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Dementia 2021, Vol. 0(0) 116

© The Author(s) 2021 Article reuse guidelines:

sagepub.com/journals-permissions DOI: 10.1177/14713012211053979 journals.sagepub.com/home/dem

You can tell it works –

Experiences from using the VIPS practice model in primary

healthcare

Marit Mjørud

Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway

Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway

Janne Røsvik

Norwegian National Advisory Unit on Ageing and Health, Tønsberg, Norway

Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway

Abstract

Introduction:Person-centred care is a philosophy rather than a method ready for implementation and utilization in daily clinical work. Internationally, few methods for person-centred care have been widely adopted in clinical dementia care practice. In Norway, the VIPS practice model is one that is commonly used for the implementation and use of person-centred care in primary healthcare.

Method:Nursing home physicians, managers and leaders in the municipalities, care institutions and domestic nursing care services were eligible for inclusion if their workplace had implemented and used the VIPS practice model for a minimum of 12 months. Individual interviews were conducted via Facetime, Skype or telephone and analysed with qualitative content analysis.

Findings:In all, 20 respondents were included: one manager of health and care services in the municipality, six managers and leaders working in domestic care or daytime activity centres and 10 managers/leaders and three physicians working in nursing homes. Two global categories emerged: category 1: Change in staff’s professional reasoning with two sub-categories: (a) an enhanced professional level in discussions and (b) a change in focus from task to person; and category 2:Changes in the clinical work, with three sub-categories: (a) effective interventions, (b) a person-centred work environment and (c) changes in cooperation between stakeholders.

Corresponding author:

Marit Mjørud, Vestfold Hospital Trust, Norwegian national advisory unit on Ageing and health, Postboks 2136, Tønsberg 3103, Norway.

Emailmarit.mjorud@aldringoghelse.no

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Conclusion:Regular use of the VIPS practice model appeared to change the work culture for the benefit of both service users and frontline staff. Increased cooperation between frontline staff, nurses, physicians and next of kin was described. Staff were more focused on the needs of the service users, which resulted in care interventions tailored to the needs of the individual with dementia, loyalty to care plans and fewer complaints from next of kin.

Keywords

dementia, person-centred care, person-centred work culture, consensus meeting

Introduction

Person-centred care, as described byKitwood (1997), is promoted by several dementia guidelines (National Institute for Health and Care Excellence (NICE), 2006;Norwegian Directorate of Health, 2017;Socialstyrelsen, 2017) and national policy statements (Norwegian Ministry of Health and Care Services, 2015,2018). Acknowledging each person’s personhood, that a person is to be met with respect and as valuable person regardless of age and cognitive abilities, is the essence of person- centred care. Kitwood emphasizes five basic psychological needs: comfort, occupation, identity, inclusion and attachment. Disregard of these needs, Kitwood calls malignant social psychology, while supporting these needs he calls positive person work (Kitwood, 1997). Another tenet of the person-centred care philosophy is to take into consideration the perspective of the person with dementia (Kitwood, 1997) when planning individual care interventions. To be able to do this, staff must become well-acquainted with the person with dementia; it is important to have knowledge and understanding about the person’s health, personality, life history and present situation. By meeting their needs, learning to interpret their non-verbal signals and adjusting care to their individual rhythms and preferences (Cameron et al., 2020;Vassbo et al., 2019) through person-centred care, staff can develop close relationships with those who have dementia and with their next of kin as well (Eldh et al., 2016).

However, person-centred care is a philosophy of care rather than a model ready for im- plementation. According to Kitwood, person-centred care comprises care for the frontline staff in a workplace as well as for the people with dementia. Factors central to creating a work culture of person-centred care are structured teamwork, training and supervision and supportive leadership (Kitwood, 1997).

In line with this, healthcare personnel have described bonding with other team members (Eldh et al., 2016) and working toward a collective practice in affirmative, collaborative teams (Eldh et al., 2016;

Kim & Park, 2017;Vassbo et al., 2019) as important prerequisites for providing person-centred care to people with dementia. In addition, job satisfaction, thriving at work and experiencing a sense of vitality and learning (Gilster et al., 2018Vassbo et al., 2019) have been found to affect staff attitudes toward people with dementia (Jeon et al., 2012;Moyle et al., 2011;Wallin et al., 2012). Regarding training and supervision, qualified healthcare personnel are essential to the provision of quality care in both domestic care and long-term residential care (Gilster et al., 2018;Kim & Park, 2017).

To promote person-centred care, management and leaders should cultivate a positive and supportive psychosocial climate where staff have autonomy in their daily tasks (Eldh et al., 2016) and experience a sense of balance between demands and control in their work (Sjogren et al., 2015).

Among people with dementia in nursing homes, person-centred, non-pharmacological inter- ventions have been found to increase quality of life (Ballard et al., 2018;Rokstad et al., 2013) and to reduce neuropsychiatric symptoms such as agitation (Ballard et al., 2018;Fossey et al., 2006;Kim &

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Park, 2017;Rokstad et al., 2013). However, very few studies have described the effect of person- centred care interventions on home-dwelling persons with dementia (Kim & Park, 2017). In- dividually tailored care may reduce challenging behaviour and may also slightly improve quality of life (Kim & Park, 2017; Mohler et al., 2020). Many home-dwelling people receiving domestic nursing services have non-medical, unmet care needs, for instance, regarding management of neuropsychiatric symptoms (NPS) (Black et al., 2019). Living with unmet needs for care represents a serious risk to their well-being and may increase the burden of care on the informal caregiver (Aaltonen & Van Aerschot, 2019).

Person-centred care has also been associated with reduced use of psychotropic drugs (Ballard et al., 2018;Fossey et al., 2006), and deprescribing these drugs has been found to be associated with improved communication among staff and between staff and the person with dementia (Harrison et al., 2019).

As described, models for implementing person-centred care are effective on outcomes related to both people with dementia and healthcare personnel. Most of this body of evidence, however, describes models that are research projects that end when the researchers leave. Few evidence-based interventions or methods for implementing person-centred care have been widely adopted and used by clinicians in clinical care practice daily over time. However, prior research tells us that team- based methods promoting learning and skill development in the frontline staff group (Ballard et al., 2018;Gillis et al., 2019;Kim & Park, 2017) are effective for ensuring sustainability.

The VIPS practice model (VPM) (Rosvik et al., 2011; Røsvik et al., 2013) is a model for implementing the person-centred care philosophy of Kitwood (Kitwood, 1997). VPM, described in the method section, has been in use in both domestic nursing and long-term residential dementia care units since 2011. Barriers and facilitators for the implementation of the VPM are described elsewhere (Rosvik & Mjorud, 2021).

The aim of this study is to explore managers’, leaders’and nursing home physicians’experiences of using the VIPS practice model for person-centred care as part of daily operations in dementia care units on a regular basis for more than 12 months.

Method

Setting

In Norway, healthcare is public andfinanced by the tax system; hence, most primary-care services are publicly owned and operated. Approximately 9% of these services are run by private non-profit or for-profit healthcare providers (Statistics Norway,https://www.ssb.no/en/helse/statistikker/pleie, 2020). The municipalities provide domestic nursing, daytime activity centres and long-term nursing home care to all people in need of these services. All counties have publicly funded centres for service development in institutions and home care (Centre for Development of Institutional and Home Care Services, 2020), providing professional supervision to the primary-care services in their affiliated municipalities. In Norway, there are approximately 101.000 persons with dementia (Gjøra et al., 2020). About 60% of frontline staff in the nursing homes is auxiliary nurses.

The VIPS practice model

Developed in Norway, the VIPS practice model (VPM) (Rosvik et al., 2011;Røsvik et al., 2013) is a model for implementing person-centred care (Kitwood, 1997). The VPM can be classified as a case conference model, which is a model for evaluating individual needs of people with dementia. Case

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conference models have been found to have positive effects on neuropsychiatric symptoms and can be used to facilitate communication and coordination between the staff (Kales et al., 2014;Nakrem et al., 2019).

The VIPS practice model is used in nursing homes and sheltered housing, at daytime activity centres for home-dwelling people with dementia, and in domestic nursing. The VPM is based on Kitwood’s factors for a person-centred work culture mentioned above (Kitwood, 1997). The hub of the VPM is a weekly consensus meeting. Participants in the consensus meeting are the head nurse and the frontline staff, who have established roles and functions in the VPM (seeText Box 1). They discuss one concrete, delineated care situation, for example, that a person with dementia resists morning care or does not open the door to let the nurses in when they come to visit. The consensus meeting adheres to afixed structure. The structure ensures that the situation is discussed from the perceived perspective of the person with dementia, and that the situation is thoroughly analysed before decisions about care interventions are made. With support from the head nurse, the meeting is chaired by a representative of the largest professional group in the frontline staff, a role called the resource person (RP). In nursing homes, the RP is usually an auxiliary nurse; in domestic nursing, it is usually a registered nurse. The starting point for the discussion is the RP explaining the situation to be discussed during the meeting. Then, the primary contact describes how she/he believes the situation is experienced by the person with dementia (seeText Box 1). To do this, the primary contact should use existing knowledge of the person, including knowledge of neurological impairment (dementia symptoms), health condition, relevant life history, personality and social needs, as de- scribed byKitwood (1993). Before the meeting, the primary contact should have (a) observed the situation; (b) talked to the person and, when relevant, to his or her next of kin and (c) assessed the situation with the use of relevant observational tools. In addition, information about the situation from frontline staff who are not present at the meeting should have been collected. Next, the rest of the staff give their views of the situation. The VIPS framework (Brooker, 2007), which encompass Kitwood’s philosphy tranformed into practical indicators, is used as an analytic tool. Interventions are then agreed upon, documented in detail, implemented and evaluated on a set date.

To use the VPM, the staff who will have roles in the consensus meeting must attend a two-day basic course; this includes the RP and the head nurse and preferably the registered nurse who is responsible for professional development in the workplace. Those who do not participate in the two- day course must attend a three-hour introduction to person-centred care and the VPM. However, many workplaces choose to present the two-day basic course to the whole staff group. The VPM basic course is facilitated by the municipality or county and is conducted by a VPM course instructor.

Healthcare personnel with a bachelor’s degree or higher is eligible to attend the two-day VPM instructor course. Typically, workplaces train their own VPM course instructor, usually a manager, head nurse or registered nurse responsible for professional quality and development at the workplace. To standardize the course, a booklet describes it in detail and all lectures are pretaped.

The course instructor receives online access to all course materials. The Norwegian National Advisory Unit on Ageing and Health is responsible for the VPM instructor courses.

A randomized controlled trial (Rokstad et al., 2013;Røsvik et al., 2013) found that people with dementia living in nursing home units where the VPM was used had significantly lower levels of depression as measured by the Cornell Scale (CSDD) (Alexopoulos et al., 1988) and fewer neuropsychiatric symptoms as measured by the neuropsychiatric inventory (NPI) (Cummings, 1997) compared to the control group.

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Participants

Managers at all levels in the municipality or organization were eligible for inclusion. In this case, those included were municipal administrative nursing care managers, institution administrators, leaders of home-based service districts, head nurses, professional development nurses and project leaders in organizations/institutions as well as nursing home physicians (seeTable 1for respondents’

characteristics). The sole inclusion criterion was that participants’(informants’) workplaces had implemented the VPM and conducted the consensus meeting regularly for a minimum of 12 months.

In all, 18 women and two men from 10 municipalities were included; their ages ranged from 30 to 65 years. In the table below, the term‘manager’refers to the administrative level, while the term

‘leader’refers to the organizational, clinical level.

Inclusion process

Dementia resource centres and Centres for the Development of Institutional and Home Care Services in all Norwegian counties were contacted by email and asked to provide a list of workplaces that had used VPM for more than 1 year. Management at one nursing home was contacted directly because the authors had information about how long they had used the model. Managers at all levels and affiliated nursing home physicians who were named were then invited by email to participate in the study. This resulted in the inclusion of seven leaders and one physician (eight in all) from three workplaces. To increase the inclusion rate, all who had attended a VPM instructor course were contacted by email and invited to participate. They were also asked to forward the invitation to workplaces they knew were using the VPM but did not have their own course instructor. This resulted in the inclusion of 12 respondents. When the interviews started, a total of 20 respondents were included: 17 managers and leaders and three nursing home physicians, representing 10 workplaces/municipalities. An additional three leaders replied by email that they were willing to be interviewed, and their names were added to a waiting list. However, after 20 interviews with managers, leaders and physicians, no new information emerged and saturation was reached;

therefore, the leaders on the waiting list were not included.

Consent statement. All respondents who replied they would participate received information about the study along with an informed consent form by email. All respondents provided a signed consent statement.

Data collection

An interview guide was developed based on the aim of the study and sent by email to the respondents a week before the interview (seeText Box 2). Individual interviews were conducted via Facetime, Skype or telephone. Both authors participated in the interviews, which were tape-recorded and lasted approximately 30 min; the shortest lasted 16 min and the longest 49 min, with a mean of 27 min. One respondent had a hearing impairment and replied in writing by email. Transcription was done verbatim, and the audio and transcribedfiles were stored in a research server and were accessible only by the two authors.

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Analysis

NVivo version 12 PRO was used to support the analysis. Qualitative manifest content analysis was chosen, which implies staying close to the text and describing the visible and obvious (Elo &

Kyngas, 2008;Graneheim & Lundman, 2004). Open coding was applied because predetermined categories were not considered to appropriately reflect the respondents’experiences of using the VPM. Coding categories were derived directly from the text data (Hsieh & Shannon, 2005). To extract the content, meaning units (e.g. sentences and paragraphs) were labelled with codes. Based Table 1. Characteristics of respondents.

Informant

#

Municipality

# Workplace Work position Profession

VPM course conductor

8 1 Nursing home Manager of three

institutions

Registered nurse No

5 1 Nursing home Head nurse Registered nurse Yes

6 2 Nursing home Institution manager Registered nurse No

4 2 Nursing home Head nurse Registered nurse Yes

7 2 Nursing home Nursing home

physician

Physician No

3 3 Sheltered

housing

Project leader Registered nurse Yes

2 3 Municipality Manager of health and

care services

Administrative education

No

1 3 Domestic

nursing

Manager home care services

Registered nurse No

9 4 Nursing home Nursing home

physician

Physician No

10 5 Nursing home Head nurse Registered nurse Yes

11 6 Day-care activity

centre

Manager of day-care services

Registered nurse No

12 7 Nursing home

(private)

Professional

development nurse

Registered nurse Yes

14 7 Nursing home

(private)

Head nurse Registered nurse No

15 7 Nursing home

(private)

Head nurse Registered nurse No

16 8 Domestic

nursing

Project leader at municipal level

Registered nurse Yes

17 8 Domestic

nursing

Head nurse Registered nurse No

18 7 Nursing home

(private)

Head nurse Registered nurse No

20 9 Nursing home Professional

development nurse

Registered nurse Yes

21 10 Domestic

nursing

Head nurse Registered nurse No

22 1 Nursing home Nursing home

physician

Physician No

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on the codes, categories and sub-categories were developed describing the manifest content of the transcripts (Graneheim & Lundman, 2004). The categories were used to further analyse the in- terviews and were modified when appropriate. In the interpretation of the data, the two researchers discussed and reflected upon the categories and sub-categories (Graneheim & Lundman, 2004). The interviews were then reread to see if any new understanding of the material emerged from the meaning units. Thefinal categories and sub-categories were discussed in light of the aim and the context of the study, and global categories were developed after reviewing the structure of the categories. The credibility of the interpretation was established by grounding the meaning units in the text using quotations from the respondents.

Both authors participated in the analysis. If the authors disagreed about an interpretation, they discussed it until consensus was reached. A third party could be consulted in the event that the authors failed to reach an agreement, but this did not happen.

Findings

In the transcribed interviews, two global categories emerged: (1) change in staff’s professional reasoning, with two sub-categories: (a) an enhanced professional level in discussions and (b) change in focus–from task to person; and (2) change in the clinical practice, with three sub-categories: (a) effective interventions, (b) person-centred work environment and (c) change in cooperation between stakeholders (seeTable 2Findings).

Domestic and institutional care managers and leaders described similar experiences; thus, no clear divide between the two types of services emerged. Naturally, the nursing home physicians described experiences related to the use of VPM in nursing homes. Their contributions supported the information provided by the nursing homes’head nurses.

1. Change in staff ’ s professional reasoning – You must learn to think in a completely different way, and it is not done overnight

Having time set aside for weekly professional meetings that focussed on care planning resulted in a larger number of professional discussions.

1a. An enhanced professional level in discussions. The informants reported that gathering information to prepare for the VPM consensus meetings and focussing on one concrete situation at a time helped them to gain an overview:Things are more manageable when you work with it like that(#21). The meeting structure required the frontline staff to constrict and delineate the situation at hand:We use

Table 2. Findings.

Category 1. Change in staff’s professional reasoning –You must learn to think in a completely different way, and it is not done overnight

2. Change in the clinical work –more committed to implementing interventions, observing their effects and evaluating the results

Sub-categories a. An enhanced professional level in discussions

a. Effective interventions

b. Change in focus–from task to person b. Person-centred work environment

c. Change in cooperation between stakeholders

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time to describe the problem. We manage that quite well. (…)…this phase is important. (...) instead of just jumping to conclusions about interventions(#5).It (the structure) gets people back on track if it (the focus of the discussion) is derailed(#18). Through the meetings, the frontline staff developed their understanding of how the person’s life history might affect behaviour and increased their awareness of changes in the condition of each person with dementia. They became skilled in verbalizing their perception of how the person with dementia might experience the situation that was the focus of concern: We see that the staff is more trained in seeing beyond the behaviour and understand it, in a way. (…) Over time, this permeates their attitude and thinking(#6). Because the entire staff group attended the meeting, several perspectives and observations of a situation were presented:…People observe different things. They have different thoughts about why things are the way they are(#12). This broadened the scope of the reflection and enhanced the professional level of the discussion:I see it clearly in the staff group when we have the‘rounds’…to take part in a group (discussion) like this and talk about the right things in the team…it does something to our heads (#21). The staff learnt to be proactive and to implement interventions that were designed to prevent the person with dementia from becoming frustrated and to avoid precarious situations:issues (are) being solved before they become problems(#6).

1b. Change in focus–from task to person. One of the informants stated:Being part of this has made me more interested in dementia(#17). The change in professional reasoning had resulted in the staff altering their views of what should be given priority in their daily work. The informants experienced that the time used for reflection and discussion had influenced the staff’s way of working:(It) strengthened the staff’s ability to consider individual needs more and to be less restricted by unit routines, I would say(#6).

Several informants described how they could observe the effect of this shift in staff’s priorities:(I can see it) particularly in the people with dementia who might not manage to put it into words; they have found a (sense of) calm. The unit is more peaceful. It has become more like a home. They do not have to take a shower at 8 a.m. on Wednesday because that suits us, as it used to be(#1).

The informants also experienced that the staff had become more empathic:They are much better at understanding what the residents need and acting on that(#1); andthere is more focus on activity and helping the residents to experience meaningful days(#5). This was supported by the nursing home physicians, who described frontline staff who had expanded their knowledge (#7) and at- tempted to understand what it is like for the person to be in the nursing home (#9).

2. Changes in the clinical work – more committed to implementing interventions, observing their effects and evaluating the interventions

This category had three sub-categories: (a) effective interventions, (b) person-centred work en- vironment and (c) change in cooperation between stakeholders.

All informants reported that using the VPM had changed how the clinical work was organized in the units, as well as the staff’s professional conduct. They experienced that the frontline staff were more coordinated in their approach to care situations. Because the structure of the consensus meeting required it, interventions were systematically evaluated to a greater extent than before.

2a. Effective interventions. Identifying successful interventions for each situation and each person with dementia was challenging and difficult work. Sometimes the staff had to discuss situations and evaluate interventions several times before they found effective solutions, but they usually suc- ceeded in the end. The physicians did not participate in the consensus meetings on a regular basis.

One expressed a minor concern that, occasionally, the staff waited too long to consult him when they

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struggled tofind solutions that worked:Sometimes I got involved later in the process than I would prefer(#7).Interventions agreed upon in the consensus meetings were describedas more accurate non-pharmacological and psychosocial interventions than how it used to be (#15), and other interventions than medication were used more often(#22). Without research to refer to, an informant stated:statistically, we use less medication(#15).This pertained to psychotropic drugs in particular, and this change was affirmed and supported by the nursing home physicians.

In line with the structure of the consensus meeting, the interventions were described in detail.

Some units had made alterations in their documentation system to ensure that it was convenient and easy for staff to update themselves on changes in the care plan for each person with dementia. Some informants also found that the frontline staff weremore committed to implementing interventions, observing their effects and evaluating the interventions(#20) agreed upon in the consensus meeting;

these were given a higher priority among the staff than care interventions decided upon before they started using the VPM.

In the nursing homes, the physicians described that, in the frontline staff group, there used to generally [be] a challenge (...) to be loyal to a treatment plan until a new assessment was made(# 7).

This was explained withpoor understanding [in the staff group] on how to approach a person with dementia or a physically ill person(#9). The physicians found that this had changed for the better after the implementation of the VPM.

2b. Person-centred work environment. Working in a person-centred way improved the work envi- ronment for the staff:There is less back-biting (now); the staff’s work climate is much better; they are singing and humming(#4). An informant referred to a member of staff who had said:Before, I did not enjoy my work, but after the implementation of this (VPM), I come to work feeling uplifted and that we do something really good(#3). Some informants also had the impression that staff sick leave had been reduced.

All informants said that the communication between staff in staff meetings had changed:

(Earlier) only the same persons talked, while the others easily became passive listeners(#21).The established roles made it easier for everyone to take part and contribute:The experience of being a valuable employee and reflecting upon care situations together with the group…it helps to create a shared value base and attitudes(#8). The informants had observed that, previously, some of the frontline staff used to feel alone and as though they were struggling on their own tofind effective solutions. Sharing their challenges regarding the person with dementia as well as their experiences and knowledge of dementia care resulted in the staff feeling supported in their work.

In both institutions and domestic care, the function of the primary contact shifted from per- forming merely practical tasks to being the spokesperson for the person with dementia. For the auxiliary nurses, this meant a higher standing in the unit, and it was recognized as important by the informants to not underestimate them as professionals(#20). Units that had not previously had a primary contact system implemented this. The primary contacts were more often in touch with the resident/service user’s next of kin.

2c. Change in cooperation between stakeholders. The informants described improved cooperation between the different stakeholders in the workplace, namely, the physician, RNs and auxiliary nurses and next of kin.

All informants reported fewer complaints from the person with dementia’s next of kin. Two reasons for this were elucidated: (1) the next of kin received information about the person and about changes in medication on a more regular basis and (2) the healthcare staff were more concrete in their requests for information and, in addition, asked for advice more often.

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In the nursing homes, both head nurses and physicians described a change in the cooperation between staff groups. The physicians saw the benefit of attending some meetings, but none attended all the consensus meetings:If the physician is involved in such things, then we are quite dominating (#7). They sometimes offered suggestions for the agenda:Can you please discuss this at the next VIPS meeting and get back to me?(#22).

When pertinent, assessment scales had been completed and information collected from both the person with dementia and, when relevant, the next of kin before the doctor’s visit. Because the staff had acquired a larger amount of information about the resident through their observations and assessments, the physician could use his/her time differently, and the amount of time for doctors’

visits could be reduced.

The physicians experienced that the staff were more consistent in the information and assess- ments presented to them:The information (…) is more consistent and comprehensive. It has been a challenge that one (nurse) describes it one way and another nurse describes it differently(#7), but it may be a little less so now than it was before(#9).

At both the morning reports and the doctor’s visit, the agenda had changed: Because there was less agitation in the units, less time was spent on discussions about agitation, which earlier used to be discussed all the time. There were also fewer requests for medication prescriptions, in particular, psychotropic medications and referrals to old-age psychiatry:In fact, (we) need much less supervision from the specialist health service because the things the specialist health service would call for are already done(#7). The informants also reported fewer petitions for the use of constraints or coercion.

Discussion

This study aimed to describe the experiences of managers and leaders in domestic nursing services and nursing homes that had used the VPM regularly in their daily clinical work for more than 12 months.

The experiences of nursing home physicians were also documented. Two main categories emerged:

changes in staff’s professional reasoning and changes in the clinical work. Thefirst category described an enhanced professional level of discussion and a shift in staff focus from task to person. The other category described how the VPM resulted in more effective care interventions, led to a person-centred work environment for staff and improved cooperation between various stakeholders.

The enhanced professional level of discussions was reported by the informants from both the institutions and the home care units. The change may be a result of participating in consensus meetings over time, where the frontline staff share their experiences and their knowledge of the person and the situation with colleagues. To have knowledge is to be able to give a theoretically sound recapitulation of a matter, in this case, of what person-centred care is. Competence is the ability to see how knowledge is relevant in concrete situations and to apply it appropriately. In- terpreting spoken words and subtle signs that, in a person with dementia, may initially seem in- comprehensible can be demanding (Vassbo et al., 2019). In the VPM, the staff are trained to use the knowledge they have about the person’s dementia symptoms, present health status and life history to talk to the person and observe his/her body language in order to present what they think may influence behaviour in the situation being discussed. The process of structured observations of the person with dementia and the use of knowledge and discussions in the consensus meeting may have helped staff to develop their abilities to interpret what they observe (Cameron et al., 2020). By participating in the consensus meeting, staff learnt to delineate the situation and analyse it using the VIPS framework. This may have helped the staff to focus on and be aware of more aspects of the situation at hand, which in turn may have broadened the scope of the discussion. It may be argued that the increased competence led to a shift in focus from the task to the person.

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We do not know why the interventions agreed upon in the consensus meeting were implemented more faithfully than was the case for those decided upon in other fora. One explanation might be that the shared decision-making process in the consensus meeting resulted in a convergence of opinions (Whitney et al., 2008). Another might be that the participation in an affirmative team (Eldh et al., 2016; Vassbo et al., 2019) contributed to a unity in the staff group that lent legitimacy to the interventions it decided upon (Rosvik et al., 2011). Deliberations were based on an analytic process, in addition to the experience and knowledge of the entire staff group, rather than on the assumptions of just one or two members of staff. It may be easier to comply with decisions when individuals have been asked for their opinions and know the rationale behind the decisions.

As described byKitwood (1997), structured teamwork, training and supervision and supportive leadership are key elements in securing a person-centred care culture. The informants described the development of a more person-centred work environment. Previous research has found that assuring quality dementia care means ensuring a supportive atmosphere that appreciates staff contributions, recognition from leaders and co-workers, sufficient training and opportunities for career growth (Eldh et al., 2016;Gilster et al., 2018;Vassbo et al., 2019). The roles in the consensus meeting confer responsibility and status to members of staff who may previously have felt ignored or were hesitant to voice their opinions in a group (Rosvik & Mjorud, 2021).

Relational aspects and cooperation between the stakeholders can affect the care and treatment offered in nursing homes (Eldh et al., 2016;Melby et al., 2019). The described cooperation between stakeholders and its effect on the medical treatment in the present study is interesting and should be further studied, as a lack of cooperation between stakeholders in Norwegian nursing homes has been described in research literature (Fosse, 2018;Melby et al., 2019). Both nutritional practices (Kuven

& Giske, 2017) and approaches to the treatment of depression (Iden, 2015) have been found to be influenced by how the stakeholders cooperate. In home-dwelling people with dementia, next of kin often play a major role in identifying and addressing the unmet needs of dementia care recipients (Aaltonen & Van Aerschot, 2019;Black et al., 2019). The communication between the primary contact and next of kin with the aim of gathering information about situations discussed in the VPM consensus meeting may explain the improved cooperation between these two stakeholders found in the present study. There is little research about this, but discussing care situations and reaching conclusions regarding care interventions in cooperation with peers may have the effect of making staff feel better prepared to provide quality care for the person with dementia as well as the ex- perience of being supported in their work.

As this was a qualitative study, we cannot quantify or refer to statistical significance regarding the reportedfindings of less use of medications and psychotropic drugs, improved job satisfaction or a reduction in complaints from next of kin. However, these were described by managers, leaders and the nursing home physicians. Thesefindings align with previous research that has found that the use of person-centred care is associated with deprescribing psychotropic drugs (Ballard et al., 2018;

Fossey et al., 2006) and improved communication among staff and between staff and the person with dementia (Harrison et al., 2019).

Strengths and limitations

Only service locations that had used the VIPS practice model for at least 1 year were included, and the experiences from service locations that failed to implement the VPM were not obtained.

However, purposive sampling was used in this study because the aim was to explore what happened in dementia care units where the model had been used regularly for more than 12 months. The informants had received the questions in advance and were notified that the authors were interested

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in both positive and negative experiences in order to be able to further develop the model. Still, it is possible that some respondents were reluctant to talk about aspects of the VPM that they found problematic. Another limitation is that only three nursing home physicians participated. Con- tributing to the strength of the study is the inclusion of informants from all four health regions and from both larger urban and smaller rural municipalities. In addition, leaders at the ground level as well as physicians and administrative managers at the municipal level were interviewed.

Conclusion

Thefindings indicate that the VPM is a method that can help staff in domestic care and nursing homes to enhance their competence in person-centred care and improve cooperation between stakeholders. There is a scarcity of research on how the use of person-centred care models in daily clinical work affects the work culture, social environment and quality of care in dementia care, in general, and domestic nursing, in particular. The impact or effect of such models should be studied in other national settings and with the use of other study designs. Most importantly, we need research not only on how using the method affects residents and service users and their next of kin but also on how it affects the work of the physician and the frontline staff.

Clinical implications

Use of the VIPS practice model can result in the following changes:

1. A staff group that is more unified in assessments of the person with dementia;

2. A staff that uses more professional knowledge;

3. A staff that is more committed to adhering to treatment plans and 4. Physicians who spend their time in the nursing home differently.

Text box 1

Roles and functions in the VIPS practice model.

Primary contact: the spokesperson for the person with dementia; he/she presents the situation from the perspective of the person with dementia.

Resource person: the chair of the meeting and a representative of the largest frontline staff group.

Head nurse: provides support to the resource person and to the primary contact if needed; he/she ensures that interventions uphold the appropriate professional level by guiding and teaching frontline staff as needed.

Questions to be answered by the primary contact

In VPM, the primary contact is responsible for presenting the perspective of the person with dementia. This can be done by answering the following questions:

1 What do you think the person is reacting to?

How do you think the person experiences the situation?

2 What information and observations do you have to indicate that this is how the situation is experienced by the person?

a What does the person say?

(For example:‘I won’t, I don’t want to’;‘Come here’;‘Ouch!’)

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b What does the person do with his or her body?

(For example: turns his or her back, looks down, and grabs the caregiver) c What do relatives say?

3 Which feelings do you recognize in the person in this situation?

a Is the person angry, anxious, frustrated or scared?

b Is the person trying to protest about something?

Text box 2

Interview guide VIPS practice model

Interview guide for physicians and leaders

1. Have you noticed any changes in the unit since you started using the VPM in regard to:

The staff?

The patients/users?

The next of kin?

2. Looking back, are there differences in the current care and treatment provided in the unit compared to before you started using the VPM?

If you answered yes, what are those differences?

In your opinion, what is the most important change that has taken place?

3. For physicians especially:

Can you explain your conception of the VPM?

Has use of the VPM affected how you function in the unit?

If you answered yes, how has your function been affected?

For managers and leaders especially:

What factors affected the implementation of the VPM both negatively and positively?

Were there factors that had to be present in order to implement the VPM? Please provide examples.

4. Now that you have used the model for a while, is there anything you would have done differently?

Do you have any advice for those who are about to start using the model?

What is important in order to be able to conduct the consensus meetings weekly and follow up on the interventions?

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the followingfinancial support for the research, authorship, and/or publication of this article: The study is funded by the Norwegian National Advisory Unit on Ageing and Health.

Ethical approval

The Norwegian Centre for Research Data (NSD) gave ethical approvement. All respondents who replied they would participate received information about the study along with an informed consent form by email. All respondents provided signed consent.

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ORCID iDs

Marit Mjørudhttps://orcid.org/0000-0002-2604-4074 Janne Røsvikhttps://orcid.org/0000-0003-2509-3744

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Author Biographies

Janne Røsvikis a registered nurse with a PhD from the faculty of medicine at the University of Oslo. She is employed as a researcher at Vestfold hospital trust, Tønsberg, works at the Norwegian National Advisory Unit on Ageing and Health in Oslo and is affiliated to the Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.

Marit Mjørudis a registered nurse with a PhD from the faculty of medicine at the University of Oslo. She is employed as a researcher at Vestfold hospital trust, Tønsberg, works at the Norwegian National Advisory Unit on Ageing and Health in Oslo and is affiliated to the Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway.

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