An evaluation of the effectiveness of Dementia Care ......the effectiveness of Dementia Care...
Transcript of An evaluation of the effectiveness of Dementia Care ......the effectiveness of Dementia Care...
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
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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
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List of Tables
1 Positive (Personal Enhancers)and negative (Personal Detractors) care actions identified in Dementia Care Mapping
12
2 VIPS Framework – Brooker 2007 15
3 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 1
23
6 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 3.
28
8 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 3.
33
10 Action Plan items from Residential Site 2 at Time 3. 36
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List of Figures
1 Cornell scores at Residential Site 2 at Times 1 & 3 24
2 Cornell scores at Residential Site 1 at Time 1 & 3 25
3 Personal Detractors and Personal Enhancers at both sites at Time 1 & 3 27
4 Personal Detractors and Fundamental Needs for Residential Site 1 at Times 1, 2 & 3
29
5 Personal Enhancers and Fundamental Needs for Residential Site 1 at Times 1, 2 & 3
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6 Personal Detractors and Fundamental Needs for Residential Site 2 at Times 1, 2 & 3
34
7 Personal Enhancers and Fundamental Needs for Residential Site 2 at Times 1, 2 & 3
35
8 QUIS observations (rate per minute) of care provided by one care workers with the same client at Times 1, 2, and 3.
38
9 QUIS ratings during two types of care interaction (rate per minute)
39
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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 person-
centred 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 post-
training 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
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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.
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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
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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
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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:
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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 sub-
contracted 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
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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 self-
report (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).
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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
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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.
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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 person-
centred 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
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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
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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.
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Methodology
The current report builds on our experience of evaluating the effectiveness of DCE
training, offered by Alzheimer’s Australia Vic (AAV) in 2009-10. 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 Post-
training.
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 ageing-
in-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
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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)
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Instruments
The methods used include: direct observation (DCM and QUIS), compilation of in-
house data (Falls, Skin Tears, Behavioural incidents, response times), survey self-
report (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
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• 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 Interactions during the appropriate delivery of physical care
Neutral Brief indifferent interactions not meeting the definitions of other categories
Negative Protective Providing Care, keeping safe or removing from danger but in a restrictive manner, without explanation or reassurance
Negative Restrictive Interactions that oppose or resist residents’ “freedom of action” without good reason, or which ignore participants as a person.
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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, non-
functional 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 30-60 minutes,
providing too few time periods for study
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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.
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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 2011.
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 10.57 --- 17.00 16.67 CORNELL 10.89 9.25 11.71 11.18 Falls (per resident)(incl 'found on floor') 0.93 0.73 0.28 0.56 Skin Tears (per resident) 0.20 0.20 0.16 0.09 Bruises (per resident) 0.07 0.13 0.06 0.22 Aggression (per resident) (verbal and physical) 0.07 0.20 0.28 0.16
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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.
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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 +1.38 +1.61 +1.52 +1.22 +1.19 +1.31 Potential for Positive Engagement 74.19 73.66 65.62 76.50 75.82 60.00 Occupational Diversity (No.) 8.00 8.00 8.00 7.00 9.00 9.00 Passive engagement (%) 17.29 17.66 17.19 6.30 13.13 20.31 Agitation (%) 1.00 0.00 1.00 3.80 3.00 2.00 Withdrawal (%) 5.94 6.62 13.75 14.47 9.67 17.38 Unresponded-to distress (%) 0.00 0.00 1.00 1.00 0.00 0.00 UNMEs (No.) 0.00 0.00 0.00 0.00 0.00 0.00 Rate of PEs (per Time Frame) 0.037 0.019 0.056 0.010 0.004 0.024 Rate of PDs (per Time Frame) 0.041 0.042 0.067 0.120 0.068 0.058
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.
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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.
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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 0 0 0 Warmth 4 1 2 Withholding 0 1 2 Holding 0 0 0 Outpacing 5 0 2 Relaxed pace 4 0 0 Sub-total 5 1 4 Sub-total 8 1 2 IDENTITY Infantilization 1 0 8 Respect 3 0 6 Labelling 0 1 0 Acceptance 1 0 2 Disparagement 0 0 0 Celebration 0 3 4 Sub-total 1 1 8 Sub-total 4 3 12 ATTACHMENT Accusation 0 0 0 Acknowledgement 0 1 0 Treachery 1 2 2 Genuineness 1 0 0 Invalidation 3 4 2 Validation 3 0 7 Sub-total 4 6 4 Sub-total 4 1 7 OCCUPATION Disempowerment 2 1 2 Empowerment 1 0 0 Imposition 13 14 13 Facilitation 3 1 3 Disruption 3 5 6 Enabling 2 0 2 Objectification 0 0 0 Collaboration 0 0 1 Sub-total 18 20 21 Sub-total 6 1 6 INCLUSION Stigmatisation 0 0 2 Recognition 1 6 2 Ignoring 2 1 2 Including 0 1 4 Banishment 0 0 0 Belonging 0 0 0 Mockery 0 0 0 Fun 4 0 1 Sub-total 2 1 4 Sub-total 5 7 7 TOTAL PDs 30 29 41 TOTAL PEs 27 13 34
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
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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.
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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)
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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 0 0 0 Warmth 1 0 0
Withholding 8 0 3 Holding 0 0 0
Outpacing 0 1 1 Relaxed pace 0 0 0
Sub-total 8 1 4 Sub-total 1 0 0
IDENTITY
Infantilization 11 3 1 Respect 1 0 0
Labelling 0 1 1 Acceptance 0 0 1
Disparagement 1 0 0 Celebration 1 0 0
Sub-total 12 4 2 Sub-total 2 0 1
ATTACHMENT
Accusation 0 0 0 Acknowledgement 0 0 1
Treachery 5 2 0 Genuineness 0 0 0
Invalidation 13 4 3 Validation 1 1 1
Sub-total 18 6 3 Sub-total 1 1 2
OCCUPATION
Disempowerment 1 5 2 Empowerment 0 0 0
Imposition 16 2 2 Facilitation 0 0 1
Disruption 8 7 7 Enabling 0 0 5
Objectification 2 6 2 Collaboration 1 0 0
Sub-total 27 20 13 Sub-total 1 0 6
INCLUSION
Stigmatisation 0 0 0 Recognition 1 0 1
Ignoring 6 5 8 Including 0 1 1
Banishment 2 1 0 Belonging 0 0 0
Mockery 0 0 2 Fun 0 0 2
Sub-total 8 6 10 Sub-total 1 1 4
TOTAL PDs 73 37 32 TOTAL PEs 6 2 13
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.
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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 (27-20-13).
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.
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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.
Evaluation of the effectiveness of Dementia Care Essentials 2012
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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).
Evaluation of the effectiveness of Dementia Care Essentials 2012
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However, it is clear from the results of mapping at Time 3 that there has been an
improvement in the number of personal Enhancers supporting an improvement in the
behaviour of staff toward residents.
Comparison of the Residential Site 1 Action Plan with the Residential Site 2 plan
shows that most of the latter items are ‘higher order’ items than the specific
behavioural items identified in the Residential Site 1 Action Plan. Although the
Residential Site 1 Plan does identify one organisational item (“Sessions to be
incorporated into Professional Training Day”) most items are focussed on specific
staff behaviours that can be improved. The Residential Site 2 items predominantly
address the organisational dimension of care improvement. Residential Site 1
focussed on changing specific staff behaviour through training and feedback to
groups of staff, particularly Activity staff. Residential Site 2 have focussed on
organisational actions that enable different staff behaviour such as “provide more
time for staff to assist during meals” as an action to address staff outpacing residents
during meal assistance.
QUIS – Community Site 1
Observations were conducted in the homes of clients of Community Site 1. The
logistic difficulties of observing the same dyads of client and care worker (and a care
worker who attended the training) meant that there were limited opportunities for
observations of care workers.
As detailed above, the observations were predominantly of social conversations
around the dining or kitchen table rather than of personal care interactions. Only one
dyad of client and direct carer was observed at each of Times 1, 2, and 3. The
results of this series of observations is shown in Figure 8 below.
It is clear that with three separate observation times there is marked variation. On
each occasion the client, a divorced elderly male gentleman living alone (except at
Time 3), was observed sitting at his kitchen table. The care worker proceeded to
Evaluation of the effectiveness of Dementia Care Essentials 2012
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engage in checking the client’s welfare with a discussion over a cup of tea about his
bills, any events that needed to be followed up from her discussions with the Care
Manager, and any shopping that needed to be done. She did not take him shopping
during each of these observations but constructed a shopping list with him for a
future visit, checked the fridge and assisted him to sort his bills.
Figure 8. QUIS observations (rate per minute) of care provided by one care worker with the same client at Times 1, 2, and 3.
At Time 2 his dog had just died and he was digging a hole to bury it when the care
worker arrived. He was distressed and tearful as indicated by the Mood scores at
Time 2. She provided social support by sitting with him rather than engaging in
checking bills, fridge and shopping. She successfully adapted her approach to his
needs.
At Time 3 his son and the son’s partner had moved back to live with him and there
was concern that the client may be exploited by this. However, the client was very
positive and enjoying the company of his son. The care worker did not impose her
concerns on the client but validated his perspective. She later expressed her
concerns to the care manager.
The same care worker was observed showering a client who had refused a shower
for several weeks. The care worker used her knowledge of client preferences to
Evaluation of the effectiveness of Dementia Care Essentials 2012
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purchase four chocolate muffins that she knew her client liked. She strategically
opened the muffins on arrival and said that the client could have one warmed up
after she had a shower. The client was initially sceptical but walked with her to the
bathroom where the care worker quickly turned on the water and engaged her in
conversation that kept the process going until she was showered and dressed. They
returned to the kitchen where she ate her warm muffin with enthusiasm.
This episode reflected the skills of the care worker in using strategic thinking and
knowledge of the person to sensitively and skilfully overcome a growing problem for
the person’s care.
Figure 9 Rate per minute of QUIS ratings during two types of care provision.
Figure 9 above shows the two types of interaction with the two clients mentioned
above at Time 3.
The care worker adapted her care work to the activity that was necessary in each
circumstance. During showering she provided more Positive care enticing the person
with the muffins and did not engage in Negative Restrictive or Negative Protective
actions to achieve her goal. In the kitchen table interaction she provided more
Positive Social interaction, conversing, asking questions to maintain connection with
him and to ascertain his views about his son’s presence in the house. There was
Evaluation of the effectiveness of Dementia Care Essentials 2012
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less Social Engagement from the showering client than the kitchen table client
although there was considerable talking by the care worker during the shower as she
kept the person oriented to and engaged with the task.
Community Site 1 Action Plan
The Community Site 1 Action Plan was developed following the QUIS observations
and staff attendance at the DCE training. It consists of items that are strategic plans
for future action rather than actions that focus on specific staff behaviour for change
now. These items are found in Appendix 4.2 The items are related to the
Organisational Review. A composite list of these items listed as changes to the
organisational review from Time 1 to Time 3 for all sites located in Appendix 1.2.
Organisational Review
The organisational review was completed using the VIPS Framework at all three
sites at Times 1 and 3. This 24-part tool provides a comprehensive assessment of
the provision of person centred care from an organisational perspective (D. Brooker,
2007). As stated above the period from Time 1 to Time 3 was three months. This is a
brief period in which to expect noticeable changes to have occurred given that the
literature on organisational change suggests that longer periods up to three years
may be necessary
The method of completion varied between sites. At Residential Site 1 the Quality
manager completed the review, at Residential Site 2 several senior staff completed
the review and it was approved by executive level managers for sign-off, and the
same process occurred for Community Site 1.
Table 3 above lists the four domains and the 6 areas per domain that comprise the
VIPS Framework indicators. A table of changes and proposed changes made by
Evaluation of the effectiveness of Dementia Care Essentials 2012
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each site is included in Appendix 1.4. The full organisational reviews are available
from the author.
All three sites rated their organisations the same at Times 1 and 3. As the rater at
Residential Site 1 explained, “The scores didn’t change but what we did in some of
the areas was different”. Scores for Residential Site 1 and Community Site 1 did not
change. Scores for Residential Site 2 changed from an average of 2.33
(representing OK-Good rating) to 2.95 with increases in 10 of 24 indicators.
Most ratings are “Good”. There were 8 ratings of “Needs more work” for Residential
Site 2 at Time 1 and only three at Time 3. All 8 indicators that needed more work
were addressed with actions or proposed actions that involved regular activities that
had not yet taken place but for which there was a plan. This activity in the action plan
had an effect that brought the rating up to “Good” in all five cases where
improvement was made. There was one “Needs more work” rating for Community
Site 1 at Time 1 and one for Residential Site 1 and these did not change at Time 3.
Appendix 1.2 contains a table of changes that were recorded against each indicator
of the VIPS Framework. The pattern of changes is different for each site. Residential
Site 1 engaged as evident in the Action Plan in more staff-focussed changes and
Residential Site 2 engaged in a broad range of changes including organisational and
staff-focussed and incorporated the organisational review into the Action Plan so that
each action was allocated to an indicator of the VIPS Framework. This integrated
approach enabled them to connect the specific actions with the organisational
consequences.
The Residential Site 1 changes focussed on the “Social” dimension of the VIPS
Framework emphasising the actions that affected the relationships staff had with the
residents in aspects such as warmth and inclusion. They recorded that there was
“more emphasis” on these indicators without identifying specific strategies as they
did in the Action Plan (see Table 9 above).
Evaluation of the effectiveness of Dementia Care Essentials 2012
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Residential Site 2 took a more broad ranging approach addressing all four
dimensions of the VIPS Framework with only five of the 24 indicators not addressed
by the Action Plan in actual or proposed changes. 14 indicators contained proposed
changes that were more long-term projects such as “Structural separation of 32-bed
unit into two 16-bed units” and “Quarterly family meetings for information and
education”. Residential Site 1 had 19 indicators in which there was no changes
made and did not identify proposed changes.
Community Site 1 utilised the ‘residential’ focus of the VIPS Framework and
successfully completed it for Time 1. They reported at Time 3 that on review nothing
had changed. The only area that needed more work was individualising care
planning. No further information was provided.
Staff Surveys
A survey was sent to all participants in the DCE training from all three sites in both
online (a link in an email) and hardcopy. Of the 62 participants 21 responded to the
survey. Of these, 18 were hardcopy responses and three online. The survey
questions are located in Appendix 2.
The training was viewed overwhelmingly positively by respondents with 100% rating
it “Extremely high quality training” or “High quality training”. What was most
memorable varied widely from “how we can handle people with dementia”, “working
together as a team” to” Creating our own person and then working together to
organise the help they needed to live a fulfilling life”. What the participants learned
included “stop and listen”, “ask for consent before providing care” and “never
underestimate what a person with dementia can do”. All agreed they were doing
things differently as a result of the course and gave examples such as “giving the
person my uninterrupted time” and “looking at the person past life history”. They
believed the training was consistent with the approach taken by their organisation to
supporting people with dementia and that this increased the extent to which hey
Evaluation of the effectiveness of Dementia Care Essentials 2012
43
were able to apply the learning from the course to their work. All respondents
believed the course has changed the way their organisation provides support for
people with dementia. Examples included more communication among staff, better
team work, and “Trained staff are happier to work with people with dementia
because they have more clear idea of their psychological needs- they are more
sensitive to the needs of people with dementia”.
Overall the survey results indicate that the subjective experience of the participants
in the DCE training course were very positive and believed they and their
organisations benefitted from the course and were able to make improvements to the
way they provide care to people with dementia.
Comparison with Competencies
The national competencies for the two units that comprised the Dementia Care
Essentials training course at Certificate III and IV levels were mapped to the
instruments that were used in this evaluation to establish if there was evidence for
the competencies in the care behaviour of staff in the three care groups.
The PEs and PDs of DCM and the positive and negative care behaviours of the
QUIS provided a ready list of indicators that were used to show such evidence
outlined in Table 11. below.
For instance for the competency, “Adapt activities to individual needs” evidence may
be obtained from levels of PEs and PDs related to the needs for Comfort and
Identity. Using this measure the competency may be regarded as present at
Residential Site 1 by Time 3 and at Residential Site 2 with low PDs for these needs
but not with high PEs for these needs.
The QUIS may also be used to provide evidence for the competency by examining
the presence of Positive Care and Positive Social care worker behaviour and the
absence or low levels of Negative Restrictive and Negative Protective care worker
behaviour. In this instance the interactions with the male client over three Times
Evaluation of the effectiveness of Dementia Care Essentials 2012
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provides good evidence for the ability of the care worker to adapt to the changing
needs of the person by providing Positive Care when needed and Positive Social
interactions when needed.
Evaluation of the effectiveness of Dementia Care Essentials 2012
45
DISCUSSION
The aim of this evaluation was to measure the effectiveness of Dementia Care
Essentials training at both Certificate III and IV levels in improving skills of aged care
staff in both community and residential settings. The evaluation utilised a multi-
method repeated measures approach that incorporated action learning.
There were mixed results for depression scores which on average remained
unchanged but when examined for individual residents revealed some improvement
in their levels of depression. Several residents showed slightly more signs of
depression. Without also noting changes to antidepressant medication it is not
possible to attribute such improvements to the effectiveness of the training.
However, improvements of the magnitude noted in the data suggest that there were
significant improvements in quality of life for some residents during the period of the
training and action planning and changes in the way staff act, particularly
attentiveness to emotional wellbeing, may be a contributing factor.
Levels of incidents (bruises, falls, skin tears, aggression) were low across both
residential sites and varied without any perceivable pattern that may be attributed to
any effect of the training.
The evidence of Dementia Care Mapping shows a mixed picture of partial
effectiveness of the training in the residential sites that improved following
implementation of the Action Plan by both sites. The QUIS showed that the staff
member observed over three times showed skills consistent with competency in the
DCE units. However, there is no evidence that this is attributable to the effect of the
training program.
As a general comment it may be said that the training did not have a consistent
effect on care staff behaviour or resident experience in the weeks immediately
following completion of the course. This is consistent with (Nolan, et al., 2008) who
suggest that training on its own is not sufficient to bring about desired improvements
in quality of care.
Evaluation of the effectiveness of Dementia Care Essentials 2012
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However, we can see improvements specifically related to the stimulus that training
provides once they are focussed and elaborated in an action planning and
implementation process. The action planning that took place following DCM at Time
2 led to specific improvements in targeted care behaviour, particularly at Residential
Site 1. Levels of PEs supporting most fundamental needs increased at Residential
Site 1 and levels of detracting care actions did not increase supporting the view that
by targeting specific care behaviour and providing a rationale and context for it with
training can enable care staff to embrace appropriate care behaviour and so improve
the quality of care provided. At Residential Site 2 the same improvement following
the action planning and implementation in targeted behaviours in lower levels of
most PDs and higher levels of most PEs at Time 3. This trend indicates that if further
cycles of action planning and mapping were conducted PEs would be greater than
PDs in one or two cycles.
Training is an integral component of this quality improvement process. It stimulates
the use of knowledge and improvement in skills by exposing staff and management
to new ideas and models of care. However, this evaluation indicates that training
should to be followed up with practical application and reflective analysis of the
practical care situation so that the knowledge and skills can be integrated and
applied to the current situation, thus causing improvement in care and care
experience.
The DCM practice improvement process is typical of such processes. It is built on
the Plan-Do-Study-Act model of stepwise systematic action based on evidence. The
development of the British Standard (PAS800) for DCM has provided a succinct
process for aged care homes to follow to implement this simple but powerful process
that supports the work of training with data gathering, reflection on practice in the
feedback and identification of specific change targets for implementation and then
further data gathering in subsequent cycles of DCM.
The standard identifies training as an essential precursor to the implementation of a
person centred approach to caregiving. It prepares the ground as it were and
Evaluation of the effectiveness of Dementia Care Essentials 2012
47
provides the participants with a language for caregiving that includes notions of
empathy and personhood, validation and attachment. It sensitises staff to the
importance of being empathically reflective about their practice so that they can take
advantage of the data that can be obtained by DCM. It also stimulates staff
members’ imagination for what care could be like, what is possible in their work.
It is clear that there is not only one type of activity that can be the focus of an action
planning process. The two residential sites in this evaluation had very different
processes and foci for their effort. Residential Site 1 focussed tightly on the feedback
from the mapping at Time 2 and made a short list of specific behaviour that staff
were to focus on and improve. Residential Site 2 used the feedback as a stimulus for
reflection that focussed broadly upon improvement but across several dimensions.
This gave them the opportunity to address individual staff care actions, program
improvements, organisational scheduling and physical structure changes,
incorporating these actions into the ongoing and existing quality improvement
procedures of the organisation. Senior executives were involved in sign-off of the
organisational review and in monitoring and contributing to identification of the action
plan indicating an organisational readiness to engage with the feedback provided by
DCM and an organisational capacity to embrace information and take action upon it.
Residential Site 1 has expressed interest in taking this process further. The success
they experienced with a focussed approach to the feedback and action planning has
added impetus to an organisational thrust for improvement in care quality that has
been under way for several years.
The organisational review with the VIPS Framework was useful to draw the attention
of participating organisations to the corporate and procedural dimension of person
centred practice improvement. All sites incorporated the action plan into the
organisational review, noting changes that were related to specific indicators.
Residential Site 2 and Community Site 1 both incorporated the action plan into their
review in a systematic manner that reflected an existing practice of integrating
actions into a process and seeing the implications of those actions for care quality.
Evaluation of the effectiveness of Dementia Care Essentials 2012
48
Residential Site 1 as an organisation has an active quality improvement process and
focussed their efforts on specific behaviour of staff. The organisational and program
dimension of quality improvement was not the focus of their attention during this
period, having already made significant inroads in recent years.
However, they have noted that this experience has provided added impetus to their
intention to roll out such a focussed approach across all areas of the organisation.
They are also intending to address the problems that were identified as a result of
the feedback from the DCM Time 3. This included awareness that the improvements
in care behaviour were taken up by some staff and not others. Once this was clear it
became a matter of identifying the reasons this occurred and now making further
action planning to address this issue. This will lead to further cycles of mapping,
feedback and action planning.
Such insight into the real situation, based on the data from direct observation that
DCM provides gave the Residential Site 1 executive the direction and impetus for
accurate and effective future action. In this way future training can be targeted
accurately and effectively to the topic that will produce needed wellbeing benefits for
residents. This is an efficient use of funds for training.
Both sites found that even though they made specific organisational, programmatic
or staff behaviour changes, this did not necessarily alter the rating they gave
themselves for each indicator. So despite effort in one area the rating may remain
“Needs more work”. This is often the case with benchmarking tools when the real
focus is on making the specific changes rather than achieving an improvement rating
from one categorical rating to another. It is also important to take into account that
three months is not a long time to bring about lasting organisational change.
It is important that each site integrated their action planning efforts into the
organisational review of their work. By doing this they were able to see where they
were located in terms of progress toward a goal of developing a more person
centred organisation and not just address discrete staff actions.
Evaluation of the effectiveness of Dementia Care Essentials 2012
49
The VIPS Framework is a means of maintaining attention on the multifaceted
experience of implementing quality improvement in care and helps organisations
avoid the mistake of thinking that providing a training course on its own is sufficient
to achieve any effective change in care quality.
The QUIS was used in this evaluation in an adapted form for the observation of the
care behaviour of staff and care experience of clients in their own homes. In its
modified form with domains that identify both client and carer actions it is more
comprehensive and practical for this community care staff group than in the form it
had when originally designed for observation in residential settings.
We can see from the work of the care worker observed over three time periods in the
community setting that she has the skills to provide effective person centred care
and that there is evidence to support her competence in the requirements for areas
of the DCE training course. However, it is not possible from the data to say that the
training course caused her to improve. The situations were so different that she
acted differently in each situation, quite appropriately, showing adaptability to the
individual in her care. The QUIS was effective in detecting the differences in types of
interactions but was not effective in detecting whether these changes were
improvements from one Time to the next. Perhaps incorporation of elements from
DCM such as PDs or PEs or the ME values to measure client response to care could
improve the sensitivity of the QUIS. There is need for the development of a tool to
reliably measure the quality of care provision and experience in the community
setting.
Limitations
The limitations of this study are several. It is small in size and so limited in the
statistical power and sophistication of any analysis. The small size also restricts the
variability that can be included in the sample, raising the question of generalisability
of these results to aged care organisations that differ from those studied in this
evaluation. It is possible that a “pilot’ study like this may provide direction for a larger
Evaluation of the effectiveness of Dementia Care Essentials 2012
50
study that includes more variation on aged care sites that reflect a more typical
sample of aged care sites.
With only one community care site in the study the conclusions that may be drawn
are tentative at best. Community aged care is a relatively recent phenomenon in the
history of the care of people living with dementia. It is the fastest growing sector of
publicly funded aged care in Australia. The client-care worker dyads that were
observed showed that there are context specific interactions that differ radically from
residential care. Care managers visit to discuss care rather than provide care, often
reflecting on the care needs of the client with the client’s spouse/adult child. Direct
care workers visit to provide specific care in the form of housework and other forms
of housekeeping that include preparation of shopping lists and actual shopping, or
assistance with personal Activities of Daily Living (ADLs). These widely varying
involvements make it difficult to systematise these interactions in a valid metric that
captures the subjective quality of life experience of living at home with dementia.
The QUIS was adapted in this study and sensitively detected the variation in care
activity. It remains to be developed as described above so that the full range of care
activity and the full range of care recipient behaviour can be captured in a measuring
instrument that validly and reliably measures the reality of community care.
The organisational context of community care providers contains inherently complex
relationships between care package providers, direct care providers and care
recipients that make the logistical tasks of organising regularly scheduled
observations difficult. Often the care or case manager works for an organisation that
sets up the care package and engages another organisation to provide the direct
care workers who will visit the client’s home regularly. In this evaluation the direct
care workers were (unusually) employed by the organisation that established the
care packages. This is an integrated model that enables much closer coordination of
care provision and communication of information from direct care worker to care
manager. Even so there are often several care workers rostered to work with an
individual client over a two week roster. An individual care worker may work with a
Evaluation of the effectiveness of Dementia Care Essentials 2012
51
different list of clients each roster period. They work part-time mostly and may work
for several care organisations. This variation makes the observation of dyads rather
unpredictable and introduces a possible source of confusion to data obtained from
community care observations. It also undermines the fundamental need for
attachment that stable caregiving fosters. As community care organisations mature
they are introducing more structure and cohesion into their provision of care (e.g.
integrated model) that may make the conduct of systematic observation in
community care a more predictable task. However, as evident in this set of
observations there remains considerable unpredictability in the care experience.
The study shows after 3 months and one cycle of action planning that changes at all
levels of the organisation are making a difference to care quality. However, as the
graph of PDs and PEs (Figure 3) shows one cycle of action planning is not sufficient
to improve the level of PDs or PEs to the point where PEs predominate. Further
cycles of action planning and further data gathering using tools such as DCM are
required to both broaden and deepen the improvements that have begun to occur.
Residential Site 1 found that one sector of the staff group responded to the action
planning but another sector had not, giving rise to further reflection and problem
solving that will in turn become an action plan for a subsequent cycle of
improvement. Future studies should include multiple cycles of action planning so that
the scope of change over time can be studied. Whatever the source of data (DCM or
QUIS or other multiple sources) these cycles of change are an essential structure
within which to embed staff training. Training then becomes a stimulus for and
reinforcer of change in care practice.
Conclusion
The results of this evaluation indicate support for the effectiveness of Dementia Care
Essentials as a mechanism for quality improvement in provision of care for people
living with dementia in residential and community aged care settings.
Evaluation of the effectiveness of Dementia Care Essentials 2012
52
However, consistent with (Nolan, et al., 2008) who maintain that education is a
necessary but not sufficient condition for success in efforts to improve quality of care,
the evaluation indicates that the training is effective when embedded within a
process of practice improvement that addresses care staff actions and the
organisational dimension of the aged care context, and not as effective in improving
care practices when used as a stand alone intervention.
Evaluation of the effectiveness of Dementia Care Essentials 2012
53
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APPENDICES
1. Organisational Review
1.1. VIPS Framework
1.2. Changes to the Organisational Review from Time 1 to Time 3 for all sites
1.3. Essential skills for participants in DCE
2. Participant Survey Questions
3. Dementia Care Mapping
3.1. Behaviour Category Codes
3.2. Mood Engagement values
3.3. Personal Enhancers and Personal Detractors
3.4. DCM Feedback Residential Site 1 Time 2
3.5. DCM Feedback Residential Site 1 Time 3
3.6. DCM Feedback Residential Site 2 Time 2
3.7. DCM Feedback Residential Site 2 Time 3
3.8. DCM Action Plan Residential Site 1
3.9. DCM Action Plan Residential Site 2
4. QUIS
4.1. QUIS (adapted) data collection sheet
4.2. Action Plan for Community Site 1
5. Mapping of national competencies to DCM PE and PD categories and QUIS
behaviour categories