Training for and Sustaining Person-Centered Dementia Care

Researchers from Project RELATE (Research and Education for Living with Alzheimer’s Disease and other Dementias: Therapeutic Eldercare) have piloted a person-centered staff development system to train nursing home staff in the care of people with dementia. Person-Centered Care (PCC) focuses on the resident as the center of the care process. Based upon Kitwood’s1 theories, PCC seeks to meet the psychological, social, and physical needs of the person with dementia. Kitwood’s research with Dementia Care Mapping led him to describe the needs of a person with dementia as a need for unconditional love, comfort, attachment, inclusion, occupation, and identity. When a person with dementia is facing anxiety, or when some hidden wound is reopened, the needs become apparent, largely through problem behaviors. Kitwood envisioned a cyclic pattern where as one need is met, others are too, thus reducing problem behaviors and leading to an enhancement of global self-worth. Understanding the needs behind the behavior of the person with dementia is an essential step to a therapeutic environment for a person with dementia. Quite a few nursing homes have tried to implement person-centered care initiatives. However, the gap in the research is evaluation of the outcomes for residents, family, and staff. In addition, sustainability over time has not been measured. The primary objective for Project RELATE is to develop a system of care to train healthcare providers, informal caregivers, and family, focusing on an individual as a human being, not an object for which a task needs to be accomplished. It is inherent in the design of this system to demonstrate consistent measurable improvement in care outcomes for people with dementia, as well as portability across different care environments and sustaining of outcomes over time. DETERMINING CONTROL POINTS There is a complex set of variables and interactions that interface between training caregivers and improving outcomes for persons with dementia. In the development of Project RELATE’s initial intervention, influence diagramming—systematically used in engineering model development—was adopted, allowing the research team to define key variables and their relationships to each other, thereby molding them into a model of dementia care. The model included the dementia care recipient, the formal care system, and the family care system. The relationships between these three systems was further defined by measurable variables linked together based on how they influence each other. In evaluating the overall model, the team identified variables to be used as control points for the initial intervention. By assessing the impact or degree of change in a variable and the influence that the change would have with the other variables in the model, allowed the team to choose variables as control points, with the ultimate change occurring in a positive improvement in the quality of life for persons with dementia. The overall model has a structure in which the family and paid caregivers are interacting in two principal ways with the person with dementia; with respect to ADL care and with respect to a person-centered response. The extent of paid caregivers’ workload and performance on their job is influenced by whether the needs of the person with dementia are being met. For example, if needs are not being met and behaviors reflect that, the staff will have a tougher workload. The family caregiver’s burden and coping is also affected by whether the needs of the person with dementia are being met. As the research team worked with the model structure, three main control points became apparent. First, it was important to improve staff’s knowledge of the individual resident with whom they were working. Second, the staff needed to be ready, willing, and able to provide person-centered care. Having both variables present in staff care was determined as pivotal to creating a person-centered response to the individual with dementia. In addition, it became apparent that to motivate and sustain excellent dementia care by certified nursing assistants (CNAs), the nurse who most closely worked with the CNAs must mentor them by observing, providing feedback, and setting goals with the CNAs. DEFINING THE INTERVENTION From this model, the research team defined four goals of staff development for training CNAs in person-centered care: 1. Knowledge about individual residents. 2. Knowledge and skills of dementia care for CNAs. 3. Knowledge and skills of mentoring for nurses. 4. Mentor’s skills in evaluating CNAs’ PCC skills. To accomplish these goals, nurse-mentors received three sessions of mentor training, a person-centered approach to mentoring the CNAs that taught them how to observe, give feedback, set goals, and problem-solve with CNAs. In addition to these sessions, they attended five sessions with the CNAs to learn and practice the skills of dementia caregiving. The research team crafted the sessions utilizing interactive techniques that were appealing to staff and drew on their experiences. For example, role playing for practicing communication techniques were used throughout the training. Specific exercises brought nurses and CNAs together to promote teamwork. The support systems put in place included individual coaching between sessions to clarify, model, and allow for skill evaluation on the unit. Tools used were appealing, job-relevant, and accessible to staff. EVALUATING ORGANIZATIONAL CHANGE In order to incrementally measure changes in staff behavior over time, Kirkpatrick’s2 model of organizational change was used to design the evaluation. Kirkpatrick’s model includes reactions, learning, behavior, and results criteria. The research team wanted to determine whether staff liked the training, if they learned the content and skills, if they changed their actual behavior on the job, and if it made a difference to the facility. These questions were measured before and after the training through staff surveys of their reaction to training and organizational variables, knowledge tests, behavioral observation, and focus groups with staff. The pilot was conducted in a 165-bed long-term care facility with 46 CNAs, 48 nurse-mentors, and 50 persons with dementia. The results of the pilot study showed some success on all four levels. First, staff reported enjoying the training. They commented most positively on the experiential training focus. Analysis of qualitative data, such as the focus groups, supported the quantitative findings. Staff intended to transfer what they had learned. Second, their knowledge tests showed that they learned the material and retained that knowledge. Third, CNAs demonstrated improvement in four of the seven PCC behaviors observed using the Behaviorally Anchored Rating Scales (BARS), which measured behavior through direct observation. And lastly, measures of agitation, depression, and quality of life showed trends toward positive results. Staff turnover was reduced by 12%, and staff satisfaction was measured the highest among all Spectrum Health facilities. FORGING AHEAD Project RELATE has received numerous requests from other long-term care settings to replicate the pilot. For the moment, the team is focused on the next study in an effort to continue the research to clearly identify that using PCC and mentoring will result in an improvement in the quality of life for persons with dementia. The next study will focus on refining the mentor training component. Other avenues being pursued are an adaptation of the PCC curriculum for use with family caregivers who are providing care for persons with dementia in the community. G This study was made possible by the Blodgett Butterworth Health Care Foundation through monies donated by Peter and Pat Cook. The authors also thank the staff of Spectrum Health Continuing Care Center for support.