Social-Professional Networks in Long-Term Care Settings With People With Dementia: An Approach to Better Care? A Systematic Review

JAMDA 17 (2016) 183.e17e183.e27

JAMDA journal homepage: www.jamda.com

Review Article

Social-Professional Networks in Long-Term Care Settings With People With Dementia: An Approach to Better Care? A Systematic Review Janet I. Mitchell BA, MEd, MBA a, b, *, Janet C. Long BSc (Hons) MN, PhD c, Jeffrey Braithwaite BA, MIR, MBA, PhD, FAIM, FFPHRCP (UK), FAcSS d, e, Henry Brodaty MD, DSc, FRACP, FRANZCP a, b, f a

Dementia Collaborative Research Centre, School of Psychiatry, UNSW Australia, Sydney, Australia Centre for Healthy Brain Ageing, School of Psychiatry, UNSW Australia, Sydney, Australia Faculty of Medicine, John Walsh Centre for Rehabilitation Research, the University of Sydney, Australia d Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia e Centre for Healthcare Resilience and Implementation Science, Macquarie University, Sydney, Australia f Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Sydney, Australia b c

a b s t r a c t Keywords: Dementia long-term care social networks BPSD

Background: Dementia is a syndrome associated with stigma and social isolation. Forty-two percent of people with dementia in the United States and almost 40% in the United Kingdom live in assisted living and residential care facilities. Up to 90% of residents with dementia experience behavioral and psychological symptoms of dementia (BPSD). Currently psychotropic drugs are often used to manage BPSD, despite the drugs’ limited efficacy and adverse effects. Even though psychosocial approaches are as effective as medical ones without side effects, their uptake has been slow. Social networks that investigate the structure of relationships among residents and staff may represent an important resource to increase the uptake of psychosocial approaches and facilitate improvements in care. Objectives: To conduct a systematic review of social network studies set in long-term care (LTC), including residents with dementia, and identify network factors influencing the care available to residents. Method: Peer-reviewed articles across CINAHL, EMBASE, IBSS, Medline, PsychInfo, Scopus, and Web of Science were searched from January 1994 to December 2014 inclusive, using PRISMA guidelines. Studies included those examining social networks of residents or staff in LTC. Results: Nine articles from studies in the United States, Europe, Asia, and Australia met search criteria. Resident networks had few social connections. One study proposed that residents with high centrality be encouraged to welcome new residents and disseminate information. The high density in 2 staff network studies was associated with the cooperation needed to provide care to residents with dementia. Staff’s boundary-spanning led to higher-status nurses becoming more involved in decision-making and problem-solving in one study. In another, the outcome was staff treating residents with more respect and actively caring for them. Conclusion: These studies suggest interventions using a network approach may improve care services in LTC. Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

The authors declare no conflicts of interest. J.I.M. was supported in the review by a scholarship from the Dementia Collaborative Research Centre, University of New South Wales, Australia. * Address correspondence to Janet I. Mitchell, BA, MEd, MBA, Dementia Collaborative Research Centre and Centre for Healthy Brain Ageing, School of Psychiatry, UNSW, NSW 2052, Australia. E-mail address: [email protected] (J.I. Mitchell). http://dx.doi.org/10.1016/j.jamda.2015.11.015 1525-8610/Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

Dementia is a syndrome associated with stigma and social isolation. A total of 46.8 million people globally live with dementia and this number is forecast to almost double every 20 years to reach 131.5 million by 2050. Forty-two percent of people with dementia in the United States1 and almost 40% in the United Kingdom2 live in assisted living and residential care facilities. Cognitive impairment is the condition that most strongly predicts entry to a care home, leading researchers to conclude that current

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and future costs of long-term care (LTC) will predominantly be determined by forecast numbers of those with dementia. Concerns about care regimens in LTC have been expressed by academic researchers,3,4 the press,4 and policy makers4 due to reports of high rates of resident depression, physical and psychological abuse, and poor quality of life. A contributor to the latter is the incidence of neuropsychiatric symptoms (NPS) or behavioral and psychological symptoms of dementia (BPSD) that occur almost universally in people with dementia.5e8 Current management of BPSD is heavily dependent on psychotropics such as antipsychotics, despite their limited efficacy and significant adverse effects including falls, hip fractures, stroke, somnolence, cognitive and functional decline, and death.7,9,10 Different approaches to managing BPSD and improving the care given to residents are therefore of key interest in this sector. The field of social network analysis (SNA) offers an approach to investigate the structure of relationships and to facilitate improvements in LTC. SNA studies focus on understanding a network’s structure and how it relates to the way people can feel socially supported or isolated and to processes such as how information and influence flow. These affect, for example, the speed with which ideas, tools, and practices are disseminated.11,12 Networks have gained prominence in public and private governing structures, over hierarchies and markets, as a preferred means to address complex problems and scarce resources, and achieve collective objectives. They are being used to tackle so-called “wicked problems”: those that are intractable.13,14 Caring for people with dementia in LTC rates as a wicked problem because cause and effect are often difficult to identify and model, there is not always consensus on the root problem and solutions, and issues are often associated with strong moral, political, and professional views. In considering an SNA approach, structural issues that negatively affect outcomes also need to be considered, such as cliques, overreliance on central agencies or individuals, and the tendency for professions to form introspective clusters or silos.12 Health system reform in many countries has looked to network governance because of the advantages identified.15 For example, the English National Health Service funded a networks program of research on clinical networks starting in 2004. A review of 8 of these noted the “utility of network forms in tackling wicked problems.”16 Introduction of a managed clinical network in Scotland, set up to improve care for people with diabetes, was effective in addressing collaboration and communication challenges across professional and organizational boundaries. The evaluation identified that the network had resulted in changes in professional practice that delivered a dramatic fall in the rates of hospital referrals and a major shift to primary care for people diagnosed with type 2 diabetes. The network also improved simpler processes faster and facilitated continuous improvement for complex processes.17 Meltzer et al18 showed how SNA could be feasibly implemented to design effective quality improvement teams in the United States. Clinical networks have been used as a key health policy approach to engage clinicians in improving patient care in Australia. A study of 2 of these undertook a qualitative analysis of stakeholder views of the factors relating to the measurement of the effectiveness of the networks.15 Findings included network effectiveness in working with multidisciplinary teams, identifying areas of need, and developing best practice through evidence-based models of care. The network engaged clinicians enabling them to plan for and address complex problems and contribute to policy. This review examines the utility of social network studies in LTC and the extent of the evidence that network structures are being exploited to achieve better care for residents.12,19 It aims to build on extant SNA conducted in health and health care settings.20,21

Table 1 Search Terms Model Criteria Search Terms Location Roles or agents

Intervention

Resident* OR “nurs* home” OR “nurs* care” OR long-term OR “residential aged care facility” Team OR professional OR multiprofessional OR interprofessional OR multidiscplin* OR interdisciplin* OR nurse OR General Practitioner OR GP OR “primary care practitioner” OR PCP OR doctor OR Geriatrician OR carer OR staff OR specialist OR worker OR psycho* OR therap* OR servic* “social network*” OR “network analys*s” OR “network structure*”

Methods Search Strategy A comprehensive literature search was conducted in the second half of 2014, over the period of January 1994 to December 2014, following Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines.22 The year 1994 was when Social Network Analysis: Methods and Applications,23 a seminal publication in this area, was published. A large number of databases were accessed for peer-reviewed articles due to the difficulty in finding a representative number of articles. Databases accessed were CINAHL, EMBASE, International Bibliography of Social Sciences (IBSS), Medline, PsycINFO, Scopus, and Web of Science. One article was selected from a hand search of reference lists. Search terms were selected after analysis of MeSH terms, advice from experts, and review of keywords in the literature. Original terms for the systematic review were “dementia” and “social network analysis.” When no articles were produced using these terms, additional terms were tried, which led to the final set of terms, namely words associated with residential care facility, nursing home, long-term; with the professions of those likely to be part of the network; for instance, nurse, primary care practitioner, doctor, service, carer, professional, worker, as well as words associated with social network, network analysis, and network structure. Search terms were applied only to abstracts and titles and not to keywords. The wild card character, “*” was used, as relevant. Each term reflected criteria in a model of location, roles or agents, and intervention, as depicted in Table 1.

Study Selection Search limits applied are summarized in Table 2. Based on these and search terms in Table 1, citations, abstracts, and references for 153 articles were downloaded into the bibliographic software

Table 2 Limits Applied to Each Database Search Database CINAHL

Inclusion Limits

English; abstract; human; 1994e2014; Medline records excluded; related words applied; linked to full text EMBASE English; human; 1994ecurrent; title only; full text; map term to subject heading IBSS English; after Jan 1, 1994; abstract; peer-reviewed journals; discipline: anthropology and sociology Medline English; humans; 1994ecurrent; abstract; full text PsychInfo English; humans; 1994ecurrent; titles only; peer-reviewed journal Scopus English; subject limit: medicine; social sciences; biochemistry, genetics and molecular biology; neuroscience; psychology; nursing; decision sciences; multidisciplinary; health professionals; 1994ecurrent; title, abstract, keywords Web of Science English; 1994e2014; title only

J.I. Mitchell et al. / JAMDA 17 (2016) 183.e17e183.e27 Table 3 Inclusion and Exclusion Criteria for Articles Inclusion Criteria

Exclusion Criteria

1. The environment is a long-term residential care setting. Ideally a person with some form of dementia is involved. 2. Research is social network oriented 3. Peer-reviewed articles written in English 4. 1994e2014 5. Human networks

1. End-of-life care, quality of dying, advance care planning 2. Pain management, relief, or equivalent 3. Any environment other than residential care (eg, primary care, hospital, community-related)

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Bridges23,26,27 or boundary spanners28e31 are those actors in the network who effect transactions and the flow of information between groups that would otherwise have no physical or cognitive access to one another or alternatively would have no basis on which to trust each other.32 Although social network studies can be analyzed at 2 levels, ties or connections between individual actor(s), and ties or connections between organizations, all studies were conducted at the actor level. Results Overview of all Studies

management package EndNote X7 (Thompson Reuters, Philadelphia, PA). Once 7 duplicates were removed, 2 authors (JL and JM) independently analyzed titles and abstracts for the remaining 146 articles using the inclusion and exclusion criteria in Table 3. Nineteen articles were reviewed in full text by one author (JM). Final articles were agreed after discussion between JM and JL. Data Extraction Data extracted included types of analysis (descriptive, bivariate, multivariate), participant type (residents, staff), research design (cross-sectional, longitudinal), social network type (egocentric, sociocentric), and network structures (size, centrality, density, network roles, bridges or boundary-spanners). Definitions for network-related words follow. An egocentric network is focused on one individual and only includes direct ties from the focal person to the rest of the study population.24 A sociocentric network, on the other hand, captures direct and indirect ties for all in the study population. Network size was measured by the number of actors (or network members) or the number of ties or the number of types of ties, depending on the article. Density is defined as the actual number of ties in a network expressed as a proportion of the maximum possible number of ties.25 Centrality identifies which actor or actors are the most connected or who interact the most with other actors.11 Network role referred either to the relation of an actor to a resident, for instance daughter or friend, or their position within the care facility, for instance nurse or doctor.

Results of searches and articles excluded are illustrated in Figure 1. The final set of 9 articles spanned 4 continents: Asia, Europe, North America, and Australia. Although there were only 9 articles, we decided not to expand our inclusion criteria and take on more for the following reasons: 1. It allowed us to stay focused on our area of interest, namely research into social networks in residential care facilities where people with dementia live. 2. It highlighted the paucity of studies in this area. 3. It opens the way for more studies to be done with this cohort, given evidence in other health settings that adopting a social network approach does lead to improved outcomes. 4. It is relevant to examine this sample given forecast increases in numbers of future residents and related costs as well as the current preferred use of psychotropics in the management of BPSD. The 9 articles came from 6 heterogeneous studies across a range of LTC settings, including a dementia-specific unit and assisted living facilities in a large nursing home complex, nursing homes, a geriatric care facility, residential aged care facilities, psychogeriatric units in nursing homes, psychogeriatric units in residential homes, and psychogeriatric group projects in residential homes. Data collection methods included sociocentric approach only (4 articles), egocentric only (3), and both sociocentric and egocentric (1). In using both, a wider group of people was captured in each resident’s network. The final article assessed residents’ social engagement using Mor’s (1995)33 social engagement scale, and depression with the Mini Data Set Depression Rating Scale.34 Data analysis approaches included descriptive (3 articles), bivariate (2), multivariate (3), and both

153 relevant peer-reviewed arcles based on tle and abstract 1 arcle added from hand searches of reference lists

146 abstracts reviewed

19 accessed in full text 10 excluded: 8 not care of people with demena in long-term residenal care 1 not SNA 1 study protocol

9 subject of review

Fig. 1. Summary of study flow.

7 duplicates removed

127 excluded: 127 not demena AND [10 not empirical OR 103 irrelevant study purpose / design OR 1 social networking OR 2 social welfare OR 1 social area analysis OR 1 no full text]

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Table 4 Summary of Included Articles’ Study Design, Context, Network Characteristics and Key Findings Authors, (Date), Country

Study Design*

Participants, Setting

Network Characteristics

1. Interpersonal 2. Cross-sectional 3. Egocentric and sociocentric interviews with residents 4. SNA, descriptive analysis

10 of 12 residents in Dementia Specific Care Unit (DSCU) and 10 of 15 residents in assisted living facility (ALF) in larger nursing home complex. MMSE38 range 16e30 in ALF and 11e25 in DSCU

Size, quality, and centrality

Abbott KM, Bettger JP, Hanlon A, Hirschman KB (2012a) United States

1. Interpersonal 2. Longitudinal 3. Egocentric interviews and resident health data 4. Multivariate analysis (generalized estimating equation modeling)

216 adults aged 60 or over who had recently moved into a nursing home or ALF or who had started to receive home and community-based services with MMSE
20

Size and composition

Abbott KM, Bettger JP, Hampton KN, Kohler H-P (2012b) United States

1. Interpersonal 2. Cross-sectional 3. Sociocentric (roster) interviews using photos 4. SNA, descriptive analysis

Size and centrality

Cheng S-T (2009) Hong Kong

1. Interpersonal 2. Cross-sectional 3. Interviews to measure functional and structural support as well as health-related (egocentric) information 4. Bivariate analysis

10 residents, half of whom were women. Mean MMSE 25.8 (SD 5.4, range: 16e30) in ALF, 25 staff provided photographs, including housekeepers, concierges, maintenance workers, secretary, certified nurse assistants, registered nurses, social workers 72 residents with MMSE
18 and
1 impairment in activities of daily living, across 7 nursing homes, residents’ age:  Range: 65e83  Mean: 81

Cott C (1997) Toronto, Canada

1. Interteam 2. Cross-sectional

93 health care workers in 5 teams, including higherstatus nurses; day,

Density Network role Bridging

Findings About Residents 1. Extent of resident’s social integration or isolation based on network size: range 0e14 (DSCU)/17 (ALF) 2. Residents with dementia, MMSE 11e25, could participate in interviews 3. Highly connected residents could serve in roles such as welcoming other residents and sharing information 1. On entry to long term support services, residents’ health discussion networks (HDNs), one form of social network were small (mean 2.5) and decreased over time 2. Small size of their HDNs and reduction over time are likely to be disadvantages when living with multiple chronic diseases. 1. Residents gave and received emotional support to/from each other (eg, listening, expressing concern, offering sympathy, and providing health-monitoring support) 2. Individuals with higher centrality have potential to influence others in their environment and help acclimatize new residents 1. Average network size of participants was 2.58 2. 56% of the 12.5% without any network members were men 3. Networks were mainly immediate family and a few friends 4. Sometimes children were excluded from network, especially eldest son who was supposed to care for parent 5. Newly admitted residents wish to comply with all routines and associated, leading to a “total institution” effect; they seek to avoid conflict with staff and other residents.

Size, network role, and frequency

1. Collaborative teamwork limited to higher-status professionals in an

Findings: Other 1. Use of photos with residents with dementia worked well 2. Basis to explore bidirectional influence of social networks and health in a population at increased risk of social isolation.

1. Nursing home placements occur at time of crisis 2. Social worker made decision for 41% of residents to enter the nursing home, children, mainly daughters for 33%, and residents themselves: 25% 3. Social worker involvement tended to strip family member of care responsibility 4. Nursing homes did not encourage visiting (eg, inflexible visiting hours) 5. Nursing homes in Hong Kong provide only basic care and support (guideline: 2.5 hours of care per week) 1. Transition to collaborative team work is still in process

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Abbott KM, Bettger JP, Hampton KN, Kohler H-P (2013) United States

Findings About Staff

evening, and night-shift nurses, as well as a core multidisciplinary team consisting of medical staff, recreational therapists, and social workers in a geriatric care facility

1. Interpersonal 2. Cross-sectional 3. Structured telephone interviews (egocentric) 4. Multivariate analysis

Person responsible for paying the residents’ fees and directors of nursing of 13 residential aged care facilities (RACF)

“organic” structure with a focus on decision-making and problem-solving; hence, higher-status professionals had most influence 2. Teamwork of lower-status staff was in a “mechanistic” structure, chiefly consisting of assisting each other with tasks 3. Substructures of teamwork act to reproduce and perpetuate control of the division of labor within health care teams Size, frequency, and network role

2. Even with more collaborative teams in long-term care facilities, there is still a dominance of some teams; 2 kinds of team work were found: (1) collaborating around decision-making and problem solving, and (2) performing work tasks together

1. 3738 people formed potential network of residents with median of 17 people per resident 2. Actual number per resident was 2 females (daughters and friends) who visited at least once per month 3. Family members feel decreasing sense of responsibility to visit residents with dementia 4. The longer the time residents were at the RACF, less frequent were the visits, especially marked at 2 years and 4 years 5. Residents who lived at RACF longest were more likely to have severe dementia

1. Social networks of rural residents have dwindled over last 20 years in size and diversity 2. Policy and practice implications include (a) encouraging males to visit (b) identifying those at risk of low social support and ensuring maximum contact possible (c) including social network profile in admission procedures (d) addressing negative impact of dementia on frequency and quality of visits (eg, communication alternatives to verbal communication) (e) encouraging family biographies and including in individualized care plans, based on input from diversity of visitors (f) addressing barriers of distance (g) Using technology(s) (eg, social media, email to maintain contact and share photos)

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Parmenter G, Cruickshank M, and Hussain R (2012) Rural New South Wales, Australia

3. Self-completed (sociocentric) questionnaire using name recognition 4. SNA, descriptive analysis using block models

(continued on next page)

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Authors, (Date), Country

Study Design*

Participants, Setting

Network Characteristics Size and type of tie (ie, embedded, boundary crossing)

1. Interpersonal 2. Cross-sectional 3. Sociocentric (roster) questionnaires for each team; ethnography 4. SNA, multivariate analysis

380þ nursing staff across 16 psychogeriatric units in nursing homes, 10 psychogeriatric units in residential homes, 11 psychogeriatric group projects in nursing homes

van Beek APA, Frijters DHM, Wagnder C, Groenewegen PP, Ribbe MW (2011) The Netherlands

1. Interteam 2. Cross-sectional 3. Assessments of residents’ depression and social engagement 4. Bivariate and multivariate analyses

Staff members responded across 16 psychogeriatric units in nursing homes, 10 psychogeriatric units in residential homes, 11 group projects in residential homes on behalf of 502 residents for whom informed consent had been given

1. Where nursing staff had greater connection with relatives and friends of residents, they treated residents with more respect and nursing staff and residents appeared more at ease with each other 2. Connections with relatives and friends were associated with the number of times nursing staff started friendly conversations with residents and the amount of time they actively cared for residents 3. The higher staff’s identification with the organization, the higher their motivation to provide better care 4. Workload was significantly negatively correlated with nursing staff taking sufficient time for residents and the number of times staff called residents by name 5. Older nursing staff were more motivated to provide good care

Findings About Residents

Findings: Other

1. Residents are given better treatment with more motivated nursing staff

1. Social networks of nursing staff play important role in care processes in longterm dementia care 2. Care may be improved by facilitating informal communication among staff members and relatives/acquaintances of residents with dementia 3. Care may be improved by changing extra- and intraorganizational communication patterns

1. Depressive symptoms and low social engagement are important problems in longterm care settings for residents with dementia

1. Depressive symptoms are not only influenced by residents’ characteristics, but also by setting in which residents live, even when controlled for differences in resident characteristics 2. Depressive symptoms were most often found in residents of psychogeriatric residential homes 3. Neither individual resident characteristics nor the type of care setting is sufficient to explain levels of depression and levels of social engagement in long-term care settings 4. Low social engagement and depressive symptoms in residents with dementia in long-term settings are not highly correlated, indicating that separate

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van Beek APA, Wagner C, Fritjers DHM, Ribbe MW, Groenewegen PP (2013) The Netherlands

Findings About Staff

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Table 4 (continued)

*Study design legend: 1. Level of analysis (network nodes as individuals, teams, or organizations), 2. Design, 3. Method of data collection, 4. Method of analysis.

4.

3.

2.

van Beek APA, Wagner C, Spreeuwenberg PPM, Fritjers DHM, Ribbe MW, Groenewegen PP (2011) The Netherlands

1. Interteam 2. Cross-sectional 3. Sociocentric (roster) questionnaires for each team and questionnaire about work satisfaction using Maastricht Work Satisfaction scale for health care 4. SNA and bivariate analysis

347 nurses for advice networks, 380 nurses for communication networks in 3 types of long-term care settings: 1. Psychogeriatric units in nursing homes 2. Psychogeriatric units in residential homes 3. Psychogeriatric group projects in residential homes

Density

1. On units with more residents and more staff, staff communicated less with each other and less often asked each other for advice 2. Communication and advice networks were more dense when staff worked part-time 3. Older staff had denser communication networks 4. Units with dense communication networks had dense advice network 5. On units with fewer staff members, nursing staff were more satisfied with their job 6. Only communication networks were positively related to job satisfaction 7. Nursing staff communicated more with each other in group projects than psychogeriatric units

1.

interventions are needed for each Communications among nursing staff is important for job satisfaction Networks are not solely shaped by formal positions of staff members Communication and advice networks of nursing staff in long-term care are relatively dense, signaling high level of cooperation needed to provide care to resident Social networks are more dense in small units and are shaped by characteristics of staff members

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bivariate and multivariate (1). Bivariate analysis used correlations or Kruskal-Wallis tests. Table 4 summarizes the study design, analysis, data collection, participants and their context, as well as network characteristics and key findings. Residents’ varying degrees of cognitive impairment are noted, as are the different types of LTC settings. Five of the 9 articles used SNA to elicit network characteristics.35e39 Of the 9 articles, 5 focused on residents and 4 on staff. Of the latter, 1 focused on multidisciplinary groups of health care professionals37 and 3 on nursing staff only.34,38,39 Two of the 5 resident-focused articles35,36 aimed to illustrate the feasibility of including elderly residents with cognitive impairment in research. The other 3 depicted a low level of social integration among participating residents.40e42 Five of the 9 articles were based on data collected from 2 studies, one conducted in the Netherlands and the other in the United States. We decided to include the 5 articles because of their slightly different focus area and difference in findings, as depicted in Table 5. We (JM, JB) contacted authors of the Dutch studies to learn of any subsequent articles that had been published. JM approached the corresponding author of the protocol study43 who confirmed that findings had not yet been published. With respect to facilitating improvements in care, only 1 study showed empirical evidence of this.38 Evidence of improvements was based on observations in which interobserver reliability achieved a mean of 0.74 (based on the Pearson correlation coefficient). Cronbach alpha was 0.84. Another made recommendations for care based on a network structural finding of residents’ low level of social integration. Recommendations supported the empirical finding in proposing more family and friend involvement in a more socially or relationally oriented model of care. Two of the articles38,39 that adopted a sociocentric approach, combined it with collection of other data about nursing staff including an assessment of their behavior toward residents, through observation,38 their organization identification via a Dutch adaptation of Mael44 and Ashforth’s45 organizational identification scale, their work motivation using 6 items from a scale developed for measurement of work attitudes,46 and job satisfaction using the Maastricht Work Satisfaction scale for health care. Observations assisted in providing more objective data than a self-reporting survey. Organizational identification was found to result in higher work motivation and residents were given better treatment in dementia units with more motivated nursing staff. Only communication networks, not advice networks, were positively related to job satisfaction. Before residents’ participation, informed consent was gained from the resident or where their Mini-Mental State Examination (MMSE)47 score was 22 or lower, from the resident’s legally authorized representative (LAR) or equivalent. Even where a proxy or staff member was interviewed, the LAR had to have provided consent for the resident to have been included in the study.39 Two articles also gained consent from staff and participating residents to use their photographs during interviews with residents.35,36 Principally this was done to assist residents with dementia with recall. Key Network Structures We investigated network structures because effective networks have been found to adopt natural structural network features, such as size, density, centrality, and bridging or boundary spanning,12 4 features that emerged in this review. Size of the network was addressed by all but 1 article. Parmenter and colleagues45 investigated the potential and actual size of 257 resident networks across 13 LTC settings in rural Australia. Through interviews, they found that residents had the potential to have a mean of 18.7 or median of 17 people in their network, consisting of a wide range of family and friends with ages ranging from a few weeks to 100 years. Yet, the actual network was 2

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women, daughters and friends, who visited approximately once per month. For the authors, this was evidence of residents’ low level of social integration. Cheng’s41 Hong Kong study revealed an actual network size of 2.58 and a visiting frequency of less than once per month. A key difference between the studies is that Cheng41 included staff in the network. She found that neither spouse and children nor other residents were often included. Also, women were the majority actors in resident networks and the main visitors. Despite one setting in high-density urban Hong Kong and the other in low-density rural Australia, their results are very similar. One US study40 reported a similar baseline average size of 2.5 members for a health discussion network consisting of family, friends, and/or health professionals. Four percent of respondents had no network and 20% reported 4 or more in their network. The unadjusted finding was that the size of the health discussion networks decreased over time. Abbott and colleagues36 explored residents’ networks using egocentric and sociocentric approaches. In the egocentric approach, residents answered 7 questions to nominate people (actors) in their network. No restriction was applied to how many people each resident could nominate. Residents chiefly named friends and family. Some residents with dementia selected people who had died. This approach produced a potential or past network rather than a currently active network. Similar to the Hong Kong and Australian studies, some residents did not nominate anyone in their network. The US and Australian studies confirmed that residents with more cognitive and physical problems experienced less social engagement.35,36,42 In network studies, density is seen as a measure of social cohesion, hence a high-density network measurement can assume greater cohesion in the network, as its actors are all or mostly connecting to each other.48 Nursing staff in both the Canadian and the Dutch studies reported high levels of helping each other with work and close informal communication whether within their shifts37 or within the units where they worked.38,39 Both gave examples of groups of staff with the highest density of 1. For authors of the Dutch study, this signaled the high level of cooperation needed to provide care to residents with dementia.49 One study demonstrated that where employees have more connections, there is lower organization turnover.12 Two US articles35,36 investigated residents’ centrality as a measure of an individual’s social integration. They proposed that residents with high-degree centrality, that is, those with the most number of connections they nominated (outdegree), and the most number of nominations they received from others (indegree), would be effective in welcoming newer residents and disseminating information. For residents who had been used to holding positions of influence across a wide range of people before entering LTC, they could be encouraged by staff to continue a similar role within their new setting. This could be used to give them a sense of purpose, by using well-honed skills, in their new home. This finding may be applicable to people with dementia who have access to procedural memories. Kawai et al50 found that patients with dementia could retain procedural memories for extended periods, with no relationship between retention ability and disease progression. It was possible for even patients with severe dementia to acquire and retain motor-type procedural memories.50 Basic social skills are often maintained, such as welcoming and showing people around. Cott37 illustrated the bridging or boundary-spanning role that higher-status nurses played to bring about changes in their working environment. Higher-status nurses were found to have multiple formal and informal communication ties across all groups, which enabled them to act as bridges between groups. In their bridging role, higher-status nurses collaborated with the core multiprofessional team in decision-making and problem-solving. However, they maintained a clearly defined hierarchy with shift nurses, leaving shift

nurses with little control in their work environment and doing the more “dirty” work. Existing organization structures and behaviors perpetuated this arrangement. Van Beek and colleagues38 confirmed that when nursing staff had a connection to a resident’s family member, friend, or acquaintance, staff treated residents with more respect, felt more at ease with them, began friendly conversations more frequently with them, and actively cared for them. This boundary-spanning from a nursing network to a resident’s network could have been direct or indirect, as more than 1 degree of separation between the staff member and the resident was permitted. The authors proposed that the improved care could have been due to (1) contacts providing information, and/ or (2) boundary-crossing ties enhancing trust and providing opportunities for better control. However, because of their study design, they were unable to determine if the better treatment was due to either criterion. Of some note is that where boundary-crossing ties existed, a staff member was more likely to treat all residents in the unit better, not just the resident with whom the boundary-crossing tie existed. This outcome relates to Granovetter’s51 discovery of the strength in weak ties, where low density in networks of socially distant actors is more effective in information exchange and innovation than a high-density network of socially distant actors. It also aligns to Burt’s52 insight that a network in which a person has contacts with few others who provide unique information, is more productive than a network in which one has many connections who provide the same information. Parmenter and colleagues42 supported these boundary-crossing findings with recommendations that nursing staff actively create opportunities to connect with members of a resident’s social network. For example, they recommended that staff collaborate with residents’ family or friends to create resident biographies to be placed in residents’ care plans and generally encourage family and friend visitation, that alternative forms of communication be used with aphasic or dysphasic residents (eg, massage, manicure, or reading to them), and that strategies be devised to increase male visitor participation, such as residents’ family members to be on advisory board(s) and involved in fundraising. Discussion The Findings in Context The review investigated empirical research of social networks in LTC to see if any were exploiting network structures to achieve better care for residents. Only one study provided evidence of staff’s boundary-spanning to a resident’s network that resulted in staff treating residents better and more respectfully.38 Another made recommendations for staff to engage specifically with residents’ key social connections and to learn more about a resident’s life history and include this within the resident’s care plan. The remaining articles specified structures (size, density, centrality, and boundary-spanning) that have been designated as facilitators of improved health and clinical care in other settings.12 In investigating resident networks, 2 key findings were the low number of residents’ social connections and methodological implications for involving people with cognitive impairment in research. The finding of a low level of resident social connections identified in 6 articles, was proffered as placing residents at risk of social isolation. Research in the past 25 years has associated objective social isolation and less social integration among individuals with less psychologically and physically healthy outcomes.53 Research has measured isolation in terms of an individual’s perception of being socially isolated, as individuals can feel lonely in a marriage, friendship, and at work54 (ie, not all perceived isolation is objectively true).

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Table 5 Rationale for Including Multiple Projects From Same Studies Location

Article

Focus Area

Netherlands

Van Beek et al 2013

Communication networks among staff as well as a connection between staff and relatives/acquaintances of residents with dementia, with regard to staff’s behavior toward residents with dementia, as well as staff motivation Communication and advice networks among nursing staff in relationship to size of 3 different types of dementia residential units, characteristics of nursing staff, and their job satisfaction Social engagement and depressive symptoms among (1) different dementia residential units, (2) composition of the resident population, and (3) differences in care setting of the residential units Feasibility of measuring ego and sociocentric networks among residents of one assisted living neighborhood and a dementia careespecific unit Development and evaluation of an approach to measure social integration among older adults in an assisted living neighborhood

Van Beek et al 2011 (35 units) Van Beek et al 2011 United States

Abbott et al 2013 Abbott et al 2012

Perceived social isolation was associated with negative mental and physical health effects, such as increased sleep fragmentation55 and changes in psychological states contributing to lower subjective wellbeing, heightened vigilance for social threats, and reduced executive functioning.54 We note that social isolation due to a personality trait such as introversion, is rarely associated with these negative conditions.53,54 Social networks were used in 5 of the reviewed articles35,36,40e42 to ascertain that objective isolation is an issue for the people with dementia who took part. The possibility of intervening and changing this objective isolation has the potential to affect outcomes. Although there is no evidence as yet that greater social integration can reduce BPSD, current management of behaviors with psychotropics can limit a resident’s opportunities for increasing or even maintaining social interactions. For instance, the resident may be too drowsy on a psychotropic medication to interact with other residents or staff, or be transferred to an acute hospital due to injuries caused by falls. Even the way a fall’s risk is managed may restrict residents’ freedom of mobility and isolate them from familiar faces. It may be useful to examine the effect of a social network approach to BPSD. Expert consensus guidelines recommend the use of multidisciplinary, individualized, and multifaceted care including psychosocial interventions for BPSD. Short-term pharmacological treatment, such as atypical antipsychotics, is recommended only when necessary, typically for safety.56 A psychosocial approach was exemplified in the recommendations from the study in rural Australia and the personal information that Dutch nursing staff received about residents in their care. Yet, despite considerable research evidence showing the effectiveness of a multidisciplined approach that includes psychosocial approaches, uptake has been slow. Cunningham et al12 noted that a delay in the adoption of evidence-based guidelines has been hindered by an overreliance on the attributes, knowledge, decision-making, and actions of individual clinicians, and an underrecognition of the network of care within which they operate. Insights from this review infer that successful biopsychosocial interventions could be facilitated through engaging the full network of care within LTC. Three structures identified in this review (centrality, density, and brokerage or boundary-spanning) were instrumental in successful change occurring within an existing organization structure.57 If adopted, social-networking structures could facilitate the development, implementation, measurement, and ongoing improvement of biopsychosocial approaches. With reference to cognitively impaired people participating in SNA research, the US study36 demonstrated that it was feasible to include them in research even with an MMSE of 11 and age range of 82 to 96. The researchers helped facilitate a successful outcome through the use of egocentric and sociocentric approaches, the use of staff and other resident photographs in the sociocentric approach, as well as great care to ensure that this group did not incur respondent fatigue. The inclusion of these residents aligns to research in the past 2 decades

that recognizes that people with dementia are able to contribute to research that is about them.58,59 Implications of the Review This article has highlighted the importance of social networks in care. Implications for policy, research, clinical care, and education emerge from the review, especially around the role of network structures, the low level of resident integration, and the inclusion of those with cognitive impairment in research. The following are presented as a basis for further discussion. In relation to network structures, first, LTC policy could be adjusted to seek out staff members who are the most connected, and then support and encourage their social centrality or boundary-spanning. To operationalize this, relevant staff could be given training, mentoring, and targeted experiences to enable them to be even more effective, for example to ensure the right messages and the right behaviors are promulgated. Reflective practice also would be encouraged. Other mechanisms to operationalize the role would include support from executive management or other relevant authority, an appropriate reward that is meaningful to the staff member and a revised job description to reflect new responsibility, which would then be reflected in their performance plan. Abbott and colleagues35 noted that staff with high centrality need not occupy a prominent place in the organizational hierarchy. Further research into network structures could investigate how social networks improve staff’s workplace experience, enable better care for residents, and contribute to organizational success in a constantly changing environment. Studies could incorporate longitudinal studies and those with a control group. Statistically significant numbers are also needed. Research also could be done not just at the actor level, but could investigate interorganization networks in this sector and their effect on care outcomes. This could be revealing in terms of information and innovation flows, key players, and those more isolated. In relation to clinical care, network structures could assist in the cost neutral roll-out of biopsychosocial approaches to care. One example that supports that a cost-neutral roll-out is feasible is a randomized controlled study that concluded that the modest decrease in cost per unit reduction in agitation with personcentered care was sufficient to warrant its systematic introduction into LTC services.3 The planned use and fostering of network structures, such a density, boundary-spanning, and centrality, could facilitate the uptake of a more evidence-based, person-centered approach to care. Review findings and associated references attest that both social and clinical knowledge of residents are needed before residents’ entry into LTC. Case conferences could commence before residents’ entry and include the resident and primary person(s) responsible so that staff receive both social and clinical knowledge briefings. A resident’s life and social history also could be made known to health professionals and paraprofessionals who visit the resident to facilitate

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more meaningful and supportive conversations with residents, as residents with dementia may not be able to initiate conversations and may have difficulty answering direct questions. Staff training could be provided on the benefits of networking, and how to approach people in other professions and/or the resident’s family, as many people have difficulty engaging with people from different backgrounds and worldviews from their own. Implications at the policy level to address low levels of resident social connections could include a review of current LTC accreditation processes with a view to incorporating a focus on a more biopsychosocial approach to care. This may involve consideration of the residents’ level of social integration, their involvement in LTC life, and what is being done to support them in their ongoing social integration, whether internally within the facility or with external parties such as family/friends or the adoption of support, such as the Consumer Directed Care packages in Australia, which are currently offered only in community settings. Preentry case conferences with the resident and/or prime person(s) responsible, as well as the inclusion of a resident’s social profile and life history in care planning, also could be monitored. The suggestion of Parmenter and colleagues42 of an organization facilitating transport arrangements so that elderly family and friends could still visit residents would be a simple way to increase residents’ social connections. This and similar initiatives could potentially have implications for local governments and LTC management. In addition, clinicians or other responsible staff members could be responsible for identifying those with the lowest social integration and exploring options for more social engagement. Limitations of the review were the small number of articles, the heterogeneity of the articles, and in the case of the article that related directly to residents’ care, an average response rate of 47%. Other limitations were the early difficulty in finding the right search terms to obtain relevant articles and the inclusion of only Englishlanguage articles. The former was overcome by moving away from the word “dementia” and the phrase “social network analysis” to adopt the terms in Table 1. Nevertheless, the review demonstrated the potential of a social network approach to affect outcomes for residents in LTC and that residents with dementia themselves can be included.

Conclusion The review has highlighted that the adoption of an SNA to facilitate the improvement of care to residents in LTC has not yet made the same progress as in other health and clinical settings, where studies have linked network structure to evidence of outcomes. Only one study has provided evidence that nursing staff’s connections with family and friends of residents resulted in improved care to that resident and to other residents in the same unit. A second study supported this empirical finding by recommending ways for staff to know more about a resident’s history and preferences and to involve friends and family in the resident’s ongoing care. Desirable characteristics of network structures necessary to improve care (size, density, centrality, and bridging or boundary-spanning) have been established in other health and clinical care settings. That residents with cognitive impairment could participate in research about them is a big step. Their inclusion here invites opportunities for this cohort to be more engaged in both other social network research as well as research about their care and well-being. The LTC sector appears only likely to benefit from further investigation into the development and implementation of health and clinical networks in other settings and to foster more research in its sector, especially to tackle “wicked problems” in long-term dementia care, given forecast numbers and costs.

Acknowledgments We greatly appreciate the support of Anne-Nicole Casey and Katrin Seeher for assisting the review.

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