Assignment on Evidence Based Practice in OT dec. 2000: Staff attitudes, social interaction and people with dementia in residential settings

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Benedict Burke
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1 Table I Studies of daily life of residents / patients in psychogeriatric or residential settings Author, year, country Design Research Focus and Results Conclusions / discussions Limitations and Study purpose intervention - Hallberg I R, Norberg A Randomised Control Study 37 patients with vocally Both groups of patients Staff resources were poor In selection of subjects, & Eriksson S (RCT) disruptive behaviour and 37 were reduced to and the care provided was there were no definition of N=74 control patients themselves and passivity rapid, fragmentary and vocally disruptive - Sweden >50% suffering from (matched for sex and ward ) most of the day. dominated by physical behaviour, and no - To describe the events of dementia of the Alzheimer in psychogeriatric wards. caring activities. information on dementia daily life and the content type Vocally disruptive assessments. It is not and amount of caring Observations focused on patients were given Despite of possible mentioned how controls activities provided for Semistructured continuous activities, behaviour and significant (P 0.01) less Hawthorne-effect, are randomised or if study demented patients with Observations for 15 hours interaction between time for activating care. understimulation is present personnel were blind to the vocally disruptive pr. patient caregiver and patient. in both groups of patient s experiment. behaviour. Notes were written at 5- Physical care was the life, thus not because of minute intervals The study was a follow up most dominant activity in behaviour. The findings Observation period is not Inter-observer reliability study on a pilot study. the patient s daily life. gave support to the idea through a whole day only controlled Patients had very limited that sensory deprivation is on mornings, that might be 1

2 social interaction. present. specially busy P-value < 0.05 was regarded as significant. - Perrin T - Descriptive study - - N= Direct observations of - Most of the clients spent - Observations indicate a The purpose was stated behaviour and the relative their day unoccupied and severe dearth of clearly and observations - UK - Inclusion criteria: persons well being or ill being of scored a minimum of occupational provision for systematically assessed - To demonstrate the having a diagnosis of residents with severe well-being. this group of clients that do occupational need of dementia and a score of 18 dementia from nine -The behaviour category not match the perceived It might be both a bias and elderly persons in or more on the Behaviour different dementia care profile showed that eating quality of their social and strength, that the author hospital or residential Rating Scale of the Clifton settings. and drinking and moving physical environment. performed observations. settings, who have severe Assessment Procedures for - Each individual was around was the only dementia and to identify the Elderly observed over the course of active behaviours of a failure of nursing and therapeutic approaches a day between 09:30 am significance. care staff teams to make - Observational method: and 4:30 pm - Social interaction is provision for occupational Dementia Care Mapping a minimal and relates to need and prolonged time-sampling and event- - Data were processed into greetings or enquiry after communication. recording tool group care scores a person s health. 2

3 Table II Studies of staff resident interactions linked to attitudes Author, year, country Design Research Focus and Results Conclusions / discussions Limitations and Study purpose intervention - Korremann G, Cross sectional study The staff tasks at nursing Residents are most active Daily life for residents is Although the study is old, Meldgaard K & N= 997 residents and 1300 homes are analysed from and do have most social very different in the the study design could be Skrubbeltrang O staffs at 19 different the view of different interaction where the staffs different nursing homes: re-used to test if attitudes nursing homes working principles/ work after principles of The results indicate that have been changed in - Denmark philosophies. interacting and self- the working principles and general. The study applies - Aiming at making Phase 1 model determination. attitudes of staff are of very well with the nursing homes a better construction and literature- The idea is to develop an higher importance than philosophy of occupational place of living, it is search alternative to the standard Where Helping functional abilities of therapy. investigated if there is a Phase 2 impression of staff only principles is the norm, the residents or on the number Results difficult to relation between daily life interviews and employed to meet the residents are significantly and qualifications of staff. analyse due to myriad of of residents and how tasks questionnaires physical needs of the more passive and with statistical analysis data. are organised at different Phase 3 residents little social interaction. nursing homes and the Analysis Salmon P Survey Nurse interactions were Nurses attitudes towards Behaviour seems to be The present study is 3

4 1993 N= 27 nurses who were observed during routine- nursing their patients more influenced on uncontrolled, and further UK observed both in periods care and formal activity failed to predict the level external factors such as research is needed of the To investigate what seems of routine care and in periods (reality-orientation or quality of their participation in organised use of reality orientation or to affect the proportion of special activities sessions) over a three- interactions with them. programs than related to similar sessions to improve nurses positive week period. The activity the nurses attitudes nurses behaviour interactions with patients Diagnosis for all patients: groups were conducted Only a minority of towards elderly people with dementia on two dementia. on the ward by nurses on interaction was recorded as and treatment Data from observations psychogeriatric wards in a week-days afternoons positive, but the proportion seems to be valid, psychiatric unit Systematic observations (a of interaction with Rather than employing reliability tested and time sampler procedure) of After this, nurses patients, which were nurses with good attitude thorough analysis; data nurse-behaviour during the completed scales positive, was greater or changing attitudes of from measuring attitudes day. A mean of 57 measuring attitudes to during formal reality nurses, it is suggested to were not presented in the observations being made elderly patients and the orientation periods than at schedule formal activity article one each nurse. philosophy of treatment other times. periods to secure positive form interactions Nurse attitudes measured Qualified nurses interacted through a questionnaire. more positively than did their enrolled or unqualified colleagues 4

5 - Armstrong, Browne and - Clinical Controlled Trial - First stage: a self- - Nurses stated that - The elderly may fall Intervention and McAfee (CCT) administered questionnaire talking to patients victim to passivity and evaluation methods from N= 306 nurses (74% to determine priorities in is very important, yet lack of activity due to the the CCT can be replicated - Canada response rate) working in nursing care during the observation very low levels of staff- for later / comparative - To investigate the nurse either geriatric or period staff did not engage patient interactions study patient interactions in two psychiatric clinical settings - Second stage: patients in social activities outside of expected acute medical geriatric Three selected groups of 8 or prolonged informal routines of patient care. Ethical aspects considered units and a psychiatric unit - N=24 patients with different conversations. positively: participants and link the stated nursing - Patients from 3 long-stay symptoms named as: lucid, - Nurses are suggested to selected on the basis of practices and preferences wards were selected using confused, demented - The elderly were sitting acquire a repertoire of willingness with actual behaviour. the Clifton assessment 95% of the observed time skills that embraces Procedure for the Elderly - Non-participant and specially the group of psychosocial and physical - Further study of nurse information and observation of patient elderly with dementia rehabilitation of skills with attitude is needed: re orientation screening test. activities and nurses spent most of half of their more therapeutic and reasons for not interacting. interaction during daytime time engaged in solitary recreational activities. - Behaviours recorded on in 2 weeks. activities. a microcomputer. 5

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7 Table III Studies of change in social interaction as part of changing treatment or environment Author, year, country Design Research Focus and Results Conclusions / discussions Limitations and Study purpose intervention - Morgan D G & Stewart - Qualitative study using - A study of the effects of The results highlight the Development of a A valid trial using N J grounded theory two different care-settings importance of the social therapeutic milieu for triangulation of data-sources techniques. on resident behaviour. environment persons with dementia also - Canada - 18 in-depth interviews - The study took place There was in general a requires a change in Data on environment- - To explore environment- conducted with 9 staff and when 53 residents moved decrease in social philosophy behaviour relationships were behaviour relationships in 9 family members from a traditional Long interaction and too little obtained both through dementia care settings with - Participants were selected term care (LTC) facility to activity in the new units. - Those involved in interviews with staff and a focus on findings related by theoretical sampling new low density Special This resulted in boredom planning must pay more relatives and by ongoing to the social environment (Strauss 1987) Care Units (SCUs) and understimulation for attention to planing a observations. - Study took place over a - Interviews started three some residents. supportive social 12 month period with months after move and Positive aspects were environment and not only A thorough investigation ongoing thematic analysis lasted for one year. increased space for focus on the physical with extensive literature -Interviews was tape- wanderers and the decrease structure of dementia units. studies that support the recorded and transcripted in noise which had been findings 7

8 verbatim. A computer overwhelming for some The investigation is useful program was used to residents. for the purpose of this facilitate coding. review - Åkerlund B M and Descriptive, pilot study - A former reality - In the new group an The therapists A small pilot study, further Norberg A N=4 orientation group was increase of verbal activity psychodynamic approach study is needed Three patients with changed when group and of social interaction seemed to support the - Sweden severe dementia and one leader felt discouraged. among group members patients mental processes There is no data on before - To see if a much more severely The intellectually oriented compared to the behaviour whereas the behavioristic after behaviour. psychodynamic therapeutic demented exercises were abandoned. in reality orientation was approach had restricted the approach in a group -Two co- therapists: Instead the patients were seen. patients behaviour. More thorough analysis on session could stimulate a psychologist and a encouraged to introduce - In the reality orientation how and why this new demented patients mental nurse their own topics. group the patients only Furthermore the staff approach seem to improve remaining mental - Cognitive status was - Therapists restricted their responded only to regained satisfaction of both demented patients and functions graded through a Mini participation to supporting questions from the group being group leader staffs behaviour and Mental State Examination dialogue and interpreting leader. Group leader felt interaction among each (MMSE) emotional contents the sessions sometimes Reflections of being two other, could be interesting. - Group sessions were monotonous and even group leaders with one videotaped boring. being qualified as a 8

9 - Qualitative analysis of psychologist could have data been included Ingstad P J & Götestam G Clinical controlled trial Three changes were made: - Significant increase in -A primary, treatment A valid study and of highly 1987 N=21 ( 11 in experimental - physical environment the experimental group for produced change in the interest to the review Sweden group and 10 in control made more social ( chairs all three behaviours patients behaviour To check changes in staff group ) turned toward each other ) assessed. Social interaction on the ward effects Description of quantitative attitude in relation to a - mealtime routines was increased in experi- positively on the staffs analysis of trial is not treatment study Pre-post design for both changed by using mental group +530% ; attitude and social included in this article, only assessments of increased time (control group: +34%) behaviour referred to. attitude and of patient - Activity materials were - Significant positive behaviour using a time distributed. change in the staff attitude This approach is In the attitude study there sample basis towards three out of four recommended as better were no controls tasks: dressing the patients, than to start with an and only self-report patients meals and attitude change. measures interaction with patients. Sandman P O and - Before - after study - Five institutionalised - When patients ate - A quiet and positive meal No conclusions can be drawn Norberg A - N= 5 patients with Alzheimer- without staff the two least environment seems to due to small sample size, Patients with dementia of type dementia were demented helped the three encourage patients to use short time frame, no Sweden the Alzheimer type observed during meals to most demented patients to their abilities and to help controls. To study the staffs According to the DSM III assess their meal- eat. each other. 9

10 influence per se on social criteria behaviour and social The study does not include interaction and meal Mini Mental State interaction. - The staff participation - Staffs seem to be more the level of patients behaviour among Examination MMSE was had marked negative effect observant of the patients collaboration and social demented patients. The used to select patients in - The study was conducted on the interaction in the nutritional needs than of contact before trial. hypothesis was that a quiet different stages of the in four phases, where staffs group but their meals their social and cultural and positive meal- disease. were instructed to give became more complete. needs at mealtime. No ethical discussions on environment could Observations were video- different support. design increase collaborative recorded. behaviour and social Videotapes were analysed Further study needed using a contact. both qualitatively and randomised design quantitatively. 10

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