The goal for all of us is to have happy, satisfied residents who are able to live at their highest practicable level of physical and psychosocial ability. Meeting this objective sometimes is difficult, because most eldercare communities have a high number of residents with dementia who may be unable to function well in the environment.
The fact that none of the staff members have experienced what dementia is like makes it difficult for them to understand and relate to some of the behaviors exhibited by residents. Additionally, residents with dementia are unable to describe what is happening to them or explain the reasons for their behavior. This can result in poor decisions, inappropriate use of psychoactive medication and unnecessary hospitalizations.
Over the past decades, there has been a shift in dementia care models from the purely medical model to a more social model. This movement has resulted in requirements to minimize the use of chemical and physical restraints along with a focus on the resident’s right to be treated with dignity and respect. These requirements have resulted in innovative care strategies and an unprecedented focus on individualized, person-centered care.
The need for observable and measurable results in this area, especially in the area of sensitivity, empathy, dignity and respect, is lacking, however. For caregivers to understand concretely what is required of them so they can provide person-centered care, it is essential to break necessary behavior dynamics into easily recognizable dynamics.
Most training programs are lecture, video or role-playing exercises that give a one-off view of dementia. They provide important information about dementia but do not allow for practical experience. Studies indicate that adult learners show the strongest learning outcomes when given the opportunity to be active participants in experiential learning, with direct feedback and concrete recommendations as if they are in the real situation.
Researchers Bogo, Regehr, Logie, Katz and Mylopouolos indicated that educational simulations result not only in improved professional competencies, but also in higher employee satisfaction. DeVinci linked patient satisfaction with the sensitivity of healthcare workers, reporting that the lack of sensitivity threatens patient safety and is a liability for health care providers. She concluded that sensitivity is the core element in quality care delivery.
The Virtual Dementia Tour, or VDT, first was published in 2001 and has been replicated over the past two decades with consistent outcomes. Research conducted on the VDT shows that the opportunity to walk in the shoes of people with dementia allows for better understanding of the behaviors and emotions exhibited by residents and allows for open dialogue about how to best meet their needs. The development of the VDT is based on studies of brain scans and how damage associated with dementia results in behavioral responses as a normal byproduct of the disease.
A three-year project was implemented in Georgia. The VDT was conducted and the Dementia Aware Competency Evaluation, or DACE, was used to determine whether staff members were able to provide empathic person-centered care. Each nursing home selected one staff member to be responsible for DACE. The selected staff member was given materials to prepare and provided with a one-hour webinar along with an assessment to ensure understanding.
The first of three DACE assessments occurred prior to a first VDT site visit at nursing homes providing a baseline. On a Likert scale, staff behaviors were tabulated during activities of daily living care. Within two weeks after the first VDT, the DACE observer conducted the second DACE assessment on staff members who experienced the VDT. Nine months after the VDT was first conducted a second VDT was conducted in the same nursing homes. Within two weeks of this visit, the third DACE was administered.
The DACE observer is tasked with observing staff providing direct care to a resident with dementia with a maximum of 40 points. Staff members are not aware of what is being observed. Where necessary, permission was obtained by the resident’s family for the observation. DACE observers, however, were trained to pay more attention to a staff member’s behavior rather than the resident’s behavior. Although resident response to care was observed, it was the staff response that was tabulated.
The charts below (Figures 1 and 2) show results from 26 nursing homes. Four variables are isolated to ensure greater reliability and validity:
- Same staff member observed on all three DACE assessments.
- Same DACE observer on all three DACE assessments
- Same domain of care on all three DACE assessments
- Same nursing home
Every domain of care shows an increased mean score suggesting that staff is improving empathic person-centered care to residents with dementia. The greatest mean differential is seen during mealtime. The implications are far-reaching in the area of weight gain, improved skin integrity and swallowing. Further study in this area is recommended.
DACE 2 and 3 show little change indicating that once the principles of empathic person-centered care are learned; the behavior is sustained over time.
The chart below shows that staff improved their person-centered care techniques in each domain. As with the cumulative totals on the previous chart shows, there is little change between DACE 2 and 3. The main difference in this chart is that the basic scores are slightly higher.
Figure 2
The behaviors were selected because they are hallmarks of person-centered care. Between first and third DACE, the largest increase in empathic person-centered care behavior was Giving Choices and Breaking Down Tasks, both of which are essential for inclusion of the resident in care resulting in building a relationship with the resident — the hallmark of person-centered care. Eye contact creates trust, caring body language with open arms creates comfort, greeting the resident creates focus, caring touch, and talking with the resident creates an inclusive approach to care with the resident at the center.
Anecdotally, there were reports of observers seeing some abusive behavior resulting in additional training and, in one case, termination of employment of the staff member. It is through assessments such as this one that supervisors are better able to determine staff training needs and avoid potential abuse.
This multi-disciplinary project yielded a positive change in staff behavior toward residents with dementia, along with a greater understanding of what dementia is like. Each measure used was designed to help staff members better understand what their residents living with dementia are dealing with and how empathic person-centered care can be improved to meet their needs.
Assessments such as this one will provide concise information about staff member weaknesses and intentional training programs tailored to DACE. They also can provide a comparative analysis from shift to shift, to pinpoint weaknesses that may need to be addressed. Most importantly, assessments like this one ensure that residents are treated with dignity and respect by holding staff members accountable for their own behavior.
Once staff members realize the importance of their own behaviors as it relates to the care of their residents, caregiving changes. Adding training programs and role-playing to the in-service programs of assisted living memory care communities and nursing homes around the tenants of DACE would escalate successful empathic person-centered care.
As the social model continues to grow in eldercare, it will be up to us to develop ways to assess staff member behavior in observable and measurable ways, thus giving them specific outcomes and parameters of acceptable behavior. The implications, not only for resident care, are implicit but also provide insight to human resource professionals for staff performance measures.
Although we are unable to change the course of dementia, we can change the course of how staff members care for those with dementia.
P.K. Beville, Ph.D., is founder and CEO emeritus of Second Wind Dreams and the author of the Second Wind & Virtual Dementia Tour.
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June 24, 2021 at 11:15AM
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Assessing staff behavior during dementia care - Marketplace Columns - McKnight's Senior Living
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