An evaluation of the effectiveness of Dementia Care Essentials in improving the quality of residential and community aged care

Transcription

1 An evaluation of the effectiveness of Dementia Care Essentials in improving the quality of residential and community aged care Sites de-identified Volume One. Report Commissioned by Alzheimer s Australia Vic. Conducted by Bernie McCarthy MAPS McCarthy Psychology Services May 2012

2 Table of Contents List of Tables 3 List of Figures 4 Executive Summary 5 Background 7 Introduction 9 Methodology 17 Sample 17 Instruments 19 Analysis 22 Results 23 Demographics PAS 23 DCM/QUIS 25 Organisational Review 39 Surveys 42 Comparison with Competencies 43 Discussion 45 References 53 List of Appendices (Full appendices in Volume Two) 56 2

3 List of Tables 1 Positive (Personal Enhancers)and negative (Personal Detractors) care actions identified in Dementia Care Mapping 12 2 VIPS Framework Brooker QUIS care interaction types 20 4 Mood scale for adapted QUIS 22 5 Existing data for residents at Residential Site 1 and Residential Site 2 at Time Dementia Care Mapping for Time 1, 2, and 3 for both residential sites 26 7 Detailed analysis of PDs and PEs related to each of the five Fundamental Needs at Residential Site 1 at Times 1, 2, and Target behaviours for Residential Site 1 Action Plan 32 9 Detailed analysis of PDs and PEs related to each of the five Fundamental Needs at Residential Site 2 at Times 1, 2, and Action Plan items from Residential Site 2 at Time

4 List of Figures 1 Cornell scores at Residential Site 2 at Times 1 & Cornell scores at Residential Site 1 at Time 1 & Personal Detractors and Personal Enhancers at both sites at Time 1 & Personal Detractors and Fundamental Needs for Residential Site 1 at Times 1, 2 & Personal Enhancers and Fundamental Needs for Residential Site 1 at Times 1, 2 & Personal Detractors and Fundamental Needs for Residential Site 2 at Times 1, 2 & Personal Enhancers and Fundamental Needs for Residential Site 2 at Times 1, 2 & QUIS observations (rate per minute) of care provided by one care workers with the same client at Times 1, 2, and QUIS ratings during two types of care interaction (rate per minute) 39 4

5 Executive Summary This report was commissioned by Alzheimer s Australia Vic. to examine the effectiveness of Dementia Care Essentials training delivered at Certificate III and IV levels to aged care residential and community care staff, in improving the quality of aged care provided to people living with dementia. The evaluation had a dual focus on the effectiveness of the training delivered by Alzheimer s Australia Vic. and also the impact of organisational culture and change efforts on this effectiveness. The evaluation was a multi-method repeated measures action learning design conducted in three aged care sites in metropolitan Melbourne, Victoria. Two sites were residential and one delivered community aged care. Measures were taken pre-training, immediately post-training and 3-months post-training. Variables measured included staff, resident and organisational aspects of the care context. Instruments included Dementia Care Mapping (DCM) and Quality of Interventions Schedule (QUIS) adapted to community care, and the VIPS Framework (Brooker, 2007) to measure the organisational context supporting personcentred care. With the two residential aged care providers Dementia Care Mapping was utilised as an outcome measure and as a stimulus for reflection on the feedback that was provided posttraining and after 3 months. With the community aged care provider QUIS was utilised as an outcome measure and stimulus for reflection on the feedback that was provided post training. An action plan was devised by each site on the basis of the feedback following a Plan-Do-Study-Act model of change. Results of the data show that there is a mixed effect of the training immediately post the training with improvement in some indicators and worsening of others. It is only after the organisation commences its action planning phase that more consistent changes emerge. The data show that the process of change has begun at 3 months and is moving in the direction of improved care but is not sufficiently developed even after 3 months to provide convincing evidence of the effort to improve quality of care practice. Given that 3 months is a relatively short period to see organisational change it would be beneficial to do further follow up. Conclusions are that the Dementia Care Essentials training is an effective and necessary stimulus to promote improved dementia care. However on its own without efforts at an 5

6 organisational level to embed this learning in a way that is consistent with the culture of the organisation will not produce change in the quality of care on its own. Multiple cycles of action planning and implementation are essential for sustained change. Providing the training as part of a broader organisational approach to improving the quality of care is more likely to produce changes that are specific and show improvement in the care experience of the residents and clients. 6

7 Background The Dementia National Health Priority Initiative, known as the Dementia Initiative was funded in 2005 by the Australian government to improve the quality of dementia care experienced by Australians with the condition and their carers. One of the programs funded as part of the initiative was Dementia Care Essentials (DCE). This program was to provide nationally accredited training to aged care staff who wished to improve their skills and further their aged care careers. In 2011 it was approved for further funding. This current round of DCE is funded by the Australian government (Department of Health and Ageing) under the Aged Care Workforce Fund. DCE is a program of nationally accredited training delivered locally by a range of agencies across the nation and in slightly varying formats. The format in Victoria is a program of three days, face-to-face training including workplace assessment and completion of tasks by participants in fulfilment of the criteria for unit competency. The first round of DCE included only the Certificate III level dementia competency from the Certificate III in Aged Care Work from the Community Services Training Package CHC02. This unit was CHCAC15A Provide care support which is responsive to the specific nature of dementia. This changed in 2010 to CHC08 and the unit became known as CHCAC319A Provide support to people living with dementia. The second (current) round of DCE includes both Certificate III and IV levels of the dementia competency both of which have been designed by Alzheimer s Australia and are from the CHC08 Community Services Training Package qualifications Certificates III and IV in Aged Care Work. They are the unit CHCAC319A Provide support to people living with dementia at Certificate III level and the Certificate IV level unit CHCAC416A Facilitate support responsive to the specific nature of 7

8 dementia. The former unit is advertised to participants as Dementia Care Essentials and the latter unit is advertised as Dementia Care Essentials Support Planning. The specific requirements of each unit from the Community Services Training Package are identified in Appendix 1.3 8

9 Introduction The current study is a selective evaluation of the effectiveness of the second round of Dementia Care Essentials (DCE) training provided by Alzheimer s Australia Vic. by sampling two residential aged care homes and one community services team in metropolitan Melbourne, Victoria in 2011 that participated in the program. Dementia is the greatest single contributor to the cost of care in nursing homes and it is estimated that 60% of people in Australia in high care and 30% in low care residential care facilities have dementia, with some 90% and 54% respectively having an obvious impairment (AIHW, 2004). Equally it is acknowledged with the ageing of the population that 69% of people living with dementia, live in their own home in the community. Consequently the majority of people living with dementia are not living in residential aged care. However the proportion of those people living with dementia in residential aged care has increased. Hence the importance of this study focusing on both residential and community aged care. Dementia is a growing health concern for our society with increasing numbers of people diagnosed and requiring care now and in the decades ahead. Best practice dementia care is recognised as person-centred (Alzheimer s Australia, 2009). This is identified by Brooker as value-based, individualised, respecting the perspective of the person with dementia and supporting their social needs and skills (Brooker, 2007). Practice evaluations have demonstrated that this is far from the truth in practice (Cohen-Mansfield & Bester, 2006; Rabig, Thomas, Kane, et al., 2006). Aged care provider organizations around the world still struggle with the transition from task oriented approaches to effective person centred dementia care. The provision of training to aged care staff has been long regarded as an essential component for improving the quality of care (Stevens, et al., 1998). Training is also a mandated and funded element of the Aged Care Act (1997). Training staff in aged care homes in an effort to improve the quality of care provided is an endeavour however, fraught with difficulties not least of which are the following: 9

10 the need to work in a constantly changing environment with people who have a combination of physical and cognitive decline, whose conditions progressively worsen, amid a tightly controlled regulatory and compliance environment, with a mix of bio-medical and person centred bio-psycho-social health care paradigms, low paid staff who are mostly part-time, with low staffing levels, whose education may be minimal and whose command of English may be poor and add in management whose priorities may not be care quality but more financial (return on investment for proprietors/ shareholders) and organisational. In the community aged care sector these issues are added to by issues of isolation as workers rarely come together as a team creating problems around ongoing support and professional development. There are also often problems of communication with direct care workers often not involved in or aware of support plans that are developed for the person they are supporting. They may also be employed by a number of different community care organisations and are subcontracted in to deliver the care. This critique presents only part of what is a more balanced view that includes the frequent efforts of talented and dedicated staff to implement cultural practice changes in care environments that improve the quality of care. There are also many generous well-motivated care staff whose values are person centred and whose care behaviour provides a person centred model for their colleagues. Many managers and aged care leaders establish and manage high quality care environments that provide experiences of hope and meaningful living for those with dementia in their care. The DCE program, based in the national competency as described above was designed to improve skills for aged care workers based on the person-centred approach to dementia care which has become synonymous with best practice (Brooker, 2007). This person centred approach is predicated on the notion that the person with dementia remains a social being who has a personal individual 10

11 perspective, can contribute to their care, remains a social participant and is more than the sum total of their neurological impairment (Kitwood, 1997). It is often difficult to measure the effectiveness of such training interventions (Hughes, Bagley, Reilly, et al., 2008). It requires a dual focus on both the skills of the caregiver and on the effect of these skills in improving or sustaining the quality of lived experience of the person receiving the care. Many methods are employed, from exit surveys of satisfaction and attitude change, through to direct observation of employees in the exercise of their duties (Norbergh, Helin, Dahl, et al., 2006). An initial focus on the skills the participants are learning in the DCE courses at Certificate III and IV levels identify essential skills (essential knowledge is also identified and is evaluated for competency, but is less observable and therefore not the focus of this review) that are required for competency in dementia care. A competent student would display a set of skills as listed in Appendix 1.3. These criteria may be used to identify markers for competency but should be accompanied by indicators of the quality of lived experience of the person with dementia. The measurement of quality of life in people with dementia received little attention until the past decade (Zimmerman, et al., 2005). Several studies have examined a range of definitions of the concept of quality of life itself (Droes, et al., 2006; Gerritsen, et al., 2007; Gerritsen, Steverink, Ooms, et al., 2004) and range of methods (Edelman, Fulton, Kuhn, et al., 2005) for responding to the contextual difficulties associated with validly and ethically assessing this domain including selfreport (Gerritsen, Steverink, Ooms, et al., 2007; Smith, et al., 2005); qualitative interview(cahill & Diaz-Ponce, 2011) and observational measures involving ratings by proxy such as Dementia Care Mapping (Brooker, 2005; Edvardsson & Innes, 2011; Sloane, et al., 2007) or the environmental rating tool TESS-NH (Sloane, et al., 2002). 11

12 One tool that encapsulates the dimensions of staff skills and resident experience is Dementia Care Mapping (DCM). DCM is an observational tool and quality improvement process created by Professor Tom Kitwood and Kathleen Bredin to measure and evaluate the quality of dementia care in residential and day care settings (Kitwood & Bredin, 1992). DCM involves a trained observer noting systematically every five minutes what the person with dementia is doing and what they appear to be feeling during this period (the quality of their lived experience). The mapper also notes the positive and negative care actions by aged care workers that have an impact upon the wellbeing of the person with dementia (University of Bradford, 2005). Positive care actions (Personal Enhancers - PEs) improve wellbeing and negative care actions (Personal Detractions PDs) decrease wellbeing or create illbeing. A list of these care actions as identified in the DCM manual (Brooker and Surr, 2005) are located in Table 1. below. Table 1. Positive and negative care actions identified in Dementia Care Mapping. Positive care actions (Personal Enhancers) Negative Care Actions (Personal Detractors) Warmth Intimidation Holding Withholding Relaxed pace Outpacing Respect Infantilization Acceptance Labelling Celebration Disparagement Acknowledgement Accusation Genuineness Treachery Validation Invalidation Empowerment Disempowerment Facilitation Imposition Enabling Disruption Collaboration Objectification Recognition Stigmatization Including Ignoring Belonging Banishment Fun Mockery 12

13 These positive and negative care actions are measurable indicators of care quality. As such, they can be utilised as indicators of change in the quality of person-centred care provision. They may also be used as indicators of the essential skills noted above for competency. DCM was designed as a tool for the improvement of quality of care and quality of life in clinical settings rather than as a research instrument (Kitwood & Bredin, 1992). The evidence for its effectiveness as a valid and reliable research tool for the measurement of quality of care and life in aged care is regarded as well established (Brooker, 2005; Fossey, Lee, & Ballard, 2002; Innes & Surr, 2001). It has been used in quality audits (Younger & Martin, 2000) and as an outcome measure (Fossey, et al., 2002). The current evaluation includes staff working with community dwelling elderly with dementia as well as those working in residential settings. This section of the aged care workforce has increased significantly in size in recent years (Productivity Commission, 2011). Research into the experience of people with dementia living in their own homes, specifically focussing on quality of life, is relatively new. There are no observational tools designed specifically for this setting. Some have been adapted for the community setting, including Dementia Care Mapping (in development as DCM-SL by Bradford Dementia Group and not available for use in Australia). One tool that lends itself readily to adaptation to the community setting is the Quality of Interactions Schedule (QUIS) (Dean, Proudfoot, & Lindesay, 1993). This observational tool was developed for the residential aged care setting as a measure of the quality of social interactions between residents and care staff. These were coded as positive social, positive care, neutral, negative protective or negative restrictive. 13

14 The original observations were conducted in a residential setting by dividing the working day into four sections and making observations over a two week period to obtain a representative sample of the social interactions occurring in the care environment. This is clearly not possible in a community care setting where care staff provide care in brief focussed interactions that may be up to one hour in duration but rarely longer. The type of work carried out may be housework, cleaning, or tidying, or it may consist of personal care such as showering, dressing or assistance in the toilet. This latter type of care is generally not visually observable due to privacy considerations and the impracticality of having a third person in the small space afforded by most domestic bathrooms and toilets without influencing the behaviour of the elder and the carer. The QUIS may be utilised for the domestic setting, however, as it can be adapted readily for short observations and is simple to learn and use. The adaptation is outlined in the Method section below. Organisation culture In addition to measuring the wellbeing of the individuals living in residential care environments and the skills of those caring for them, increasing attention has been paid to the organisational culture within which care is provided. Organisational typologies from a wide range of industries abound in the literature (Hawkins, 1997). However, the application of organisational theory to health care and specifically to aged care is attracting attention only relatively recently. Kirkley, Bamford, Poole, et al. (2011) in a study of the opinions of staff and managers providing respite services to people living with dementia in the community, identified five themes in relation to organisational culture that influence person-centred care: understandings of personcentred care, attitudes to service development, service priorities, valuing staff and solution-focused approaches. They interviewed 49 staff and operational managers of community based respite services in the UK and found that views of person centred care were diverse reflecting a lack of common understanding about the nature of person centred care. Participants also identified barriers and facilitators to person 14

15 centred care in the knowledge, attitudes and personal qualities of care staff. Leadership style was also implicated. The way managers support and value staff and the way they manage risk were influential, i.e., a controlling management style was not associated with person centred care. Other organisational models have included the V.I.P.S. Framework (Brooker, 2007) in which Brooker uses the well-known acronym for Very Important People to identify four elements to person-centredness: V=Value base and value of the person regardless of disability; I=Individualised care; P=care provided from the Perspective of the person themselves rather than shaped by institutional imperatives; S=the Social dimension of the person is sustained. Table 2. VIPS Framework Brooker (2007). Element Indicator Value V1 Vision V2 Human resource management V3 Management Ethos V4 Training and staff development V5 Service environments V6 Quality assurance Individual I1 Care planning I2 Regular reviews I3 Personal possessions I4 Individual preferences I5 Life history I6 Activity and occupation Perspective P1 Communication with service users P2 Empathy and acceptable risk P3 Physical environment P4 Physical health P5 Challenging behaviour as communication P6 Advocacy Social S1 Inclusion S2 Respect S3 Warmth S4 Validation S5 Enabling S6 Part of the community 15

16 Philosophically this model is based in the work of Tom Kitwood and draws on the work of (Rogers, 1961) whose client centred psychotherapy and the philosophical approach that is derived from it, underpins many changes in modern health care initiatives to enhance patient wellbeing in acute hospitals (Doherty & Doherty, 2005), disability services (McCarron, McCallion, Fahey-McCarthy, et al., 2011), and dementia care (Kitwood, 1997; Kitwood & Bredin, 1992). Brooker built a 24-indicator organisational review on this model to assist aged care providers (residential care homes) to identify areas of excellence in person centred care delivery and areas for improvement. These are listed in Table 2. above. The review may be self-rated on a four point scale: Excellent, Good, OK and Need to work on this. Brooker identifies three uses for this tool: Raising awareness of person centred care across the organisation; Evidence collection and benchmarking; and action planning for improvements in key elements. In this evaluation there is a focus both on facilitating a change and measuring that change at an organisational level. It is believed that by stimulating skill and knowledge improvement (with DCE training) and then supporting this with reflection on practice (using DCM/QUIS and the organisational VIPS Framework) there may be positive shifts in the indicators for person centred care at an individual staff and organisation level. 16

17 Methodology The current report builds on our experience of evaluating the effectiveness of DCE training, offered by Alzheimer s Australia Vic (AAV) in This evaluation of DCE uses a multi-method repeated measures action learning approach to identify differences at three time points: Pre-training, Post-training and 3-months Posttraining. All sites have been de-identified. Sample Of the organisations participating in the Dementia Care Essentials training program conducted by AAV, a sample of two residential sites and one community site participated in the evaluation. These were a convenience sample of sites that were willing to engage in the evaluation on approach from AAV. The scale of the evaluation was limited by financial and time considerations. Residential Site 1 Residential Site 1 is a not-for-profit aged care home that has a philosophy of ageingin-place, providing serviced apartments, mixed and high care to 90 residents. They have a 15-bed dementia specific secured unit where the evaluation observations took place.. Staff that attended training from Residential Site 1 were: Certificate III: 15 (13 completed assessment) Certificate IV: 10 (all completed assessment) Residential Site 2 Residential Site 2 is part of a not-for-profit aged care organisation that provides residential and community services. At Residential Site 2 there are 96 beds with 17

18 mixed care and high care and a 32 bed dementia specific unit that is secure. This is where the observations took place. During the project period the Nurse Unit Manager resigned and the unit was without a permanent leader for several months. Proposed physical division of the 32-bed unit into two 16-bed units did not take place as planned in the project period. Staff that attended training from Residential Site 2 were: Certificate III: 10 (9 completed assessment) Certificate IV: 27 (27 completed assessment) Community Care Site Community Site 1 hosts the community services team that provides Community Aged Care Packages (CACPS), Extended Aged Care in the Home (EACH) and Extended Aged Care in the Home Dementia (EACH-D). This team provided direct care staff and care managers (one senior care manager, 2 care managers, 2 Community Support Workers (CSW) (Carers) and one Team leader) who participated in the training at Certificate IV level only and who were observed during their work. They have an integrated model in which there is direct communication between care workers and the care managers. Clients were observed with workers in in three locations where their clients lived. These interactions consisted of discussion between care managers and clients/carers or between direct care workers and clients/carers. Only one observation involved provision of direct personal care (showering). The observer rated the interaction from outside the bathroom to preserve privacy. Staff that attended training from Community Site 1 were: Certificate IV: 6 (5 completed assessment) 18

19 Instruments The methods used include: direct observation (DCM and QUIS), compilation of inhouse data (Falls, Skin Tears, Behavioural incidents, response times), survey selfreport (participants survey), proxy reports (Cornell, PAS). Dementia Care Mapping Dementia Care Mapping is an observational tool as described above that is used as both a tool for measurement of person centred care and for the improvement of person centred practice within a continuous cycle of Mapping-Feedback-Action Planning-Mapping. Observations are made every five minutes for up to six hours by a trained mapper who records data in four domains: Resident actions (alphabetical Behaviour Category Codes, e.g., A=Articulation: Interacting verbally or nonverbally; B=Borderline: Passively observing interactions of others; C=Cool: withdrawn), Resident wellbeing (ordinal scale +5, +3, +1, -1, -3, -5 where +5=extremely high level of wellbeing, pleasure or happiness, +3=Moderate levels of wellbeing, pleasure and enjoyment, +1=no signs of wellbeing or illbeing observable, -1=small signs of illbeing, distress or irritation, -3= Moderate signs of illbeing, upset or agitation, and - 5=Extreme distress, anger or upset), Personal Enhancers and Personal Detractors (listed in Table 2), and a narrative of events throughout the map. All domains are shown in detail in the Appendices. DCM was conducted according to the British standard PAS800: Use of Dementia Care Mapping for improved person-centred care in a care provider organization Guide. This involves pre-mapping meetings with stakeholders, obtaining consent from participants on the day of mapping, conducting mapping in a person centred manner, providing feedback to staff and management and conducting an action planning meeting to enable practice improvement. Data available from the mapping at each time point includes: Individual and Group WIB scores and profiles Individual and Group Behaviour Category Profiles 19

20 Personal Detractors (PDs) Personal Enhancers (PEs) Potential for Positive Engagement Passive Engagement Occupational Diversity Agitation Withdrawal The Quality of Interactions Scale (QUIS)(Dean, et al., 1993) was modified by (Procter, et al., 1998) to avoid ceiling effects of the original and further modified in this study to form the basis for the measurement of social interactions between older people living in their own home in the community and the care workers who visited them in their own homes. The original version was designed for use in residential aged care homes as outlined above. The QUIS is an observational instrument for recording the number of times a target social interaction occurs in a time period. Target staff interactions identified in the original QUIS are: positive social, positive care, neutral, negative protective or negative restrictive. These are defined in Table 3 below. Table 3. QUIS staff interaction types Positive Social Interaction principally involving good, constructive, beneficial conversation and companionship Positive Care Neutral Negative Protective Negative Restrictive Interactions during the appropriate delivery of physical care Brief indifferent interactions not meeting the definitions of other categories Providing Care, keeping safe or removing from danger but in a restrictive manner, without explanation or reassurance Interactions that oppose or resist residents freedom of action without good reason, or which ignore participants as a person. 20

21 The Proctor adaptation added to the above descriptions of staff behaviour by including the following categories of resident behaviour to capture the activity of residents during the observation period. (1) Disengaged. Resident is inactive, sitting passively or sleeping, or involved in unpurposeful activity such as fiddling with clothes, smoking or aimless walking. (2) Non-social engagement. Resident is engaged in purposeful activities which do not involve social interaction with others; for example, combing hair, reading, watching television, actively listening to music, knitting. If it becomes clear that the resident s engagement is not functional (e.g. they repeatedly vacuum or wipe the same place, wander aimlessly), then change code to disengaged or challenging behaviour, whichever applies. (3) Social engagement. Resident is engaged in some form of communication with others where there is a state of reciprocity with at least one other person or the resident is initiating contact with another person. This includes recognizable speech, attempts to speak, vocalizations, signs or gestures, physical prompting in a manner which gains, attempts to gain or maintains the attention of another person. It also includes clearly giving attention (as evidenced by eye contact or orientation of the head) to another person who has begun to interact with the subject. (4) Challenging behaviour. Resident is engaged in solitary repetitive, nonfunctional motor activity (e.g. body rocking, pacing), verbal activity (e.g. crying out, grunting, continuous swearing), self injury, aggression to others, damage to property or other inappropriate behaviour such as spitting, pestering others or stripping. The author added a mood rating scale to determine the nature and range of mood change during the interactions. This is detailed in Table 4 below. The time period for recordings was reduced to five minutes due to the short period of time community workers are with their clients. The original 15 minutes would not have provided sufficient sensitivity as home visits may only last minutes, providing too few time periods for study 21

22 Table 4. Mood scale for adapted QUIS. +3 High positive mood +2 Considerable signs of positive mood +1 Mild signs of positive mood 0 Neutral or lack of positive or negative signs of positive mood -1 Mild signs of Negative mood -2 Considerable signs of negative mood -3 High signs of negative mood Resident measures of quality of life included depression (measured with Cornell Scale for Depression), falls, skin tears, behavioural incidents, bruises and rate of call bell uses. Level of cognitive impairment (measured with Psychogeriatric Assessment Scale PAS) was included as an indication of the level of disability experienced by residents. These were taken at Times 1 and 3. Organisational Review The VIPS Framework by (Brooker, 2007) was selected to measure change in person centred organisational markers. As described above in Table 2 the framework consists of 24 markers that are rated on a four point scale. Ratings were scaled numerically so that Excellent =4, Good =3, Average =2 and Needs more work =1. Answers to questions within each indicator provided detailed records of organisational activity that were used to detect change in organisational practices following the training intervention. This tool was used prior to the training intervention (Time 1) and at 3 months post-training (Time 3). It was completed by management personnel at all sites. Analysis Due to the small number of sites it is not possible to establish levels of significance of any change that may be evident. However, descriptive statistics were obtained for all sites. 22

23 Results Demographics Three sites participated in this evaluation. Two sites were residential and one was a community team. The Unit within Residential Site 1 had 15 residents and the Unit within Residential Site 2 had 32 residents. Pre-training Time 1 was 13 June 2011 to 12 July 2011 for DCM. The three months prior to this period (April-June) was the selected time for resident data at Time 1. Post training Time 2 was 30 August 2011 to 13 September 2011for DCM. Resident data was not gathered at this time. 3 month follow up Time 3 was 03 January 2012 to 06 January 2012 for DCM. Resident data was collected for the period October to December In-house resident data Existing resident data was collated for Times 1 & 3 for both residential sites. This is presented in Table 5 below. Table 5. Existing data for residents at Residential Site 1 and Residential Site 2 at Time 1 and 3. Residential Site 1 Residential Site 2 Time 1 Time3 Time 1 Time 3 PAS CORNELL Falls (per resident)(incl 'found on floor') Skin Tears (per resident) Bruises (per resident) Aggression (per resident) (verbal and physical)

24 Level of cognitive impairment did not change significantly at Residential Site 2 between times 1 & 3 (t(3)=1.00, p=.39). Data for Residential Site 1 were obtained for Time 1 only and although lower than for Residential Site 2 was only obtained for residents able to respond verbally to an interview, therefore omitting the more impaired residents. Levels of depression were not significantly different between Time 1 and 3 at both Residential Site 1 and Residential Site 2 (t(5)=2.03, p=.10). For remaining variables there was insufficient data to conduct analysis of variance. At Residential Site 2 the pattern of decrease in depression was more consistent for residents for whom data was obtained at both times (Figure 1.) than at Residential Site 1 where three out of seven residents for whom data was obtained at both times had lower Cornell scores at Time 3 than Time 1 and four had higher scores on the Cornell at Time 3 than at Time 1 (Figure 2). Two residents at each site had Cornell Scores at Time 3 that indicated they had improved in their depression to below the threshold for diagnosis (score of 14). Figure 1. Cornell scores at Residential Site 2 at Times 1&3 24

25 Figure 2. Cornell scores at Residential Site 1 at Times 1&3 It is clear that for some variables such as skin tears there was little change from Time 1 to Time 3. However, for falls at Residential Site 2 there was a twofold increase from.28 to 0.56 falls per resident. This relates to an increase in falls for one resident who was found on the floor several times and died toward the end of the Oct-Dec period. Aggression at Residential Site 1 increased from 0.07 incidents of aggression per resident to 0.20 incidents per resident. This represents an increase from one incident in three months to three incidents in three months from three different residents. Bruises increased at Residential Site 1 (0.07 to 0.13 per resident) and at Residential Site 2 (0.06 to 0.22 per resident). However, levels remained low for each three month period. 25

26 Dementia Care Mapping Results for Dementia Care Mapping for Residential Site 1 and Residential Site 2 are displayed in Table 6. below. The DCM output shows a mixed result for both sites. Wellbeing scores fluctuated across Time1 to Time 3 remaining modest at both sites. The level of wellbeing indicates that on average the groups of residents experienced little above the +1 level of no signs of wellbeing or illbeing observable. Table 6. Dementia Care Mapping results for Times 1, 2, and 3 for both sites Residential Site 1 Residential Site 2 Time 1 Time 2 Time 3 Time 1 Time 2 Time 3 Wellbeing group score Potential for Positive Engagement Occupational Diversity (No.) Passive engagement (%) Agitation (%) Withdrawal (%) Unresponded-to distress (%) UNMEs (No.) Rate of PEs (per Time Frame) Rate of PDs (per Time Frame) Potential for Positive Engagement (PPE) decreased from Time 1 (74.19%) to Time 3 (65.62%) at Residential Site 1 and from 76.5% to 60.0% at Residential Site 2. Negative indicators also increased including Passive Engagement which increased at Residential Site 2 across all three mapping periods from 6.30% to 20.31% but remained stable at Residential Site 1 (17.29%, 17.66%, 17.19%). Withdrawal increased across all observations at Residential Site 1 (from 5.94% to 13.75%) and improved initially at Residential Site 2 (from 14.47% to 9.67%) and then increased to higher than pre-training levels (17.38%). This pattern across all measures maybe indicative of increasing burden of disease as residents progress in their dementia. The period from Time 1 to Time 3 was approximately six months. 26

27 Rate of Personal enhancers (PEs) initially decreased at both sites (Time 2) and then improved to almost double at both sites at Time 3. Personal Detractors (PDs) and PEs are displayed in Figure 3. below for Times 1-3. Figure 3. Personal Detractors (PDs) and Personal Enhancers(PEs) at both sites at Times 1-3. Rate of PDs on the other hand remained stable at Residential Site 1 (0.041, 0.042) and then worsened (0.067), and at Residential Site 2, rate of PDs improved at Time 2 (from 0.12 to 0.068) and then remained low (0.058). It may be that immediately following training staff were more wary of interacting with residents and so overall there is decrease in rate of interaction both positive and negative. By far the greater decrease is for negative care actions at Residential Site 2. As the action plans took effect the rate in interaction increased at Time 3 and there is an improvement in rate of positive care actions and a continuing decrease in negative care actions at Residential Site 2 but not at Residential Site 1 where there was an increase in negative care actions as well as positive care actions. Detailed Analysis of DCM by Site Residential Site 1 Table 7 below shows a detailed analysis of PDs and PEs related to each of the five Fundamental Needs at Residential Site 1 at Times 1, 2, and 3. 27

28 Table 7. Detailed analysis of PDs and PEs related to each of the five Fundamental Needs at Residential Site 1 at Time 1, 2, and 3. DETRACTORS Time 1 Time 2 Time 3 ENHANCERS Time 1 Time 2 Time 3 COMFORT Intimidation Warmth Withholding Holding Outpacing Relaxed pace Sub-total Sub-total IDENTITY Infantilization Respect Labelling Acceptance Disparagement Celebration Sub-total Sub-total ATTACHMENT Accusation Acknowledgement Treachery Genuineness Invalidation Validation Sub-total Sub-total OCCUPATION Disempowerment Empowerment Imposition Facilitation Disruption Enabling Objectification Collaboration Sub-total Sub-total INCLUSION Stigmatisation Recognition Ignoring Including Banishment Belonging Mockery Fun Sub-total Sub-total TOTAL PDs TOTAL PEs Display of these results in Figure form reveals the specific nature of the change from Times 1-3 for each need at each site. In Figures 4 and 5 the PDs and PEs respectively for Residential Site 1 are displayed related to each need. At all three maps Occupation is the need most undermined. The care staff at Residential Site 1 tended to take over and impose care (cf Table 7). There was a 28

29 high level of interaction but when it was to provide care it was often done without permission or informing the person and this remained high at each map. This is mostly done by failing to ask permission, imposing care upon residents without asking them if they would like the care to be provided. Instances included putting aprons on the person or removing them, moving the person, taking plates, disrupting activity to move the person onto the next activity or to prepare them for mealtime. The next most commonly undermined need was Identity at Time 3 with eight instances of Infantilisation (using forms of address like Darling and Eat your lunch, you ll make me happy ). There were however, improvements in the care actions that influence Attachment needs with staff engaging in fewer Invalidating interactions at Time 2 and Time 3. Figure 4. Personal Detractors and Fundamental Needs for Residential Site 1 at Times 1-3 Figure 5 below shows the Personal Enhancers for Residential Site 1 at each Time 1-3. Most notable in Figure 5 is the decrease in rate of positive engagement from staff across the board for all needs at Time 2 and the increase in support for Identity from staff at Time 3. At Time 3 there was improvement in the care actions that support four of the five needs (Comfort, Attachment, Identity and Occupation). Care actions that support Inclusion increased from Time1 to Time 2 and then remained stable from Time 2 to Time 3. 29

30 The Time 2 decrease is consistent with the wariness of staff to interact with residents following the training that may indicate an awareness of what is appropriate behaviour but some anxiety or lack of confidence to put this knowledge into action. Figure 5. Personal Enhancers and Fundamental Needs at Residential Site 1 for Times 1-3. The greatest improvement was for care actions supporting Identity. Specifically this included Acceptance of a resident s refusal of care when it was offered; Celebration of participation in a balloon activity; a guitar-playing musician singing well-loved song for one of the residents; Respectfully asking permission to take a plate; Respect in listening to a resident instruct staff about the science and function of batteries and electrical charge from his knowledge and experience as a university lecturer. The increase in Identity support is consistent with the specific actions addressed in the action plan (see below) to remedy high levels of negative care actions detected in the map at Time 1. Other needs to receive better attention at Time 3 included Attachment and Occupation. Mapping at Time 3 showed there were some staff (particularly among the Activity staff) who were very supportive of Attachment, Identity and Occupation. However, care staff specifically, tended to maintain patterns of Impostion and Disruption at all maps. Management of Residential Site 1 reported that they had 30

31 made a concerted effort to address the Action Plan with the Activity staff but were aware that more work needed to be done to address with care staff the issues of Imposition and Disruption that undermine Occupation needs. It may be that these PDs are driven by cultural expectations of appropriate caring behaviour, i.e. provide care regardless. However, these PDs show up consistently in most aged care homes where a traditional style of care is dominant. The pattern of initial decrease in rate of positive care actions when combined with the mixed result for PDs at Residential Site 1 indicates that the training did not initially improve care actions. However, three months later with the support of an Action Plan targeting specific care actions, the staff care actions improved. This is supportive of the importance of follow up to face-to-face training with an action plan that identifies specific behaviour and focuses staff attention to improve specific care actions. Action Plan Residential Site 1 The Action Plan is an integral step in the practice improvement process when DCM is used to improve care quality over time (BSI, 2010). It consists of the formulation of a strategy for improvement from specific items at individual staff, group and organisational levels, and review of the effects of this in subsequent maps. The Action Plan at Residential Site 1 was developed following the map at Time 2 and is shown in full in Appendix 3.8 and the Action Plan for Residential Site 2 is at Appendix 3.9. The target behaviours identified in the Action Plan for Residential Site 1 are shown below in Table 8. This plan relates closely with the outcomes of the mapping and was specific so it could be taken up by staff in practical actions to improve care. These actions are listed in the Appendix 3.8. Mapping at Time 3 shows that the plan has been effective in making a difference to staff behaviour in these areas with higher rates of staff informing residents before providing care and seeking permission (Items 2-5). This 31

32 was mostly successful with Activity Staff who adopted these behaviours consistently at Time 3. Table 8. Target behaviours for Residential Site 1 Action Plan. Target behaviour 1. Break the task into small instructions during ADLs 2. Tell residents what you are going to do 3. Ask permission 4. Use of names, affirm identity residents need to know that you know who they are 5. Use of physical & verbal prompts rather than taking over 6. Focus on creating calm atmosphere. Avoid excessive loud voices, noises which creates more agitation 7. Sessions to be incorporated into Professional Training Day Residential Site 2. Table 9. below shows a detailed analysis of PDs and PEs related to each of the five Fundamental Needs at Residential Site 2 at Times 1, 2, and 3. (see next page) 32

33 Table 9. Detailed analysis of PDs and PEs related to each of the five Fundamental Needs at Residential Site 2 at Times 1, 2, and 3. DETRACTORS Time 1 Time 2 Time 3 ENHANCERS Time 1 Time 2 Time 3 COMFORT Intimidation Warmth Withholding Holding Outpacing Relaxed pace Sub-total Sub-total IDENTITY Infantilization Respect Labelling Acceptance Disparagement Celebration Sub-total Sub-total ATTACHMENT Accusation Acknowledgement Treachery Genuineness Invalidation Validation Sub-total Sub-total OCCUPATION Disempowerment Empowerment Imposition Facilitation Disruption Enabling Objectification Collaboration Sub-total Sub-total INCLUSION Stigmatisation Recognition Ignoring Including Banishment Belonging Mockery Fun Sub-total Sub-total TOTAL PDs TOTAL PEs Display of these results in Figure form reveals the specific nature of the change from Times 1-3 for each need at each site. In Figure 6 and 7 the PDs and PEs respectively for Residential Site 2 are displayed related to each need. 33

34 Figure 6. Personal Detractors and Fundamental Needs for Residential Site 2 at Times 1-3. There is a consistent decrease in PDs from Time 1 to Time 2 for all needs. This continues for Identity, Attachment and Occupation. PDs that undermine Inclusion and Comfort increase from Time 2 to Time 3. The most impressive decrease was in PDs that undermine Occupation ( ). These were Imposition (16-2-2), Disempowerment (2-5-2) and Objectification (2-6-2). Observed examples of these care actions include: feeding a person too quickly, and not waiting for them to swallow before offering the next spoonful; taking a fork from a person and feeding them because they were slow; and Come with me I ll take you to the toilet. Figure 7 below shows the Personal Enhancers for Residential Site 2 at Times 1-3 for each Fundamental Need. Levels of Personal Enhancers were low across all needs in the map at Time 1 and Time 2. It is not until Time 3 that we see a marked increase in the frequency of positive care actions in all but care actions that are supportive of Comfort. 34

35 Figure 7. Personal Enhancers for Residential Site 2 at Times 1-3 for each Fundamental Need. The most notable increase is for actions that support Occupation. These include Enabling (1-0-5), Empowerment (0-0-0), Facilitation (0-0-1) and Collaboration (1-0- 0). Enabling contributed most to this increase. Although the level of positive events was lower than the level of negative events the trend is important for assessing the effectiveness of the effort for change in care practices. The Enabling care actions included: staff slowly and patiently supports person with apraxia to stand; staff keeps the conversation going with the person so he could enjoy the book on Australiana, asking questions and prompting with comments; Inclusion increased from 1 event at Times 1 and 2 to 4 at Time 3. This was due to staff providing Recognition and Inclusion (Person looks lost, staff notice it and invites her with a gesture to sit with her), and Fun (joking with a resident about the name for her bear; joking about sleeping in the unit on a hot night). There was no increase in comforting care actions and little increase in care actions affirming Identity. 35

36 Action Plan Residential Site 2 As with Residential Site 1 the Action Plan for Residential Site 2 was developed by management and staff at Residential Site 2 following the Time 2 map and feedback session. This is shown in full at Appendix 3.9. The specific items identified in this Action Plan are listed in Table 10 below. Table 10. Action Plan items from Residential Site 2 at Time 3. Ensure all residents have " what matters to me " completed Reduction of large 32 bed unit to more home like environment Monthly visit by DCC to each site La Trobe unit team meeting Improved sensory boxes established " All about me " poster Residents family meetings Person Centred Care framework Sunshine Club - Daily sensory stimulation group Improve knowledge and understandings of PCC Lower level of stimulation during meal times Address outpacing during meal times New staff program Improving staff communication to residents Improve holistic care / shift from task focus culture There are specific actions identified in this plan that address the documentary, environmental and organisational supports that facilitate change to improve resident experience and also changes that directly address staff behaviour to improve resident experience. An example of this is the environmental change of turning the television off during meals to address the need for Lower level of stimulation during meal times. A documentary support was to conduct an annual random audit of files to ensure all residents have " what matters to me " completed. A staff behaviour change was to improve staff communication to residents. The specific behaviours to be improved are not identified in either the item or the strategy (staff education). 36