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The Person, Interactions and Environment Programme to improve care of people with dementia in hospital: a multisite study

Health Services and Delivery Research, No. 6.23

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Author Information
Southampton (UK): NIHR Journals Library; .


The programme changed ward practices and patient experience but there was no evidence that it improved clinical outcomes; although it worked on two wards, organisational upheaval contributed to non-adoption in most wards.



Improving the care of people with dementia on acute hospital wards is a policy priority. Person-centred care is a marker of care quality; delivering such care is a goal of service improvement.


The Person, Interactions and Environment (PIE) Programme comprises an observation tool and a systematic approach to implement and embed a person-centred approach in routine care for hospitalised patients with dementia. The study aims were to evaluate PIE as a method to improve the care of older people with dementia on acute hospital wards, and develop insight into what person-centred care might look like in practice in this setting.


We performed a longitudinal comparative case study design in 10 purposively selected wards in five trusts in three English regions, alongside an embedded process evaluation. Data were collected from multiple sources: staff, patients, relatives, organisational aggregate information and documents. Mixed methods were employed: ethnographic observation; interviews and questionnaires; patient case studies (patient observation and conversations ‘in the moment’, interviews with relatives and case records); and patient and ward aggregate data. Data were synthesised to create individual case studies of PIE implementation and outcomes in context of ward structure, organisation, patient profile and process of care delivery. A cross-case comparison facilitated a descriptive and explanatory account of PIE implementation in context, the pattern of variation, what shaped it and the consequences flowing from it. Quantitative data were analysed using simple descriptive statistics. A qualitative data analysis employed grounded theory methods.


The study furthered the understanding of the dimensions of care quality for older people with dementia on acute hospital wards and the environmental, organisational and cultural factors that shaped delivery. Only two wards fully implemented PIE, sustaining and embedding change over 18 months. The remaining wards either did not install PIE (‘non-implementers’) or were ‘partial implementers’. The interaction between micro-level contextual factors [aspects of leadership (drivers, facilitators, team, networks), fit with strategic initiatives and salience with valued goals] and meso- and macro-level organisational factors were the main barriers to PIE adoption. Evidence suggests that the programme, where implemented, directly affected improvements in ward practice, with a positive impact on the experiences of patients and caregivers, although the heterogeneity of need and severity of impairment meant that some of the more visible changes did not affect everyone equally.


Although PIE has the potential to improve the care of people with dementia when implemented, findings are indicative only: data on clinical outcomes were not systematically collected, and PIE was not adopted on most study wards.

Research implications:

Further research is required to identify more precisely the skill mix and resources necessary to provide person-focused care to hospitalised people with dementia, across the spectrum of need, including those with moderate and severe impairment. Implementing innovations to change practices in complex organisations requires a more in-depth understanding of the contextual factors that have an impact on the capacity of organisations to absorb and embed new practices.


The National Institute for Health Research Health Services and Delivery Research programme.


About the Series

Health Services and Delivery Research
ISSN (Print): 2050-4349
ISSN (Electronic): 2050-4357

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 11/1017/18. The contractual start date was in February 2013. The final report began editorial review in March 2017 and was accepted for publication in July 2017. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors


Last reviewed: March 2017; Accepted: July 2017.

Copyright © Queen’s Printer and Controller of HMSO 2018. This work was produced by Godfrey et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Bookshelf ID: NBK508098PMID: 29989761DOI: 10.3310/hsdr06230


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