10th Annual Provincial Conference Long Term and Continuing Care Association of Manitoba May 14, 2013 Lori Schindel Martin, RN, PhD Associate

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1 10th Annual Provincial Conference Long Term and Continuing Care Association of Manitoba May 14, 2013 Lori Schindel Martin, RN, PhD Associate Professor, Associate Director SRC Daphne Cockwell School of Nursing Chair, GPA Advisory Committee, AGE

2 Background Caregivers want and need to learn compassionate, effective ways to help persons with dementia when they are upset and frustrated After an incident, caregivers (all departments) report feeling unprepared, helpless, vulnerable Concern that all persons with dementia be treated with respect, dignity Focus on older adults, with cognitive impairment, some of whom are frail

3 Why Education on Responsive Behaviour? Patient safety Improved quality of care for elderly patients who are cognitively challenged Staff safety and work place satisfaction

4 Background: Dementia in LTC 59.3% of new admissions to Ontario LTCHs ( ) had significant dementias, more than half of these people had very severe impairments (Brink, 2013) 33.5% of new admissions had aggressive behaviours, more than half of these people displayed severely aggressive behaviours (Brink, 2013) Studies report that between up to 60% of physically aggressive responsive behaviours occur in 10% 50% of persons with cognitive impairments in LTCHs Responsive behaviours associated with dementia include pacing, exit-seeking, repetitive vocalizations, and resistance to care

5 Responsive Behaviours and Burden of care 60% of front-line staff report distress with resident behaviour (Sourial et al., 2001 ) Few report formal training in behavioural management during their educational programs (Fessey, 2007; Hooker & Larkin, 2010)

6 6 Provincial and professional practice standards Ontario Patient Restraint Minimization Act Occupational Health and Safety Amendment Act (Violence and Harassment in the Workplace) Accessibility for Ontarians with Disabilities Act (AODA) College of Nurses of Ontario Restraint Standard

7 Target-directed, prevention and consequence focused training target-directed (staff focus) prevention (recognize and modify antecedents) consequence (recognize and respond respectfully to catastrophic behaviour while regulating personal emotional response)

8 Uncertainty Temporal uncertainty not knowing when an inevitable harm will occur Event uncertainty probability of the occurrence varies

9 Framework for Dementia Education If you know what to do you can spend more thinking and devote more energy to problem solving during responsive behaviour episodes. This notion builds on Bandura s (1986) theory of self-efficacy (SE): whereby care providers with high SE set and self-regulate appropriate practice goals and cope with practice challenges high SE among practitioners is thought to enhance knowledge transfer.

10 10 The new culture of dementia care is providing person-centred care

11 Overall Goal of Gentle Persuasive Approaches TM Dementia Care To use a person-centred, compassionate, and gentle persuasive approach, when responding respectfully, and with confidence and skill to responsive behaviours of a more escalated nature associated with dementia.

12 GPA Participant Materials Module 1: Introduction Module 2: Brain and Behaviour Module 3: Interpersonal Environment Module 4: Gentle Persuasive Techniques

13 GPA Stats LTC: Currently over 60% of Ontario s LTC homes have staff trained in GPA Geographics: GPA is being offered throughout Ontario and has coaches trained in PEI, Newfoundland, Saskatchewan, and British Columbia. Coaches: AGE currently has 750 coaches certified to teach GPA Participants: Over 100,000 front-line staff members have been trained in GPA Colleges: There are 30 colleges in Ontario that have instructors trained or are in the process of being trained in GPA for PSW students

14 Core Concept of GPA TM Dementia Care Reframing the Meaning Behind Responsive Behaviour Aggressive behaviour is best understood as a responsive behaviour to exert control or to protect or defend oneself. (Talerico & Evans, 2000)

15 19f Harmful interactions: Kitwood Infantilize Treating an adult like a baby or child. Label Using a term as the main way to describe or relate to a person. Outpace Providing information, choices, activities, etc. at a pace too fast for someone to follow. Impose Forcing a person to do something that over-rides her/his desires or denying the possibility of choice. Ignore Carrying on a conversation or an action in the presence of someone as if he/she was not there.

16 Kitwood (cont d) Personhood-promoting interactions: Validate Supporting the emotions and feelings the person is experiencing. Collaborate Working together with the person to enhance his/her abilities and encourage his/her control and choice. Facilitate Accommodating the person s disabilities to enable her/him to do a task or activity. Play & Celebrate Encouraging spontaneity, self-expression, joyfulness and celebration just for fun. Relax Helping the person to relax and feel comfortable without making any intellectual demands. 20f

17 17 ABC of Brain Function ffective Emotions Actions Thoughts ehavioural ognitive

18 18 Behaviour via Information Processing S ensation External stimuli initiate brain processes. P erception Internal interpretation of external world. E motion Each memory links to an emotion. E valuation Feelings are evaluated then a response is determined. D emonstrated behaviour Feelings and thoughts become behaviour.

19 39 The A s of Dementia A nosognosia A mnesia A phasia A gnosia A praxia A ltered Perception A ttentional Deficits A pathy

20 S - Stop & Whatever you are doing can wait. T - Think about what s happening O - Observe P - Plan Give the person undivided attention. Why is she/he behaving this way? Recognize verbal and nonverbal cues and acknowledge the person s emotional message. Consider when you should resume care and how you should modify your approach. 20

21 21 Stopping, Looking & Listening is the Key Russell s story Stop and Go

22 Best Practices in Bathing Unique history Bathing preferences Bathing environment Brain changes 5 A s of dementia Alternate strategies Stop and Go Towel bathing

23 Bathing Strategies It is important to pay MORE ATTENTION TO THE PERSON who is being bathed, than to the task at hand observe the person s feelings and reactions respond positively, not defensively always protect privacy, comfort and dignity look out for signs of agitation be prepared to STOP

24 Towel Bathing Excellent technique for those residents who are sensitive to temperature, have reflex rigidity, or are afraid of water Keeps the resident s body covered at all times Keeps water temperature comfortable for a long period of time

25 Towel Bathing Uses material you already have on hand Can be adapted to residents who require only spot washing of small areas of the body Very helpful for aggressive residents

26 Towel Bathing (Sloane, Hoeffer, Mitchell, et al., 2004) Towel bathing: Reduces aggressive incidents by 60% (P<.001) Reduces discomfort during bathing Does not significantly increase time in bathing (although person-centred showering increases time by mean of 3.3 minutes) Improves skin condition Did not increase colonization with pathogenic bacteria, corynebacteria or Candida albicans

27 Better/Best Basic Practice Divide bathing up into three phases Phase One Therapeutic relationship Phase Two Introduce the bathing event Phase Three Bathe the resident, using Stop and Go

28 Better/Best Basic Practice No rinse soap Towel warmers Potpourri for aromatherapy Music - suitable songs for relaxing Beautifully decorated bathrooms Linens, particularly hand-sized towels and large bath towels Heat lamps Prop products such as bubble baths and soap-on-a-rope to coax residents A prop cart or box to hold prompt items

29 Better/Best Basic Practice Look to the environment Keep the resident warm Keep the resident covered Keep the resident pain free

30 Better/Best Basic Practice Break the care up into small pieces Be prepared to postpone, modify, abandon Bathe the resident at the sink, in the spa tub, in the shower Residents who are progressed far into the disease state should be bathed in bed Remember Towel Bathing

31 Better/Best Basic Practice Modify communication techniques Coax and cajole, never force If bathing must be done, use a gentle approach, and ensure the care plan explicitly states this Remember Stop & Go

32 Better/Best Basic Practice Plan for managing emotional distress of resident Plan for addressing emotional needs of staff

33 33 Tips for Successful Verbal Redirection 1. Validate the person s reality and emotional state. 2. Join in that person s reality and listen to her/his perspective. 3. Distraction is then easier and works best with people who have severe memory or attention problems. 4. Redirection may finally be possible without directly thwarting the now-forgotten goal. You don t need any help to bathe? I understand why you are so upset. You are a very independent person. I know you would prefer to do this yourself. My job is to just help you. Let me get the washcloth ready for you. I ve made sure the water is lovely and warm, just as you like it. Have this biscuit while I massage your back, you may be hungry.

34 Quality Assurance 1. What did I do today that made you happy? 2. What did I do today that you would like me to repeat tomorrow? 3. What did I do today that you would like me to never repeat again?

35 Discussion Point What is your proudest dementia care moment? What made it special? What made it successful? How could you pass this moment on to others? How could this moment be used to change practice in your workplace?

36 Questions? Contact Lori Schindel Martin Daphne Cockwell School of Nursing Ryerson University , ext