abstract

Aim

To identify personal beliefs of Dutch nursing staff about encouraging psychogeriatric nursing home residents in daily activities.

Design

Qualitative study following COREQ guidelines.

Methods

Fifteen semi‐structured interviews with Dutch nursing staff of wards hosting psychogeriatric residents were conducted in Spring 2021. Data were systematically analysed through deductive coding analysis in NVivo.

Results

Most nurses indicated to encourage residents frequently to perform activities independently, although many also indicated to take over tasks habitually. Nurses seemed to show sufficient awareness, reflected by adequate knowledge of what encouraging residents entailed and insight in the risks of not encouraging residents. Nurses' motivation to encourage residents seemed high, reflected by expressing multiple advantageous and few disadvantageous beliefs and a high willingness to encourage residents. Managerial support was perceived ambiguous. Self‐efficacy was perceived high, although little time, staffing shortages and resistance of residents reduced self‐efficacy. Nurses were often unable to anticipate such situations and expressed the need of skills, e.g. patience.

1. INTRODUCTION

Although the majority of people age in place, some of them reach a point in their lives where access to institutionalized long‐term care, for example a nursing home, is unavoidable (WHO, 2020). A nursing home is the most common form of institutionalized long‐term care in the Netherlands, hosting both residents with severe somatic (physical) and psychogeriatric (cognitive) impairments who require round‐the‐clock care support or supervision. Increasingly, most nursing home residents need psychogeriatric care, e.g. the proportion of residents requiring intensive dementia care has increased from 32% in 2015 to 41% in 2019 (Verbeek‐Oudijk & Koper, 2021). For people residing in nursing homes is pivotal to remain active and engage in daily activities, which can be divided into activities of daily living (ADL), such as washing and eating, and instrumental activities of daily living (IADL), such as preparing food and watering plants (Edemekong, Bomgaars, Sukumaran, & Levy, 2021). Performing daily activities independently is associated with improved physical functioning, increased self‐esteem and a higher quality of life of nursing home residents and should therefore maximized (Edvardsson, Petersson, Sjogren, Lindkvist, & Sandman, 2014; Gronstedt et al., 2013).

2. BACKGROUND

Given their frequent and direct contact to those in need of care, nursing staff play a major role in encouraging resident activity, i.e. motivating and facilitating residents to optimize their independence in performing daily activities. However, nursing staff often work in a task‐oriented manner rather than person‐centred and a large part of daily activities is unnecessarily, however, well‐intended, taken over (Tuinman, de Greef, Krijnen, Nieweg, & Roodbol, 2016; V&V, 2020). An observational study of den Ouden and colleagues showed that in almost half of the activities observed, nursing home staff took over resident's activities (den Ouden et al., 2017). To encourage residents' participation in these activities, a behaviour change among nursing staff is needed towards more supervision and support, thereby considering the residents' abilities and nursing care needs (den Ouden et al., 2017). Although nursing staff acknowledge their prominent role in encouraging resident activity, a change in day‐to‐day care behaviour can be challenging since nursing staff experience several barriers (Swoboda, Dahlke, & Hunter, 2020). These barriers may relate to themselves (e.g. low self‐efficacy), the resident (e.g. capabilities of the resident), the social context (e.g. lack of managerial support) and the organizational and economic context (e.g. lack of resources) (Kuk et al., 2018). Clearly nursing staff need support to overcome these barriers and make an effective change in their day‐to‐day care behaviour towards encouraging resident activity.

Nursing interventions, such as Function‐Focused Care (FFC), aim to support and motivate nursing staff to increase involvement of residents in daily activities, rather than simply completing nursing tasks (Resnick, Galik, Gruber‐Baldini, & Zimmerman, 2011). Generally, FFC interventions are holistic in nature and focus on intrapersonal (e.g. mood of resident), interpersonal (e.g. self‐efficacy of nursing staff), environmental (e.g. walking space) and policy components (e.g. vision of care) (Resnick, 2012).

Recent work, however, suggests a lack of unambiguous effectiveness of Dutch but also internationally developed FFC interventions in changing nursing staff's and residents' behaviour (Lee, Kim, Jung, & Chang, 2019; Rooijackers et al., 2022). In the Netherlands, a thorough evaluation of divergent FFC interventions from various nursing care settings suggests that a lack of evidence may lay in the minor incorporation of behaviour change theory within the interpersonal component (Vluggen et al., 2021). Although all FFC components may provide relevant targets to facilitate the behaviour change of nursing staff, intrapersonal, environmental and policy factors are difficult to change and might only influence behaviour change indirectly. Interpersonal factors, such as a person's knowledge, attitudes or self‐efficacy, may influence nursing staff behaviour and thus resident's activity behaviour more directly, and therefore, it is evident to understand the personal beliefs of nursing staff about encouraging resident activity.

About interpersonal factors, current FFC interventions mainly focus on outcome expectations and self‐efficacy as determinants of resident activation behaviour (Resnick, 2012). However, more integrative behaviour change models such as the Integrated Model for Behavioural Change (I‐Change Model) assume that a broader spectrum of personal determinants play a role in changing behaviour (De Vries, 2017). The I‐Change Model comprises three sequential phases (awareness, motivation and action), each consisting of a set of determinants (De Vries, 2017). In turn, all determinants are predicted from beliefs, which first need to be identified before a decision can be made about which beliefs need to be changed, reinforced or added, in order to successfully change behaviour (Bartholomew et al., 2016). Therefore, it is important to identify beliefs of nursing staff about the target behaviour, i.e. encouraging resident activity.

The aim of this study was to identify personal beliefs of Dutch nursing staff about encouraging psychogeriatric nursing home residents' daily activities. Psychogeriatric focus was chosen because this concerns the largest group of nursing home residents in the Netherlands, and nursing staff may hold specific personal beliefs towards encouraging activity in psychogeriatric compared with somatic nursing home residents. The following research question has been formulated: which personal beliefs about encouraging psychogeriatric nursing home residents in the performance of daily activities can be identified among Dutch nursing home staff. The findings will gain a better understanding of nursing staff's beliefs and can lead to the development of tailored interventions to facilitate the behaviour change of nursing staff.

3. METHODOLOGY

3.1. Design and ethical approval

A qualitative study among Dutch nursing home staff was conducted using semi‐structured, individual interviews. This study was approved by the Faculty of Health, Medicine and Life Sciences Research Ethics Committee (FHML‐REC) of Maastricht University Ethics Committee of Maastricht University REC‐number: FHML/HPIM/2021.040. To improve reliability and value of published health research literature, the consolidated criteria for reporting qualitative research (COREQ) checklist were used as recommended for qualitative studies by the EQUATOR network (Tong, Sainsbury, & Craig, 2007).

3.2. I‐Change Model

The I‐Change Model (Figure 1) is a theoretical framework integrating various well‐known socio‐cognitive theories (Ajzen, 1991; Janz & Becker, 1984; Prochaska & DiClemente, 1983). The model assumes the existence of several successive behaviour change phases and posits that an individual first needs to become aware of the necessity of change in order to form motivation (De Vries, 2017). Awareness can be obtained by acquiring cognizance (i.e. whether nursing staff can adequately estimate their level of encouraging resident activity), accurate knowledge (i.e. the meaning of encouraging resident activity), risk perceptions (i.e. recognizing the possibility and severity of consequences for nursing staff due to not encouraging residents) and by cues to action (i.e. stimuli that trigger nursing staff to encourage resident activity). Subsequently, motivation to change a behaviour depends on a person's attitude, social influences and self‐efficacy. Attitude refers to positive and negative outcome evaluations of encouraging residents. Social influences consist of the perception of other colleagues encouraging resident activity, for example social support, social modelling and social norms. Self‐efficacy refers to nursing staff's perception of their capability to encourage resident activity, particularly in challenging situations. Together, these motivational factors determine the intention of an individual to change behaviour. However, positive intentions do not warrant behaviour change. The model assumes an action phase including preparatory planning, coping planning and skills, to increase the likelihood of positive intentions being translated into the desired behaviour. For instance, nursing staff could prepare encouraging resident activity by planning where, when and how to perform this behaviour. Moreover, by anticipating challenging situations in which encouraging resident activity is likely to be difficult (e.g. little time), nursing staff can increase the likelihood of performing the desired behaviour successfully.

FIGURE 1.

The integrated model for behavioural change (I‐Change Model)

3.3. Method and procedure

This study focused on nursing home staff working in wards hosting psychogeriatric residents. These wards mainly house residents with neurodegenerative diseases related to old age, such as dementia (Schols, Crebolder, & van Weel, 2004). In the Netherlands, direct care nursing staff have different qualification levels based on the length of their training and responsibilities, e.g. bachelor‐educated registered nurses and vocational‐trained registered nurses (4 years of training), certified nursing assistants (2–3 years of training), nurse assistants (2 years of training) and nurse aides (0.5–1 years of training). Most direct care is provided by certified nursing assistants in collaboration with nursing aides, nursing assistants and bachelor‐educated and vocational‐trained registered nurses (Verkaik et al., 2011).

Nursing staff were recruited in Spring 2021. The sampling method used to recruit nursing staff was maximum variation sampling, which is a purposive sampling method to generate a heterogeneous sample (Beck & Polit, 2003). To generate a wide array of perspectives, purposeful efforts were made to recruit a heterogeneous sample in terms of age, gender, care organization, geographical area, care experience, number of contract hours per week and qualification level of nursing staff.

From each province in the Netherlands (to assure spread in geographical area), five random care organizations providing nursing home care to psychogeriatric residents were approached via their general e‐mail address to draw attention to the study and to request participation through an information letter. Different care organizations were chosen because these organizations may have different care visions, which could influence nursing staff's beliefs on encouraging resident activity. In case of willingness to participate, either a board member or ward manager forwarded the information letter including the participation request to eligible nursing staff. Nursing staff were considered eligible to participate if they spoke the Dutch language, were employed at wards hosting psychogeriatric residents and had a day‐to‐day influence on residents' daily functioning and activities. In addition, a minimum of 1 year of care experience was required. Nursing staff who worked in a ward hosting somatic geriatric residents besides that they also worked in a ward hosting psychogeriatric residents were not excluded from participation. However, for the nursing staff to whom this applies, they were asked to provide their answers taking into account their work on a ward hosting psychogeriatric residents. After providing nursing staff 1 week of consideration time, in case of willingness to participate, individual eligible nursing staff could confirm participation via e‐mail or telephone to the researcher. Subsequently, an interview date was planned. In some cases, nursing staff were approached via social and personal networks of the authors.

We aimed to conduct as many interviews as necessary until sufficiently representative results were obtained. After these interviews, three additional interviews were conducted to confirm data saturation and content validity (Francis et al., 2010). The included nursing staff were interviewed in Spring 2021. Interviews started with asking the participant to confirm their willingness to participate and consent to audio record the interview, familiarization between respondent and interviewer and explaining the interview duration. Hereafter, respondents were requested verbal consent for both interview participation and audio‐recording on tape. All interviews were conducted by author JvS (female, junior researcher) via telephone due to COVID‐19 measures and recorded by means of a Dictaphone application on a mobile device. Afterwards, the interviews were transcribed verbatim and pseudonymized by excluding names and traceable characteristics of respondents. The recordings and transcripts of the interviews were securely stored on databases of the academic institution according to the local laws of data storage, after which recordings were deleted from the mobile device.

The I‐Change Model was used as a theoretical basis for the interview guide. The model assumes rational thought processes as predictors of behaviour (De Vries, 2017). Many behaviours, however, are not merely the result of rationally considered choices, but are sometimes unconscious (habitual) and unintentional (Brug, van Assema, Lechner, & Kremers, 2022). Therefore, the determinant ‘habit’ was also included in the interview guide. The determinants are operationalized into questions in Table 1. The semi‐structured nature of the interviews allowed the interviewers to ask follow‐up or sub‐questions based on the answers given by the respondents to add depth or clarification.

TABLE 1.

Operationalization of I‐change model determinants

Determinants	Operationalization
Awareness beliefs
Cognizance	To what extent do you (think) you stimulate resident activation?
Knowledge	What is the effect of stimulating resident activation?
Risk perceptions	What are consequences for you if you do not stimulate resident activation? What is the possibility and how severe would that be?
Cues to action	What are direct triggers for you to stimulate resident activation?
Motivational beliefs
Attitude	What are (dis)advantages for you to stimulate resident activation?
Social influence	To what extent do you think your colleagues stimulate resident activation? Are there people who think you should stimulate resident activation? Do you experience support in stimulating resident activation?
Self‐efficacy	To what extent do you have the ability to stimulate resident activation? In which situations is it more difficult or easier?
Intention	To what extent are you planning on improving your stimulation to optimize residents' participation in daily activities?
Action beliefs
Action planning	How do you prepare yourself to increase your stimulation to optimize residents' participation in daily activities?
	Which coping plans do you have to stimulate resident activation when facing a difficult situation?
Skills	What skills are needed to stimulate resident activation? Do you have the appropriate skills?
Barriers	What barriers do you experience when stimulating resident activation?
Additional belief
Habit	Is it a habit for you to take over/stimulate residents' participation in daily activities?

3.4. Analysis

All interviews were analysed using NVivo software version 12. First, transcripts were read several times to become familiar with the data. A deductive coding approach was selected for which a predefined coding tree was developed based on the behaviour change phases and determinants of the I‐Change Model, including habit (Staa & Evers, 2010). Then, author JvS applied the predefined coding tree to organized the data of three randomly selected transcripts to review the coding tree fit In consultation with author SV (male, senior researcher), no additional codes were created. JvS coded the remaining transcripts in close consultation with SV, and inconsistencies were discussed and agreed upon. Quotes are included to confirm and clarify interview results, displaying the participant's qualification level of nursing staff, age and gender.

4. RESULTS

4.1. Sample characteristics

After 12 interviews, data saturation was considered reached. After conducting three additional interviews, which confirmed data saturation and content validity, our sample comprised of 15 respondents who all met the eligibility criteria and consented to participation and audio‐recording. No participant withdrew consent during the study. The 15 respondents were employed in 11 different care organizations, spread over a wide geographical area in the Netherlands. The majority of the respondents were female (n = 12), and the mean age of the respondents was 39.3 years (SD = 14.0). The respondents were bachelor‐educated and vocational‐trained registered nurses (RN) (n = 7), certified nursing assistants (CNA) (n = 7) and nursing assistants (NA) (n = 1). The respondents had an average care experience of 17.4 years (SD = 12.7) and an average number of 27.5 (SD = 9.6) contract hours per week. Interviews lasted on average 28.2 (SD = 8.2) minutes.

4.2. Awareness beliefs

4.2.1. Cognizance

The vast majority of the nursing staff believed to encourage residents frequently to perform daily activities independently.

Even if residents can't wash their own face, I will let them try first, then they do it partly [themselves], but I always think, they have been active because of that… and after that I can still take it over. [CNA_41_F]

Some nursing staff, however, mentioned they took over many daily activities from residents. About half of the participating nursing staff stated that residents could be encouraged and involved in daily activities even more.

There are also those [residents] whose patient file states they are doing it [daily activities] themselves, but residents indicate that you [nursing staff] can take it over, because then it will go faster. And I think 9 out of 10 [nursing staff] will take it over, because it goes faster, and time is limited anyway. [CNA_46_F]

4.2.2. Knowledge

All nursing staff viewed daily activities as activities that residents were used to do at home, such as washing and dressing. Encouraging residents in these daily activities was considered crucial and, according to several nursing staff, related to many things, such as mobility and energy expenditure. All nursing staff indicated that encouraging activity was advantageous for residents. Most frequently mentioned advantages for residents were related to the retention of self‐esteem and independence and an improved physical condition and quality of life.

It [involving residents in daily activities] can result in sustained independence, actually having better control on their [residents'] lives. Having the feeling that they can still do things themselves instead of everything being taken over completely. [RN_23_F]

A few nursing staff members stated that taking over daily activities meant that it was no longer visible what residents themselves were able to do. For example, this could cause deterioration of their remaining abilities more rapidly. In addition, several nursing staff indicated that every resident was different. To meet those varying needs, opportunities to encourage residents should be exploited, but it was considered important not to overload and overestimate residents in their capabilities.

4.2.3. Risk perceptions

Near all participating nursing staff felt less satisfied when they took over daily activities from residents. In addition, about half of the nursing staff indicated that taking over daily activities increased the physical demands of their work.

I think that it is often also physically demanding for me to take over daily activities which they [residents] can do themselves. It actually comes at the expense of my physical condition, so I have more back problems… things like that. [CNA_28_M]

4.2.4. Cues to action

Most participating nursing staff stated that they were sometimes reminded by the behaviour of residents to encourage resident activity.

If you comb someone's hair once and that resident has comments about it or takes the comb again, you will notice that (s)he really wants to do that her‐/himself and that (s)he is able to do that too. [RN_23_F]

Other less often mentioned cues that triggered nursing staff to encourage resident activity entailed restless residents, being addressed by colleagues during team meetings, supervising nurse interns (e.g. nurse interns telling they have been taught to encourage resident activity) and when ideal circumstances arise to involve residents in daily activities (e.g. sufficient staff).

4.3. Motivational beliefs

4.3.1. Attitude

All participating nursing staff identified advantages for themselves of encouraging resident activity. Often, residents indicated advantages such as improved (work) satisfaction, an improved relationship with residents, the timesaving aspect, a reduction of work and improved ergonomics.

Yes, that I am physically less burdened within the care tasks… you have more time for other tasks, such as paperwork, chatting with residents, because that is also often something which doesn't happen … you actually learn more about the residents. [CNA_28_M]

Many nursing staff initially indicated no disadvantages for themselves of encouraging resident activity. However, during the interview, implicitly some disadvantages were put forward. All nursing staff indicated the disadvantage that encouraging resident activity took a lot of time. In addition to the time aspect, one nursing staff member mentioned to become impatient when a resident did not understand how to perform daily activities after several explanations. Moreover, one nursing staff member stated that involving residents in daily activities causes disadvantages for nursing staff, but advantages for residents.

4.3.2. Social influence

The first domain of the determinant social influence is social support. The amount of support in involving residents in daily activities from management was perceived ambiguous. Some participating nursing staff indicated they experienced support from management, for example by removing time pressure. Others experienced no support and mentioned that management mainly had a different focus, such as a financial viewpoint. Almost all nursing staff stated they received support from colleagues and team coaches in encouraging resident activity. For example, several nursing staff indicated to address self‐reliance and the issue of colleagues taking over daily activities. Moreover, most nursing staff stated they received satisfying support from certain allied health professionals. For example, a psychologist helped with challenging behaviours and a physiotherapist, occupational therapist and exercise therapist provided advice and supportive tools. The amount of support provided by family was perceived ambiguous too, where the lack of support prevailed.

Family does not always support it [encouraging resident activity], because they say, ‘our mother has been washing herself all her life, why should she wash her own face now’. [CNA_41_F]

The second domain of social influence is social modelling. The majority of the participating nursing staff indicated that colleagues do involve residents in daily activities and that colleagues could support, learn from and imitate each other by talking to or observing each other. According to some nursing staff, this mainly applied to nurse interns. A few nursing staff members, however, noted that they often worked alone, which made it difficult to assess and imitate the working methods of colleagues. Social norm is the last domain of social influence. The vast majority of nursing staff indicated that the vision of the organization focused on encouraging resident activity. Most nursing staff stated that they and their colleagues tried to encourage activity, as the vision propagates.

It [involving residents in daily activities] is a goal from the management, but in the department here it is really a priority of the staff themselves. They are very aware of that. [CNA_46_F]

Some nursing staff said that continuity among colleagues in encouraging resident activity was important and that residents should be encouraged and involved in daily activities from the start of their stay.

When I wash someone's face for 9 days and on day 10 my colleague gives a washcloth to wash the face [of the resident] him‐/herself, I don't think (s)he will be able to do that. [CNA_47_F]

Furthermore, several nursing staff experienced pressure from family members of residents as they sometimes mentioned that encouraging their relative in activity was considered important.

4.3.3. Self‐efficacy

The vast majority of participating nursing staff indicated a high level of self‐efficacy in encouraging resident activity. The level of self‐efficacy to involve residents in daily activities was influenced by the experienced number of situations in which involving residents was believed to be easy or difficult. Sufficient staff availability and time, and residents being calm and willing to perform daily activities themselves, were most often mentioned easy situations.

When it is quiet and if there is enough time and we have enough staff available, then it is easier to give that individual attention that someone [a resident] needs at a certain moment. [CNA_59_M]

Encouraging resident activity was believed to be more difficult when time and staff were limited, when residents were sick or bedridden and when residents were restless or did not want to perform daily activities.

For example, if there are no other colleagues or you are very busy, there is little time, a resident does not want to participate. [RN_22_F]

In addition, almost all participating nursing staff emphasized the difficulty of encouraging psychogeriatric residents to participate in daily activities, partly because the behaviour and mood of psychogeriatric residents may vary from day to day. Moreover, many nursing staff believed that psychogeriatric residents sometimes no longer knew how to perform simple daily activities, such as brushing teeth. A few nursing staff members also mentioned that it was difficult to find out what a psychogeriatric resident is willing and able to do, because often they cannot indicate this by themselves. This compared to wards hosting somatic geriatric residents, where residents mainly experience physical rather than cognitive complaints.

4.3.4. Intention

Near all participating nursing staff mentioned the importance of self‐reliance and the willingness to involve residents in daily activities. Several nursing staff indicated that resident activation must be safe and therefore daily activities sometimes must be taken over preventively.

Because there are always things you [nursing staff] want to keep under control yourself. Suppose someone [a resident] can wash his/her lower body part, but not well enough and that has consequences for blemishes and bedsores, because it is not properly cleaned. Then I feel obliged to take over that part, because it is in the interest of health. [CNA_47_F]

4.4. Action beliefs

4.4.1. Action planning

The vast majority of the participating nursing staff indicated that encouraging resident activity is often discussed with colleagues during team meetings. Several nursing staff mentioned that reading care plans in advance, stating what a resident can still do him‐/herself and being aware of this, is a good preparation to involve residents in daily activities. A few nursing staff members also stated the importance of knowing a resident, such as knowledge about the life history, and that a good handover for new residents could help. In addition, some nursing staff indicated the importance of having everything at hand during a care moment and creating a clear overview for residents (e.g. clothes laid out in the correct order).

I actually try to do as much preparatory work as possible and you can see if you already have everything at hand, if you give the resident a clear overview at the time of care, a lot is possible. [RN_26_M]

The majority of the participating nursing staff indicated that despite a difficult situation, attempts were made to encourage resident activity. Several nursing staff stated to ask for help from a physiotherapist, occupational therapist and psychologist when they got stuck with either encouraging residents, implementing a behavioural approach, or when supportive tools were missing. For example, a psychologist provided tools to encourage resident activity when they did not want to perform daily activities.

If you have questions, you can also ask her [physiotherapist] to look at the care to see how things are going and she can then observe and give advice… often you can figure it out yourself, but sometimes you are blind to something, for example. [CNA_46_F]

When little time is perceived available, some participating nursing staff indicated they adjusted the schedule, such as getting residents out of bed earlier or waiting with certain care tasks until there is more time. Some nursing staff also mentioned they asked a colleague for help when being busy or when they were unable to encourage a resident, because another approach could sometimes help. Another type of coping behaviour mentioned by some nursing staff was discussing problems with the team and solving it together and explaining to the resident why resident activation is important. However, a small minority indicated that it was not always possible to cope with a difficult situation.

4.4.2. Skills

According to several participating nursing staff, several skills were considered important for encouraging resident activity. For example, understanding what a resident can do him−/herself, being able to choose the right behavioural approach for a resident, patience, knowledge about illnesses and the situation of the residents and persuasiveness. Less often mentioned skills were perseverance, affinity with the target group, being able to distance yourself from the resident (nursing with your hands behind your back), being strong in communication, calm and able to perform care tasks correctly.

You have to communicate well, you have to be motivating, you have to be able to do what is asked, you have to be knowledgeable about the illnesses to estimate what someone [a resident] can do because you also quickly overload someone and feeling overloaded is not pleasurable for a resident. [RN_23_F]

4.4.3. Barriers

A barrier that several participating nursing staff experienced to encourage resident activity was the limited physical space, such as small showers, doorsteps and a small space for residents to walk around.

And now I notice that in the other nursing home there were a lot of restrictions to self‐care. We had a lot of small showers, small spaces, doorsteps… And here it is all set up much more broadly and then I notice that it is easier to work. [CNA_59_F]

Another barrier mentioned by several nursing staff was being dependent on or having to wait for allied health professionals, such as a physiotherapist. In addition, feeling pressure from colleagues when daily activities take longer was experiences as a barrier to persist in encouragement behaviour.

4.5. Habit

About half of the participating nursing staff stated that traditionally the emphasis was more on providing care for residents rather than retaining residents' autonomy. Many nursing staff habitually took over daily activities from residents to make it as easy as possible for them. Several nursing staff automatically thought that residents could no longer perform certain daily activities independently and thought they had to care for instead of care with residents.

In the past, nursing staff generally took over everything; they went for their own planning and structure as much as possible. We are now very demand‐oriented, by looking at what a resident needs. And that requires a different approach. [RN_26_M]

Several participating nursing staff noted that nursing staff should become aware of their way of working. They said that a behaviour change is needed and that the habit of automatically taking over daily activities from residents should be broken.

We are often not yet used to let residents perform daily activities themselves, but it is advantageous for residents. It is also a bit of a switch for us to see what we can let someone [a resident] do him‐/herself. [CNA_59_F]

On the other hand, a small majority of the participating nursing staff indicated that resident activation is a habit. In addition, most nursing staff stated that nursing staff who have been working in care for a longer period took over more daily activities than new employees did. A few nursing staff members, however, were of the opposite opinion, indicating that new employees took over daily activities more often.

5. DISCUSSION

This study aimed to identify personal beliefs of Dutch nursing staff about encouraging psychogeriatric nursing home residents in daily activities. On the one hand, the results demonstrate that nursing staff encourage residents frequently in performing daily activities independently. On the other hand, nursing staff also tend to take over daily activities from residents habitually. Within all behaviour change phases addressed in the I‐Change Model, personal beliefs seem to play a role in nursing staff's activity encouragement behaviour. About the awareness phase, nursing staff demonstrated sufficient knowledge of what encouraging resident activity entailed and sufficient insight in the risks of not involving residents. Nursing staff's motivation and intention to perform encouragement behaviour seemed high and multiple advantageous beliefs and few disadvantageous beliefs were put forward. The general self‐efficacy was perceived high, although for example little time and staffing shortages seemed to reduce self‐efficacy. About the action phase, nursing staff were not always able to anticipate such difficult situations and expressed the need of skills, such as patience.

About the awareness phase, the vast majority of the nursing staff indicated to encourage residents frequently in performing daily activities independently, but also to take over activities habitually. In Henderson's definition of nursing care, it is emphasized that the dependent person should be aided towards independence and should be supported in their autonomy (Henderson, 1966). Our results partly indicate a discrepancy between current clinical practice and literature. A recent observational study conducted in Dutch nursing homes confirms that a large part of daily activities is still taken over (den Ouden et al., 2017). Other research shows that nursing staff tend to overestimate their time spent in encouraging residents in daily activities (Cotter, Burgio, Stevens, Roth, & Gitlin, 2002). This could mean that nursing staff's cognizance level – the level of having a correct insight into one's own behaviour – is inadequate, and that a discrepancy exists between what nursing staff say and actually do. However, one should acknowledge that a shift towards increased activity encouragement behaviour seems ongoing as expressed by nursing staff, although (video) observations would have provided a more objective reality.

From a behaviour change perspective, awareness is distal to behaviour and an important prerequisite for motivation (Weinstein, 1988). Nursing staff's motivation and outcome expectations to encourage resident activity seem sufficient. Frequently mentioned advantages included the timesaving aspect of resident activation, improved work satisfaction, an improved relationship with residents and improved ergonomics. This corresponds with advantages addressed in the study of Resnick (Resnick, 2012). On the contrary, these findings are not entirely in line with the study of Metzelthin and colleagues where nursing staff had to rate outcome expectation statements with regard to encouraging resident activity (Metzelthin et al., 2021; Resnick, 2012). In this questionnaire, outcome expectation statements were included related to benefits for nursing staff (e.g. improved job satisfaction) but also to benefits for residents (e.g. improved independent functioning). In order to understand and improve activity encouragement behaviour of nursing staff, the appropriate beliefs should be identified, measured and improved accordingly. Therefore, outcome expectation statements to be rated in questionnaires, but also statements related to other determinants, should focus on beliefs directly derived from the behaviour of nursing staff – such as identified in this study – and not on indirect outcome expectations such as those for residents (Bartholomew et al., 2016). Another explanation for the assumed sufficient level of motivation is that the general self‐efficacy of nursing staff to perform activity encouragement behaviour was considered high. Nevertheless, self‐efficacy seems to be negatively influenced by limited time, staffing shortages and residents' resistance to perform daily activities independently. For example, some nurses indicated that encouraging residents in wards hosting psychogeriatric residents was more difficult than in wards hosting somatic geriatric residents. In the study of Swoboda and colleagues, it is stated that nursing staff spent their limited time on medically directed tasks, which is viewed as a priority over encouraging activity (Swoboda et al., 2020). Nursing staff should be supported by the management and organizational policy in encouraging residents in daily activities, for example by making resident activation a priority and securing sufficient time and staffing levels (Resnick, 2012). Self‐efficacy techniques, including verbal encouragement, the use of role models and actual performance of skills and activities (e.g. demonstrations by nursing staff of how to interact with residents using a FFC‐approach), could also enhance nursing staff's self‐efficacy, particularly in those situations experienced as difficult (Braun et al., 2015; Smith & Liehr, 2018).

Although the intention of nursing staff to engage residents in daily activities seems considerably high, some stated not to enact this willingness accordingly. The discrepancy that people develop an intention to change their behaviour and do not enact their willingness, has been labelled as the intention–behaviour gap (Sheeran & Webb, 2016). Action planning and implementation intentions, which are if–then plans that specify when, where and how persons will instigate responses that promote goal realization, appear to be effective in bridging the intention–behaviour gap (Gollwitzer & Sheeran, 2006). The FFC philosophy, however, contains no such personal determinants that facilitate the translation from intention to behaviour (Resnick, 2012). Therefore, determinants of the action phase should be considered, for example, nursing staff should plan when, where and how to encourage resident activity, have the skills they need to encourage activity adequately and be able to cope with situations in which their self‐efficacy is compromised.

Contrary to the rational thought process of explaining and changing behaviour assumed in the I‐Change Model, many behaviours are not merely the result of rationally considered choices, but also descent from automatism (De Vries, 2017). For example, many nursing staff in our study indicated to take over daily activities automatically. Habits are long‐lasting behaviour patterns and difficult to break, but important to tackle in order to optimize the ongoing shift from the traditional medical care model towards a social model of care. Behaviour change techniques known to successfully break habits are using prompts or cues, action planning and conserving mental resources (Gardner et al., 2021). For example, a poster could serve as a cue that provides a visual reinforcement of encouraging resident activity, and action planning could specify where, when and how to encourage activity (Resnick, 2012).

Although in general nursing staff provided similar answers, there was also some variation about several questions. For example, some nursing staff were more aware, knowledgeable and willing to encourage resident activity or experienced less barriers than others. Therefore, interventions aligned to the specific set of beliefs of an individual are needed, which will be perceived as more personally relevant compared with generic interventions (Kreuter & Wray, 2003; Schoberer, Leino‐Kilpi, Breimaier, Halfens, & Lohrmann, 2016). However, nursing staff do not work as individuals, but work in multidisciplinary teams consisting of various educational backgrounds (Schols et al., 2004). Teamwork is often promoted as an important aspect of culture change (Tyler & Parker, 2010). Therefore, tailoring the content of interventions to the beliefs of an individual nurse and a specific nursing staff team may support nursing staff during the behaviour change process (Rooijackers et al., 2021). A comprehensive interactive tailored training programme for nursing staff addressing the relevant beliefs is needed (Lee et al., 2019; Metzelthin et al., 2017). Although nursing staff training is a key component in changing behaviour, particularly about altering prior beliefs, education alone is not sufficient (Blair, Glaister, Brown, & Philips, 2007; Resnick, 2012). A holistic approach, involving a review of FFC‐related policy and the physical environment, and coaching, which involves ongoing motivation and mentoring of nursing staff, is needed to ensure that encouraging activity is put and consolidated in practice (Resnick, 2012).

5.1. Strengths and limitations

This study shows some strengths and limitations. A first strength is the use of a theoretical framework (the I‐Change Model) which incorporates factors known to determine behaviour. Second, a heterogeneous sample was recruited to generate a wide array of perspectives; however, the generalizability of the results should be viewed with caution given the qualitative nature of the study and the relatively small sample. A limitation is that interviews were conducted via telephone. As a result, non‐verbal aspects were not noticed. However, given the COVID‐19 pandemic, this way of interviewing was deemed most suitable and appropriate. Furthermore, nursing staff who had worked in both a ward hosting psychogeriatric residents and a ward hosting somatic residents were not excluded. This may have resulted in some questions being answered from a somatic ward's viewpoint; however, in advance of the interviews, it was made clear to nursing staff they had to answer from a psychogeriatric ward's viewpoint. In addition, it is likely that more motivated nursing staff participated, who may be more engaged with the topic, resulting in different beliefs. Last, the qualitative design of this study provided in‐depth findings, but quantitative studies are needed to examine which beliefs actually predict resident activation behaviour.

5.2. Conclusion and implications

This study shows an ongoing shift towards resident activation behaviour. It is not merely important for nursing home residents to optimize their activity and with that improve their quality of life, but also the scarcity in nursing home staff may stress the need to shift towards self‐reliance and capability of residents. However, still care tasks are unnecessarily and habitually taken over by nursing staff, reflecting a difference between practice and literature recommending enablement of residents towards independence. Within all behaviour change phases addressed in the I‐Change Model, personal beliefs seem to play a role in nursing staff's activity encouragement behaviour. Therefore, it is important to expand the interpersonal component of the FFC philosophy with determinants addressed in the I‐Change Model and habit. The beliefs identified from this study may form the basis for comprehensive, tailored interventions aiming to improve resident activation behaviour in clinical practice.

AUTHOR CONTRIBUTIONS

All authors contributed equally to the manuscript, directed by author SV and supervised by authors SM and SZ. All authors were responsible for the detailed design and development of the study and consequently the reporting of the data in the current paper. JvS was responsible for data collection. JvS and SV were responsible for data‐analysis. All authors read and approved the final version of the manuscript.

All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]:

• substantial contributions to conception and design, acquisition of data or analysis and interpretation of data;

• drafting the article or revising it critically for important intellectual content.

FUNDING INFORMATION

No funding was received for the study.

CONFLICT OF INTEREST

The authors declare no potential conflicts of interest concerning the research, authorship and/or publication of this article.

ETHICAL APPROVAL AND PATIENT CONSENT STATEMENT

This study was reviewed and approved by the Faculty of Health, Medicine and Life Sciences Research Ethics Committee (FHML‐REC) of Maastricht University Ethics Committee of Maastricht University REC‐number: FHML/HPIM/2021.040. Verbal consent was obtained from participants for both interview participation and audio‐recording of the interview.

van Sambeek, J. , Metzelthin, S. , Zwakhalen, S. , & Vluggen, S. (2023). Identifying personal beliefs of nursing staff about encouraging psychogeriatric nursing home residents in daily activities: A qualitative study. Nursing Open, 10, 2229–2239. 10.1002/nop2.1473

DATA AVAILABILITY STATEMENT

Original data (in Dutch) is available at a reasonable request.