The Journal of Quality Research in Dementia Issue 5, May 2008

Dan Nightingale, Director of Medical and Nursing Healthcare and Clinical Hypno-Psychotherapy, The Abacus Clinic, 13 The Meerings, Sutton on Trent, Newark, Nottinghamshire, NG23 6QQ.
Graham Stokes, Head of Mental Health, BUPA Care Services, BUPA House, 15-19 Bloomsbury Way London WC1A 2BA.
Shirley Tikasingh, Becket House Specialist Care Unit, Greenhive Residential Home
50 Brayards Road, London, SE15 2BQ.

Abstract

There are 700,000 people in the UK living with dementia, one third them are living in care homes (Alzheimer's Society 2007a). Good-quality care improves the lives of care home residents with dementia and it is therefore essential to address the current quality of dementia care in care homes and the challenges excellent outcomes for all. 

Serious concerns have been raised about the inconsistencies and lack of person centred focus in the provision of care to people with dementia (National Audit Office 2007, Alzheimer's Society 2007b, Ballard et al 2001), and the Alzheimer's Society believes that standardised, mandatory dementia training is needed for all staff working in the care home sector. 

The clinical directors of two large private providers of private residential and nursing home care (Dr Daniel Nightingale and Dr Graham Stokes); and a nurse manager from an NHS continuing care unit for people with dementia (Shirley Tikasingh) provide their thoughts on training.

Dr Daniel Nightingale

Training of staff in residential care homes should be focussed around three main themes:

1. the impact of the environment on people living with dementia
2. breaking down barriers as part of a true person centred approach to care
3.  holistic care strategies that focus on a humanistic, non-medicalised approach with a strong emphasis on psycho-social interventions

1. The impact of the environment
A great deal has been written about care home environments, much of it based on research outcomes while other information has been anecdotal in most parts. However, I don't believe that care homebuilders and designers have truly thought about the psychological impact one's environment has on well-being. It would suggest the need for this to be in depth. This must happen for the care home environment to be relaxing and homely.

2. Breaking down barriers
Many care and nursing homes continue to develop and encourage barriers, for example through uniforms, staff toilets, staff having their own cups and nursing stations. These barriers encourage a mind-set of 'us and them' and people living in the homes are made to feel both dehumanised and disempowered. Once again, not enough thought goes in to the impact of such practices. It is impossible to provide true person centred care while barriers continue to exist.

3. Holistic care strategies
Psychosocial interventions are proving to have a positive impact with people with dementia when dealing with difficult behaviour. There is much researched based evidence to back this up. However, the intervention is not widely available or offered and there are very few specialists trained in its application. At the same time, in practice, care staff are keen to recommend medicines and some medical personnel are quick to oblige.

There is no evidence to suggest that medicine does have an impact on, for example, behavioural symptoms. Training courses need to include this topic in depth. Though I believe there is a need for more specialists to be trained in the application of CBT, psychotherapy and hypno-psychotherapy for those with dementia, I also think we should be teaching more basic techniques to care staff. Interventions based around doll therapy, pet therapy, aromatherapy can be less alarming for residents. Staff must also be taught how to communicate effectively with people in various stages of the dementing process.

How Might These Key Objectives Be Achieved?

First and foremost, a consistent approach based on best practice guidelines must be implemented. Services across the board have different philosophies, ideals and, of course, priorities. For this reason, I would suggest that consistent training guidelines be made mandatory and receive monitoring through the Commission for Social Care Inspection (CSCI).

Funding bodies must make available the necessary resources to train staff in psychosocial interventions. However, a good, solid induction course for support staff in the care home (prior to carers commencing their direct enabling role in the home) would go a long way to ensuring they have a good understanding of the meaning of person centred care.

The removal of barriers needs to be a directive as opposed to a recommendation. A failing in this issue weakens the person centred approach to care. Also, a directive needs to be issued that ensures people moving into care homes go through a proper transitional process. People should experience a gradual introduction and move into a home appropriate for that individual. Direct family members should be offered the appropriate support, information and guidance and the person with dementia should be offered support through cognitive therapy, other forms of psychotherapy, including hypno-psychotherapy and/or Rogerian Counselling whenever there is an identified need for such interventions.

Dr Graham Stokes

In 2003 BUPA provided 3,954 registered dementia care beds, yet that year's residents' survey revealed that 5,896 residents were assessed by nursing and care staff to have dementia. In addition, a further 4,654 residents were assessed to be 'forgetful and confused' of whom 40% may convert to dementia within three years (i.e. the conversion rate for Mild Cognitive Impairment that initially presents with exaggerated forgetfulness).

Unsurprisingly, many care home residents with dementia, possibly as many as half, do not reside in registered dementia care beds. This is not necessarily an inappropriate outcome, for many will be presenting with co-morbidity and the driver of their care plans may well be their physical health needs. Yet what is certain is that virtually all these people will be cared for by staff who have no specialist skills in dementia care. Understanding aggression when a person resists their care, identifying and measuring the severity of their pain and determining the efficacy of pain relief may be beyond the competence of those whose primary role is not caring for people who are intellectually disabled and are consequently unable to express their needs in ways that are readily understood. And this is the essence of the question that needs to be addressed.

Only ten years ago people with severe dementia lived their lives in psychiatric hospitals; the asylums of a bygone time. While we can be damning of the bleak and austere surroundings within which they lived it was felt that their dementia warranted care by qualified nurses, psychiatrists and other clinicians. Nowadays the care of people with dementia is to be found in care homes where the competence environment is very different. Although many staff are unqualified, this was always the case. Of greater concern is that qualified nurses may have no specialist training in dementia and while this was also observed when care was provided within the NHS, now there are no clinicians to hand who can provide specialist knowledge and interventions. Some care homes function as 'isolated wards' in the community.

This knowledge gap has been addressed by the Alzheimer's Society's report, 'Home from home' (2008). It recommends that 'Training in dementia care must be mandatory for care home staff.' The training needs to not only commend knowledge and skills but also capture the hearts and minds of staff thereby enabling them to work 'with the person first, dementia second'. It recommends training that not only develops specific care competencies but is also geared to drive forward the quality of life of the residents who live in the care homes where they work. However, workplace training as a solution is not without its challenges.

Within the Alzheimer's Society's report one particular challenge was noted. Staff leave, and when turnover is very high problems are created in the development of skills. However this is not the only challenge to address when it comes to introducing and more importantly maintaining gains observed in the training room.

• Change can be stressful - in particular changing to a person-centred culture of care and therefore new ideas from someone returning from a training course are likely to be resisted.
• Does the organisation have a critical mass of staff who can be the agents of change or is the responsibility going to fall on the shoulders of one person who may not be in a position of authority to action change?
•  To what degree do care homes receive on-going external support to maintain training benefits seen in the classroom and prevent likely slippage as staff are eventually consumed by the daily tasks of care?
• What rewards are there for staff who have been trained to be more able and work better in particular if they were the ones who saw the need for change in the first instance?
• Does funding of residents allow staff to be covered so they can be released to attend training opportunities and on their return make change happen? 

Solutions to some of these challenges lie in moving away from sending staff away to attend ad hoc classroom-based training events. Instead, a programme of training and e-learning opportunities geared to meet an identified service and carer need that is centred on a specific care home offers a better chance of success. With a group of workers from the same care setting in attendance it is not just a sole 'hero-innovator' who is trained and then confronts resistance on their return, but a 'critical mass' of people.

The added-value input is workplace mentoring and coaching. Skilled and experienced nurse and care practitioners with leadership skills, possibly badged as 'dementia champions' should provide training in action each and every day by the example they set, thereby sustaining and fostering the lessons of the training. Without this new approach training effects readily dissipate and all that is left are the fine words heard in the classroom.

Ms Shirley Tikasingh

The unit that I manage was relocated to its present site in Nunhead in 2006. It occupies one of four wings in an Anchor Housing Association residential home.

It is a 14 bedded mixed sex unit providing continuing care for older people with mental health problems, many of whom have dementia and   challenging behaviours. Each resident has his own room with en suite facilities and access to a garden. Cooked meals are provided three times per day; snacks and drinks are available throughout the day and night.  The philosophy is to support individual care through enablement, engagement, the promotion of dignity, respect and privacy while allowing choices.

This specialist area requires staff to be suitably equipped with necessary skills to provide care that is sensitive and empathetic. Although the approach to care is multi-disciplinary, it is a very nurse-led environment. A qualified staff nurse is on duty at all times to ensure that recommended practices are maintained and staff carry out safe practices.  Each resident is allocated a key and co-key worker whose responsibility it is to ensure that each resident - and relatives wherever possible, is involved in planning and reviewing his or her care.  The package of care that is therefore prepared reflects his or her unique needs and includes his or her likes or dislikes, assessments, risks and how any needs should be met.                                                                                     

The approach to care attempts to focus on the abilities of the person rather than the disabilities, therefore each resident is enabled to continue enjoying some of the activities he or she did before, with the help of staff. This includes housekeeping, leisure and work activities, visits to places of interest, day centres and shops.
Residents also have a monthly forum in which they are able to express their views about their care and discuss their concerns with staff.
 
To support this person centred approach to care and ensure that quality is implemented, staff have been trained in specific areas to meet the complex needs of residents and the changing needs of the service.  Many are skilled in managing physical  problems such as wound care, infection, diabetes and catheterisation. Others are trained in assessing risk, handling and moving, first aid and infection control. Added to this all staff are trained in caring for older people with dementia, through a course that was developed by the unit's staff.

Practices are sustained through an active teaching programme, good role modelling and development of a competency framework. This framework involves coaching, instructing and mentoring junior staff in specific areas of care before assessing their competency.

This approach to learning is supported by monthly supervision and yearly appraisal which focuses on performance and development of skills and by a rolling 'dementia course' programme, which is also open to staff from the care home sector more broadly. 

The course focuses on the whole person so the topics chosen attempt to meet these needs -  from  physical conditions like diabetes, infections, incontinence,  arthritis  to  behavioural and psychiatric problems,  delirium and depression.  Other areas covered include appreciating sexuality in older people, bereavement and grief, managing risks and spirituality.
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Good dementia care requires staff who have a commitment to working with people with dementia and the right attitude to caring. It is essential that they are able to differentiate between poor practice and different kinds of abuse. Therefore stricter recruitment and selection processes must be implemented.

Summary and Overview

All three expert contributors have emphasised the importance of training, and highlight similar key principles of person centred care . Dr Stokes and Dr Nightingale highlight the importance of training being mandatory and Dr Nightingale has stressed the importance of monitoring through the CSCI inspection process.  Dr Stokes describes some of the practical barriers to the routine implementation of high-quality training, which emphasises the importance of very detailed guidelines that include clear mechanisms for the funding of the training, travel costs and payment of staff for the time they invest attending training as a core part of their job.  Dr Stokes has also highlighted the need for mandatory training to include the opportunity for experiential learning.

Ms Tikasingh describes the training procedures in an NHS continuing care setting, where there is a higher proportion of trained nursing staff and a system in place for more rigorous training, coaching, supervision and appraisal.  Although there are greater resource limitations in the private care home sector, but it will be essential to determine which components of this intensive supervision, coaching and appraisal process could work across the care home sector, so that they can be embedded in any mandatory training. Ms Tikasingh also emphasises that training needs to include a number of key elements beyond dementia care, including assessing risk care and expertise in complementary therapies. 

Ms Tikasingh also emphasises the importance of more stringent recruitment.  This is an interesting idea that merits further exploration so that potential barriers can be overcome and suitable standards can be determined.

Overall,  all three experts concur with the view of the Alzheimer's Society that mandatory training in dementia care is essential across the care home sector.  All three make excellent points about the key issues and components of dementia training, emphasising the rigour and detail that is required in order to achieve workable and effective guidelines.  There is also a need to enable better support of the care home sector from specialist mental health services, including the often forgotten considerable expertise within NHS continuing care provision.

References

Alzheimer's Society 2007, Dementia UK: The full report.

Home from Home: Alzheimer's Society 2007.

National Audit Office 2007, Improving services and support for people with dementia, National Audit Office.

Ballard, C, Fossey, J, Chithramohan, R, Howard, R, Burns, A, Thompson P, et al. (2001) Quality of care in private sector and NHS facilities for people with dementia: cross sectional survey. British Medical Journal 323: 426-427.