Anexos

Since the goal for phase 2 was not to create generalisations, but to gain an in-depth understanding of the management of BPSD in CHs and to learn from cases, purposive sampling was chosen as a suitable method (Stake, 1995). The main aim of the

purposive sampling was to gain a sample of CHs most likely to include people with BPSD. In turn, it was hoped this would work to illuminate more of the strategies used to manage these symptoms and therefore, adequately answer the research questions. A second aim of the sampling was to gain a heterogeneous sample (Tashakkori & Teddlie, 1998). Heterogeneous sampling allowed the study to include a variety of CH factors (For example, those CHs with different levels of reported antipsychotic use and CHs providing and not providing qualified nursing care) across the case studies,

enabling a variation of cases to be studied (Robson, 2002). Since using heterogeneous cases can make distinct patterns and underlying factors in the data easier to

distinguish (Eisenhardt & Graebner, 2007), it was hoped that differing practices or strategies could be illuminated. The sample for the case studies was derived from the survey responses from phase 1. It was potentially more likely that these homes would agree to take part in Phase 2 since they had already taken part in the study to a smaller extent. To select the target CHs the information the postal survey provided was revisited to see what it would represent for the cases. Table 5.1 shows the

knowledge categories the survey provided, what these categories were proxy for, and the relevance they would have within the case studies.

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Table 5.1: Survey response categories and relevance for case studies

Knowledge Category Proxy for: Relevance for Phase 2 of

study Location

(County/Address)

Deprivation - Affluence  Staff/resources

 Paying/ funded residents Rural – Urban  Inside/outside space  Visitor access  Available activities Impact on BPSD/ strategies Community links

Number of residents Organisation, Homeliness, Busyness

Size of staff team

Recognition of residents’ individuality

Impact on BPSD/ strategies Environmental effects

Ownership Values

Resources

Rules – regulations – policy Staffing levels, Environment Control over admittance

Impact on BPSD/ strategies CH Environmental/contextual effects

Ethos

Residential/nursing Staff training levels

Biomedical influence Needs of residents

Types of strategies may differ Approaches may differ Medical influences, or not

Specialising in Dementia/Old Age

More/less equipped for dementia More/less likely to have PWD in CH

BPSD more/less pervasive More/less effective strategies in place

Caring for people with D: Yes/No

Yes -Experiencing dementia Likely to have strategies in place, Higher likelihood of BPSD

Admit people with CB: Yes/No

Likelihood of CB in home Acceptance of CB – strategies may/may not be in place Attitude towards BPSD/Control

Likely prevalence of BPSD in CH

CB in last week: Yes/No

Frequency of CB More likely to expose strategies within case study

Difficult behaviours Identified

CB an identified issue

CB can be difficult to cope with

More likely to identify issues or difficulties in managing BPSD

Prevalence of BPSD - Indicator

Use NPIs Tackling issue

CH open to new approaches

Interested in Quality of life/wellbeing

Allow a view of formal strategies

Antipsychotic use: level

CB may have been problematic CH lacks other adequate

strategies/has residents with severe BPSD

Allow knowledge of

administrations to be gained Illuminate place of medication in strategies ‘As required’ Antipsychotic use Flexibility – responsiveness of strategies CB not constant

Allow a view of the antecedents, context, decision making and

subjectivity of deciding to use antipsychotics

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These categories led to the development of a staged exclusion criteria to narrow down the sample pool of potential case study CHs. The sampling pool started with n = 291 survey responses, the steps of exclusion outlined in Table 5.2 reduced the

possible case study candidates to n = 80.

Table 5.2: Sample exclusion process and rationale Step

number

Exclusion steps and rationale n=Sample

size

Start No exclusions n=291

1 Exclude homes not caring for PWD (n=45). If homes are caring for PWD there should be a higher likelihood of BPSD and strategies used in the CH.

n=246

2 Exclude homes not experiencing challenging behaviour in the last week (n=128). If challenging behaviour is frequent, it is likely that more strategies will be exposed within case studies.

n=118

3 Exclude homes not identifying difficult behaviours (n=3). An indicator for BPSD. If homes identified difficult behaviours it is likely that issues or difficulties in managing BPSD will be salient. (n=2 did not identify difficult behaviours, but stated they did not see behaviour as challenging- these CHs were kept within the sample pool)

n=115

4 Exclude homes not using NPIs (n=0). If homes are using NPIs it would allow a view of the nature of formal strategies and how they are used.

n=115

5 Exclude homes that do not admit people with challenging behaviour (n=34). If homes admit people with challenging behaviour the likely prevalence of BPSD will be higher.

n=81

6 Exclude homes not supplying antipsychotic use data (n=1).Those homes not supplying antipsychotic data were difficult to classify for next sampling procedure and the lack of data could indicate a reluctance to be transparent or open.

n=80

Finish Total sample pool left n=80

The remaining eligible care homes (n=80) were sorted into the categories shown in Table 5.3. Although the aim was to gain a heterogeneous sample the small sample size sought for phase 2 meant that all relevant CH variables could not feasibly be included. Instead the categories of CH providing qualified nursing care and CH not providing qualified nursing care were prioritised along with the reported antipsychotic

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prescription levels to further separate out the sample pool. These dynamics were thought to be the most appropriate factors to base the sampling on, since they could impact greatly on the management style of BPSD within the CHs. The survey results showed that 12% of CH residents within all CHs were prescribed antipsychotic medications. Consequently, 12 % was chosen as the centre cut off point of

antipsychotic prescription. Responses showing 12% of residents, or more, prescribed antipsychotic medication were categorised as having a high antipsychotic use and those showing below 12% as low antipsychotic use. As shown in Table 5.3 four sample categories were made. By focusing on these four characteristics and including two of each across the sampling subgroups replication could occur, allowing the opportunity to look for similarities and differences between cases during analysis (Yin, 2009). One CH in each section was sought to gain a heterogeneous sample. When choosing potential homes from each of the four sections care was taken to first approach those CHs citing the most instances of difficult behaviours and/or NPI use. This was to increase the likelihood of gaining relevant findings. As the research progressed one case study was indeed secured in each category, making up the four case studies within Phase 2. The pseudonyms for the four case studies conducted are also shown in Table 5.3

Table 5.3: Sampling subgroups for case studies and CHs in the final sample Care home factors n=number in sample

pool for each sample subgroup

Participating case study CH

pseudonym Care home providing qualified nursing care:

High Antipsychotic use – 12% or higher

14 Mirabelle Way

Care home providing qualified nursing care: Low Antipsychotic use - less than 12%

13 Cherry-Plum

Care home not providing qualified nursing care: High Antipsychotic use – 12% or higher

27 Gage Hill

Care home not providing qualified nursing care: Low Antipsychotic use – less than 12%

26 Bullace View