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HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE
ABSTRACT Hospital clinical staff routinely confront challenging behaviors in
Instructions
patients with dementia with limited training in prevention and
1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must:
management. The authors of the current article conducted a survey
1. Read the article, “Knowing Versus Doing: Education and Training Needs of Staff in a Chronic Care Hospital Unit for Individuals With Dementia” found on pages 26-34, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.
(SD = 2.61), reflecting high level of disease knowledge. However,
2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until November 30, 2016.
Contact Hours This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
of staff on a chronic care hospital unit concerning knowledge about dementia, perceived educational needs, and the care environment. The overall mean score for a 27-item knowledge scale was 24.08 staff indicated a need for more information and skills, specifically for managing behaviors nonpharmacologically (92.3%), enhancing patient safety (89.7%), coping with care challenges (84.2%), and involving patients in activities (81.6%). Although most staff (i.e., nurses [80%] and therapists [86.4%]) believed their care contributed a great deal to patient well-being, approximately 75% reported frustration and being overwhelmed by dementia care. Most reported being hit, bitten, or physically hurt by patients (66.7%), as well as disrespected by families (53.8%). Findings suggest that staff have foundational knowledge but lack the “how-to” or handson skills necessary to implement nonpharmacological behavioral management approaches and communicate with families. [Journal of Gerontological Nursing, 40(12), 26-34.]
Activity Objectives 1. Discuss the learning needs of staff on a dementia care unit. 2. Describe challenging behaviors that occur in patients with dementia.
Disclosure Statement Neither the planners nor the authors have any conflicts of interest to disclose.
D
ementia, a disabling, costly, and challenging disease, affects approximately 5 million individuals in the United States and 15 million families who provide dementia care (Alzheimer’s Association, 2013). The number of individuals with dementia is expected to increase by 300% by 2050 (Hebert, Weuve, Scherr, & Evans, 2013). For those with dementia, age and disease progression, medical comorbidities, neuropsychiatric behav-
Katherine A. Marx, PhD, MPH; Ian H. Stanley, BA; Kimberly Van Haitsma, PhD; Jennifer Moody, RT; Dana Alonzi, OTR; Bryan R. Hansen, MSN, RN, FNE-A; and Laura N. Gitlin, PhD
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iors, physiological instability, and safety concerns result in increased risk of hospitalizations (Callahan et al., 2012; Toot, Devine, Akporobaro, & Orrell, 2013). In the hospital, staff often confront behavioral challenges, for which little formal training is provided. Common behavioral challenges include medication refusal, rejection of needed assistance, fearfulness of medical procedures, heightened confusion, agitation, and verbal/ physical aggression toward staff (Galvin et al., 2010). Managing behaviors is associated with low job satisfaction and burnout (Brodaty, Draper, & Low, 2003; Miyamoto, Tachimori, & Ito, 2010). To manage behaviors, staff
frequently rely on pharmacological agents, which have limited benefits and present risk for adverse events (Gitlin, Kales, & Lyketsos, 2012; Kales, Gitlin, Lyketsos, & Detroit Expert Panel on the Assessment and Management of the Neuropsychiatric Symptoms of Dementia, 2014; Sadowsky & Galvin, 2012). Although nonpharmacological approaches to managing behaviors are endorsed by medical organizations as frontline treatment, they are not typically used because of a lack of knowledge of their evidence, a lack of training in using nonpharmacological strategies, the perception that such strategies require more time, and a lack of supportive clinical environments for their use
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(Kolanowski, Fick, Frazer, & Penrod, 2010). Central to the nonpharmacological approach is the principle of person-centered care, in which strategies are tailored to the specific needs and preferences of patients (Cohen-Mansfield, 2001; Sadowsky & Galvin, 2012). Identifying strategies requires knowledge of the patient and a problemsolving approach for which health providers are not typically trained. To inform the development of training programs in nonpharmacological strategy use in hospital settings, the authors of the current article conducted a staff survey to evaluate disease knowledge, perceived education needs, and the care environment.
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METHOD Procedure and Participants A three-part, anonymous, crosssectional, institutional review boardapproved survey was conducted from August 2012 to September 2012 with staff on a unit specializing in geropsychiatry at an urban hospital. Surveys were distributed at nursing staff meetings (morning and evening shifts) and unit rounds, as well as individually to therapy and social work staff over 2 weeks by research staff. Supervisors distributed surveys to nursing staff not in attendance. Staff placed completed de-identified surveys in envelopes, which were handed to research staff. Measure The survey was developed by an expert panel of researchers, administrators, health providers, and unit staff. The first section focused on staff knowledge and included a modification of the Alzheimer’s Disease Knowledge Scale (Carpenter, Balsis, Otilingam, Hanson, & Gatz, 2009), a 30-item true/false self-report questionnaire. The authors’ modification eliminated 14 items (e.g., “It has been scientifically proven that mental exercise can prevent a person from getting [Alzheimer’s disease] (AD)”; “After symptoms of [AD] appear, the average life expectancy is 6 to 12 years”; and “Having high cholesterol may increase a person’s risk of developing [AD]”) because pretesting revealed that items were confusing or the science has evolved such that a true/false response was not completely accurate. The authors added 11 items culled from research, as well as statements that were made by unit staff and presented to the authors by the staff’s clinical supervisors. Items reflected behavioral challenges and use of nonpharmacological strategies (e.g., “If a person with [AD] feels threatened by you, he/she will be more cooperative”; and “It doesn’t matter if you introduce yourself to a person with [AD] because they can’t remem-
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ber your name”) (Griffiths, Knight, Harwood, & Gladman, 2014; Teri et al., 2009). The final scale included 27 true/false items. A total knowledge score was derived by summing the number of correct responses; higher scores reflect greater knowledge about AD (range = 0 to 27). The second part of the survey focused on staff perceptions of educational needs in dementia care and included the following 11 yes/no items: (a) communicating with family members; (b) commu-
Providing hands-on skills training in using nonpharmacological, person-centered, tailored interventions is an important step toward providing dementiaappropriate care.
nicating with medical staff or care team; (c) communicating with patients; (d) managing behaviors nonpharmacologically; (e) involving patients in activities; (f) managing patients’ resistance to care; (g) enhancing patient safety; (h) preventing injury to self; (i) identifying and managing patients’ pain; (j) coping with challenges of caring for patients with dementia; and (k) other. The third part of the survey examined the care environment (i.e., confidence, frustrations, and challenges). Items were co-constructed by examining unpublished staff surveys previously used by project team members and at project team meetings in which clinical staff identified care challenges. Three items asked staff to rate (i.e., very, some-
what, or not at all confident) their confidence in care provision concerning their abilities to (a) identify needs and provide care, (b) identify capabilities, and (c) use problem solving to manage behaviors. Four items asked staff to rate (i.e., not at all, somewhat, or a great deal) frustration levels. Questions included: ● To what extent does your care contribute to patients’ wellbeing? ● Do you enjoy providing care for patients? ● Do you feel frustrated or overwhelmed when caring for patients? ● Do you raise your voice or lose patience with patients? For care challenges, staff rated (i.e., not at all, somewhat, or very difficult) difficulty level on six items: (a) communicating with patients with dementia; (b) communicating with family members; (c) communicating with coworkers; (d) helping patients perform activities of daily living; (e) managing patient behaviors; and (f) engaging patients in activities. Another seven yes/no items asked if staff (a) experienced being hit, bitten, or physically hurt by patients with dementia; (b) know who a supervisor is to report patient challenges; (c) are comfortable reporting challenges; (d) feel their supervisor listens; (e) have been disrespected by family members; (f) have been disrespected by coworkers; and (g) are able to perform their job effectively. Data Analysis All analyses were conducted using IBM SPSS Statistics version 20. Continuous variables (i.e., age, months working with patients with dementia, and total knowledge scale score) were assessed using measures of central tendency (i.e., mean, standard deviation, and range). Group differences between nursing and therapy staff were assessed with independent t tests. The remaining categorical variables were examined by running frequency distributions.
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Pearson chi-square tests examined group differences between responses by nursing and therapy staff.
DEMOGRAPHICS OF SURVEY RESPONDENTS (N = 39)
RESULTS
Characteristic
Of the 62 staff on the unit during the survey period, 39 (62.9%) completed and returned questionnaires. Only one survey from nursing staff was completed outside of staff meetings. In addition, one of six physicians completed the survey, although all were invited to participate.
Sex (female)
Participant Characteristics Most participants (94.9%) were female and 35 or older (64.1%) (Table 1). Overall, 15 (38.5%) were nursing staff (i.e., RN, licensed practical nurse, geriatric nursing assistant, or patient care technician), 22 (56.4%) were therapy staff (i.e., occupational therapist, physical therapist, recreational therapist, or speech-language pathologist), and 2 (5.1%) were other (i.e., nursing unit secretary or medical doctor). Staff worked on the unit for an average of 48.9 months (SD = 49.1 months, range = 0 to 252 months). Most (82.1%) had prior experience working with patients with dementia, primarily in skilled nursing homes (61.5%) or hospitals or rehabilitation facilities (53.8%). Eleven staff (28.2%) indicated that they either had been or are informal caregivers. The physician and the unit secretary were not included in further analyses, given that their professional backgrounds did not fit the two possible analytic groups (i.e., nursing or therapy) and differences in schooling and professional activities would render it impossible to include them as their own group. The final sample was 37. Knowledge About Dementia The overall mean score for the knowledge test was 24.08 (SD = 2.61, range = 15 to 27), reflecting high knowledge levels with no statistically significant difference (p = 0.705) between nursing
TABLE 1
n (%) 37 (94.9)
Age (years) 18 to 24
2 (5.3)
25 to 34
11 (28.9)
35 to 44
11 (28.9)
45 to 54
7 (18.4)
55 and older
8 (18.4)
Position RN
9 (23.1)
Physical therapist
8 (20.5)
Occupational therapist
7 (17.9)
Recreational therapist
6 (15.4)
Licensed practical nurse
2 (5.1)
Geriatric nurse assistant
2 (5.1)
Patient care technician
2 (5.1)
Speech-language pathologist
1 (2.6)
Nursing unit secretary
1 (2.6)
Medical doctor
1 (2.6)
Months on unit (mean [SD], range)
48.9 [49.1], 0 to 252
Prior experience with patients with dementia (yes)
32 (82.1)
Prior work settings with patients with dementiaa Skilled nursing home
24 (61.5)
Hospital/rehabilitation facility
21 (53.8)
Assisted living facility
6 (15.4)
Home care
5 (12.8)
Adult day care center
5 (12.8)
Clinical experience with patients with dementia (months) (mean [SD], range) Informal caregiver (yes) a b
b
155.6 [115.6], 3 to 360 11 (28.2)
More than one answer was possible. Staff indicated they either had been or are informal caregivers.
(mean = 23.93, SD = 1.79) and therapy staff (mean = 24.27, SD = 3.10). Several questions approached statistically significant differences between the two groups. For example, “When people with AD repeat the same question or story, it is helpful to remind them they are repeating themselves” was correctly answered false by 100% (n = 22) of therapy staff but
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only 86.7% (n = 13) of nursing staff (χ² = 3.10, df = 1, p = 0.078); “One symptom that can occur with AD is believing other people are stealing one’s things” was correctly answered true by 100% (n = 22) of therapy but only 86.7% (n = 13) of nursing staff (χ² = 3.10, df = 1, p = 0.078); and “When a person has AD, using reminder notes is a crutch contributing
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TABLE 2
STAFF EDUCATIONAL NEEDS (N = 37) Nursing Staff (n = 15)
Therapy Staff (n = 22)
Yes, n (%)
Yes, n (%)
Communicating with patient?
9 (60)
17 (77.3)
Communicating with family?
10 (66.7)
11 (50)
9 (60)
8 (36.4)
Managing behaviors nonpharmacologically?
13 (86.7)
21 (95.5)
Involving patients in activities?
13 (86.7)
17 (77.3)
Managing patient resistance?
12 (80)
16 (72.7)
To be more effective, would you like to learn more about:
Communicating with medical staff?
Enhancing patient safety?
13 (86.7)
20 (90.9)
Preventing injury to oneself?
12 (80)
17 (77.3)
Managing patient pain?
9 (60)
16 (72.7)
13 (86.7)
18 (81.8)
3 (20)
2 (9.1)
Coping with care challenges? Othera a
Topics dealt with difficult families and psychiatric medications.
to decline” was correctly answered false by 95.5% (n = 21) of therapy staff but only 73.3% (n = 11) of nursing staff (χ² = 3.73, df = 1, p = 0.053). Overall, staff had a mean accuracy of 90.9% (SD = 9.80). Individual responses to the following three questions fell below one standard deviation of the mean (i.e., ≤81.1% of staff responding correctly to the item): “Once people have AD, they are no longer capable of making informed decisions about their care” (79.5% answered correctly); “When changing location or routine of persons with AD, it is best to prepare them several hours in advance” (57.9% answered correctly); and “When persons with AD are screaming curse words at you, a good practice is to say that you will give your attention to them when cursing stops” (71.1% answered correctly). Perceived Educational Needs Most staff identified wanting more information about nine of 10 areas (Table 2). Managing behaviors nonpharmacologically was
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endorsed the most (91.9%, n = 34), followed by enhancing patient safety (89.2%, n = 33), coping with care challenges (83.8%, n = 31), and involving patients in activities (81.1%, n = 30). Care Environment All nursing and therapy staff similarly reported being either very or somewhat confident in caring for patients with dementia (Table 3). Most nursing (80%) and therapy (86.4%) staff perceived that their care contributed a great deal to patients’ well-being. However, frustration and being overwhelmed was indicated by most (75.7%, n = 28). Regarding care challenges, two areas most frequently listed as somewhat or very difficult were communicating effectively with patients with dementia (69.2%) and engaging patients with dementia in activities (69.2%). Small, but not statistically significant, differences were found between nursing and therapy staff responses (Table 4). Most reported being hit, bitten, or physically hurt
by patients (66.7%) (Table 5). More than one-half reported being disrespected by family members (53.8%), and 43.6% reported that other staff had been disrespectful toward them. However, most staff reported being able to perform their jobs effectively (79.5%). Of eight staff indicating otherwise, primary reasons cited for being unable to perform their job effectively were staff shortages (87.5%, n = 7), stress (50%, n = 4), and poor teamwork (37.5%, n = 3). Pearson correlation revealed that despite most staff indicating having been physically hurt by patients, no significant association existed among those expressing a desire to know more about preventing injury to self (r = –0.010, p = 0.951). In addition, no significant association existed between reporting being disrespected by families and wanting more information on communicating with families (r = 0.152, p = 0.363). However, a significant association, albeit weak, existed with wanting more knowledge about managing patient resistance to care (r = 0.337, p = 0.045).
DISCUSSION As the number of individuals living with dementia increases, a pressing need exists to prepare a healthcare workforce with new knowledge and skills. The current study examined staff knowledge, self-described educational needs, and the care environment on a geropsychiatric hospital unit to inform training. Regarding dementia knowledge and consistent with other surveys, staff appeared to have adequate foundational knowledge, with a 90.9% mean accuracy for staff overall (Page & Hope, 2013). However, three items fell one standard deviation below the mean, suggesting a need for additional education and skills training. The first item (i.e., “Once people have AD, they are no longer capable of making informed decisions about their own care”) relates to how patients are involved in directing their own care. Staff appear to need hands-on skills
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TABLE 3
CONFIDENCE AND FRUSTRATIONS CARING FOR DEMENTIA PATIENTS (N = 37) Nursing (n = 15), n (%)
Confidence How confident are you that you can:
Therapy (n = 22), n (%)
Somewhat Confident
Very Confident
Somewhat Confident
Very Confident
Identify needs and provide care to patients with dementia?
5 (33.3)
10 (66.7)
8 (36.4)a
13 (59.1)a
Identify what a patient with dementia is still capable of doing?
9 (60)
6 (40)
10 (45.5)
12 (54.5)
Use problem solving to manage a challenging behavior?
9 (60)
6 (40)
13 (59.1)
9 (40.9)
Nursing (n = 15), n (%)
Frustrations To what extent do(es):
Therapy (n = 22), n (%)
A Great Deal
Somewhat
12 (80)
3 (20)
0
19 (86.4)
3 (13.6)
0
10 (66.7)
5 (33.3)
0
13 (59.1)
8 (36.4)
1 (4.5)
You feel frustrated/overwhelmed when caring for patients with dementia?
1 (6.7)
11 (73.3)
3 (20)
0
17 (77.3)
5 (22.7)
You raise your voice or lose patience when individuals with dementia do not follow instructions?
0
3 (20)
12 (80)
0
4 (18.2)
18 (81.8)
Your care contribute to the wellbeing of patients with dementia? You enjoy providing care to patients with dementia?
a
Not at all A Great Deal Somewhat
Not at all
One therapy staff answered not applicable.
to effectively involve individuals with dementia in daily care routines. The second item (i.e., “When changing the location or routine of persons with AD, it is best to prepare them several hours in advance”) has enormous implications for best practices for informing patients of impending therapeutic procedures or discharge. Typically, it is not helpful to inform patients with dementia too far in advance; as such, a better understanding of how to handle this common clinical scenario is needed. The third endorsed item (i.e., “When a person with AD is screaming curse words, a good practice is to say that you will give your attention to them when the cursing stops”) reflects the possibility that staff are inadvertently reinforcing behaviors they want to avoid by reacting and paying attention to negative verbalizations and not supporting positive, prosocial behaviors.
Endorsement of this item reflects a fundamental misunderstanding of dementia-related challenging behaviors and that such behaviors are typically consequences of an unmet need or inappropriate environmental stimuli. Regardless of a strong knowledge base, staff wanted to know about four key areas. Each of these areas (i.e., managing behaviors nonpharmacologically, enhancing patient safety, coping with care challenges, and involving patients in activities) require new skills in problem solving, nonpharmacological strategy use, and the tailoring of approaches to patients’ abilities and interests. The high endorsement of patient safety is similar to the culture of safety in nursing homes and hospitals (Bonner, Castle, Perera, & Handler, 2008) and may reflect tension between the need of staff to ensure safety but also preserve autonomy
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(Edberg et al., 2008). The third highest identified need (i.e., coping with challenges) is also supported by previous research (Edberg et al., 2008; Kolanowski et al., 2010). The emotional and physical stresses of caring for individuals with behavioral challenges is well documented in the formal caregiving literature (Brodaty et al., 2003; Schmidt, Dichter, Palm, & Hasselhorn, 2012; Zwijsen et al., 2014). Consistent with prior research, the authors of the current article found that staff members wanted to obtain a better understanding of how to actively involve patients with dementia in their own care and adopt new skills for managing behaviors (Kolanowski et al., 2010; Page & Hope, 2013). Staff appeared to have insight that they needed more handson skills training. The discrepancy between high knowledge scores and
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TABLE 4
DIFFICULTY OF DAILY CARE CHALLENGES (N = 39) Total Group, n (%)
Nursing (n =15), n (%)
Therapists (n = 22), n (%)
Not at all Difficult
Somewhat Difficult
Very Difficult
Somewhat/ Very Difficult
Somewhat/ Very Difficult
Communicating effectively with patients with dementia
12 (30.8)
26 (66.7)
1 (2.6)
10 (66.7)
15 (68.1)
Communicating effectively with family members
18 (46.2)
19 (48.7)
2 (5.1)
8 (53.3)
12 (54.6)
Communicating effectively with coworkers
28 (71.8)
10 (25.6)
1 (2.6)
2 (13.3)
9 (40.9)
Helping patients with dementia perform ADLs
11 (28.9)
18 (46.2)
3 (7.7)
9 (60)
11 (50)
Managing patient behaviors
11 (28.2)
25 (64.1)
2 (5.1)
9 (60)
16 (72.7)
Engaging patients with dementia in activities
12 (30.8)
27 (69.2)
0 (0)
9 (60)
16 (72.7)
Area
Note. ADLs = activities of daily living.
TABLE 5
CARE ENVIRONMENT (N = 39) Yes, n (%)
Item Know who supervisor is
39 (100)
Feel comfortable reporting challenges to supervisor
39 (100)
Feel that supervisor listens and supports you
37 (94.9)
Feel you can perform the job effectively
31 (79.5)
Been hit, bitten, or physically hurt
26 (66.7)
Have been disrespected by family member of a patient with dementiaa
21 (53.8)
Have been disrespected by staff member
17 (43.6)
a Of those disrespected by family members, 71.4% reported it to supervisors, and 100% were comfortable reporting the incident.
feelings of frustration, as well as the expressed need for skills, reflects the “knowing versus doing” gap; that is, staff appeared to have the requisite knowledge but lacked the repertoire of strategies and techniques necessary to deliver better and more effective care to individuals with dementia and engage their families. Prior studies have found that staff trainings that use less academic di-
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dactic and more hands-on, on-thejob approaches are preferred and highly valued by staff (Griffiths et al., 2013; Teri et al., 2009). Handson methods can include interactive Webinars (e.g., essentialAlz [access http://www.alz.org/essentialz] and Nurses Improving Care of Healthsystem Elders [access http://www. nicheprogram.org]), role-playing, shadowing experts, hands-on coach-
ing, and problem solving around active cases. Behavioral symptoms are complex and occur because of multiple factors, some of which are modifiable (Steinberg et al., 2008). These factors may include unmet care needs, emotional distress, unaddressed pain, lack of appropriate structure, boredom, and/or social and physical environmental complexity. Because pharmacological treatments do not address the most pressing care challenges staff confront, nonpharmacological approaches are essential. However, these approaches require a different method than the method in which staff are traditionally trained; specifically, nonpharmacological approaches include problem solving and tailoring strategies to patient needs, interests, and capabilities. These strategies have been successfully taught to informal caregivers to manage behavioral symptoms (Gitlin et al., 2008; Gitlin, Winter, Dennis, Hodgson, & Hauck, 2010; Teri et al., 2012) and, similarly, could be taught to hospital staff. Regarding care environment, staff members were confident in the care
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they provided and most believed that their care contributed to patient well-being. However, with 75.7% expressing frustration, 66.7% being physically hurt by patients, and more than one half being disrespected by family members, this group may be at high risk for low job satisfaction and burnout (Choi, Flynn, & Aiken, 2012). In addition, 20% of staff reported they could not perform their job effectively due to shortages, stress, and poor teamwork.
LIMITATIONS The results from the current cross-sectional survey conducted on one hospital unit may not generalize to other settings or staff. In addition, the majority of completed surveys were returned by day-shift nursing staff and therapy staff; therefore, views of night-shift and other staff are not well represented. Future studies could potentially increase participation by having the survey available online or providing more time to complete the survey. Important questions not asked on the survey related to whether staff had knowledge of the roles of others and whether they perceived themselves as part of an effective team, both of which are important concepts in dementia care (Mitchell et al., 2012).
IMPLICATIONS FOR NURSING PRACTICE Providing nursing care to individuals with dementia is complex and highly demanding. Addressing behavioral symptoms can be challenging, even when nursing staff are highly skilled and have a strong knowledge base about dementia. When nursing staff lack necessary skills or knowledge to address behavioral symptoms, the challenge of providing patient care is even greater. Providing hands-on skills training in using nonpharmacological, personcentered, tailored interventions is an important step toward providing dementia-appropriate care. Although traditional didactic educational
KEYPOINTS Marx, K.A., Stanley, I.H., Van Haitsma, K., Moody, J., Alonzi, D., Hansen, B.R., & Gitlin, L.N. (2014). Knowing Versus Doing: Education and Training Needs of Staff in a Chronic Care Hospital Unit for Individuals With Dementia. Journal of Gerontological Nursing, 40(12), 26-34.
1 2 3
Staff on a chronic care unit had good foundational knowledge of dementia. Staff reported needing more training on how to use nonpharmacological strategies for managing difficult behaviors in individuals with dementia. Hands-on, on-the-job training is preferred to a more didactic, prescriptive approach to training.
offerings on building knowledge about dementia are important, equal consideration should be given to actively engaging nursing staff in mentored and guided hands-on learning experiences that allow them to safely explore and practice tailoring nonpharmacological approaches to the needs of individuals with dementia. For example, use of simulated roleplay, expert coaching, and case presentations with feedback from interprofessional teams may advance care skills for this clinical population.
CONCLUSION Clinical staff members are on the frontline treating patients with dementia, many of whom experience challenging behaviors. Training staff to understand behavioral symptoms as expressions of unmet needs and other modifiable factors (e.g., environment), as well as providing them with the skills to effectively communicate with and involve patients with dementia in care, is desperately needed. Knowledge of and opportunities to practice basic nonpharmacological strategies are typically not part of staff training. The current study’s findings suggest that staff have foundational knowledge about dementia but do not have the know-how to provide nonpharmacologically based care. Novel learning approaches that provide (a) hands-on opportunities to learn and
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practice skills in behavioral management and (b) an opportunity for staff to receive coaching and feedback are required. Future staff education programs should include interactive, skill building, and opportunities for case sharing. REFERENCES Alzheimer’s Association. (2013). 2013 Alzheimer’s disease facts and figures. Retrieved from http://www.alz.org/ downloads/facts_figures_2013.pdf Bonner, A.F., Castle, N.G., Perera, S., & Handler, S.M. (2008). Patient safety culture: A review of the nursing home literature and recommendations for practice. Annals of Longterm Care, 16(3), 18-22. Brodaty, H., Draper, B., & Low, L.F. (2003). Nursing home staff attitudes towards residents with dementia: Strain and satisfaction with work. Journal of Advanced Nursing, 44, 583-590. Callahan, C.M., Arling, G., Tu, W., Rosenman, M.B., Counsell, S.R., Stump, T.E., & Hendrie, H.C. (2012). Transitions in care for older adults with and without dementia. Journal of the American Geriatrics Society, 60, 813-820. doi:10.1111/j.15325415.2012.03905.x Carpenter, B.D., Balsis, S., Otilingam, P.G., Hanson, P.K., & Gatz, M. (2009). The Alzheimer’s Disease Knowledge Scale: Development and psychometric properties. The Gerontologist, 49, 236-247. doi:10.1093/geront/gnp023 Choi, J., Flynn, L., & Aiken, L.H. (2012). Nursing practice environment and registered nurses’ job satisfaction in nursing homes. The Gerontologist, 52, 484-492. doi:10.1093/geront/gnr101 Cohen-Mansfield, J. (2001). Nonpharmacologic interventions for inappropriate behaviors in dementia: A review, sum-
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mary, and critique. American Journal of Geriatric Psychiatry, 9, 361-381. doi:10.1097/00019442-200111000-00005 Edberg, A.K., Bird, M., Richards, D.A., Woods, R., Keeley, P., & Davis-Quarrell, V. (2008). Strain in nursing care of people with dementia: Nurses’ experience in Australia, Sweden, and United Kingdom. Aging & Mental Health, 12, 236-243. doi:10.1080/13607860701616374 Galvin, J.E., Kuntemeier, B., Al-Hammadi, N., Germino, J., Murphy-White, M., & McGillick, J. (2010). “Dementia-friendly hospitals: Care not crisis”: An educational program designed to improve the care of the hospitalized patient with dementia. Alzheimer Disease and Associated Disorders, 24, 372-379. doi:10.1097/ WAD.0b013e3181e9f829 Gitlin, L.N., Kales, H.C., & Lyketsos, C.G. (2012). Nonpharmacologic management of behavioral symptoms in dementia. Journal of the American Medical Association, 308, 2020-2029. doi:10.1001/jama.2012.36918 Gitlin, L.N., Winter, L., Burke, J., Chernett, N., Dennis, M.P., & Hauck, W.W. (2008). Tailored activities to manage neuropsychiatric behaviors in persons with dementia and reduce caregiver burden: A randomized pilot study. American Journal of Geriatric Psychiatry, 16, 229239. doi:10.1097/JGP.0b013e318160da72 Gitlin, L.N., Winter, L., Dennis, M.P., Hodgson, N., & Hauck, W.W. (2010). Targeting and managing behavioral symptoms in individuals with dementia: A randomized trial of a nonpharmacological intervention. Journal of the American Geriatrics Society, 58, 1465-1474. doi:10.1111/j.15325415.2010.02971.x Griffiths, A., Knight, A., Harwood, R., & Gladman, J.R. (2014). Preparation to care for confused older patients in general hospitals: A study of UK health professionals. Age & Ageing, 43, 521-527. doi:10.1093/ ageing/aft171 Hebert, L.E., Weuve, J., Scherr, P.A., & Evans, D.A. (2013). Alzheimer disease in the United States (2010-2050) estimated using the 2010 census. Neurology, 80, 1778-1783. doi:10.1212/WNL.0b013e31828726f5 Kales, H.C., Gitlin, L.N., Lyketsos, C.G., & Detroit Expert Panel on the Assessment and Management of the Neuropsychiatric Symptoms of Dementia. (2014). Management of neuropsychiatric symptoms of dementia in clinical settings: Recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society, 62, 762-769. doi:10.1111/jgs.12730 Kolanowski, A., Fick, D., Frazer, C., & Penrod, J. (2010). It’s about time: Use of
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nonpharmacological interventions in the nursing home. Journal of Nursing Scholarship, 42, 214-222. doi:10.1111/j.15475069.2010.01338.x Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C.E.,…Von Kohorn, I. (2012). Core principles & values of effective team-based health care [Discussion paper]. Washington, DC: Institute of Medicine. Retrieved from http://www. iom.edu/Global/Perspectives/2012/ TeamBasedCare.aspx Miyamoto, Y., Tachimori, H., & Ito, H. (2010). Formal caregiver burden in dementia: Impact of behavioral and psychological symptoms of dementia and activities of daily living. Geriatric Nursing, 31, 246253. doi:10.1016/j.gerinurse.2010.01.002 Page, S., & Hope, K. (2013). Towards new ways of working in dementia: Perceptions of specialist dementia care nurses about their own level of knowledge, competence and unmet needs. Journal of Psychiatric and Mental Health Nursing, 20, 549-556. doi:10.1111/jpm.12029 Sadowsky, C.H., & Galvin, J.E. (2012). Guidelines for the management of cognitive and behavioral problems in dementia. Journal of the American Board of Family Medicine, 25, 350-366. doi:10.3122/ jabfm.2012.03.100183 Schmidt, S.G., Dichter, M.N., Palm, R., & Hasselhorn, H.M. (2012). Distress experienced by nurses in response to the challenging behaviour of residents— Evidence from German nursing homes. Journal of Clinical Nursing, 21, 3134-3142. doi:10.1111/jocn.12066 Steinberg, M., Shao, H., Zandi, P., Lyketsos, C.G., Welsh-Bohmer, K.A., Norton, M.C.,…Cache County Investigators. (2008). Point and 5-year period prevalence of neuropsychiatric symptoms in dementia: The Cache County Study. International Journal of Geriatric Psychiatry, 23, 170-177. Teri, L., McKenzie, G.L., LaFazia, D., Farran, C.J., Beck, C., Huda, P.,…Pike, K.C. (2009). Improving dementia care in assisted living residences: Addressing staff reactions to training. Geriatric Nursing, 30, 153-163. doi:10.1016/j. gerinurse.2008.07.002 Teri, L., McKenzie, G., Logsdon, R.G., McCurry, S.M., Bollin, S., Mead, J., & Menne, H. (2012). Translation of two evidencebased programs for training families to improve care of persons with dementia. The Gerontologist, 52, 452-459. doi:10.1093/ geront/gnr132 Toot, S., Devine, M., Akporobaro, A., & Orrell, M. (2013). Causes of hospital ad-
missions for people with dementia: A systematic review and meta-analysis. Journal of the American Medical Directors Association, 14, 463-470. doi:10.1016/j. jamda.2013.01.011 Zwijsen, S.A., Kabboord, A., Eefsting, J.A., Hertogh, C.M., Pot, A.M., Gerritsen, D.L., & Smalbrugge, M. (2014). Nurses in distress? An explorative study into the relation between distress and individual neuropsychiatric symptoms of people with dementia in nursing homes. International Journal of Geriatric Psychiatry, 29, 384-391. doi:10.1002/gps.4014 ABOUT THE AUTHORS
Dr. Marx is Senior Research Program Coordinator, Mr. Stanley is Health Educator, and Dr. Gitlin is Professor and Director, Center for Innovative Care in Aging, Johns Hopkins University School of Nursing; Ms. Moody is Recreational Therapy Manager, and Ms. Alonzi is Rehabilitation Services Clinical Coordinator, Bayview Hospital; Mr. Hansen is Doctoral Candidate, Johns Hopkins University School of Nursing, Baltimore, Maryland; and Dr. Van Haitsma is Director, Polisher Research Institute of the Madlyn and Leonard Abramson Center for Jewish Life, North Wales, Pennsylvania. The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was funded in part by a grant from the Alzheimer’s Association. The authors would like to thank the staff of the Lakeside Medical Unit at the Johns Hopkins Bayview Medical Center who graciously took the time to participate in this study and who succeed daily in providing excellent care for individuals with dementia and other diseases. They would also like to acknowledge the work that Andrea Nelson and Carletta Betz contributed to developing the survey. Address correspondence to Laura N. Gitlin, PhD, Professor and Director, Center for Innovative Care in Aging, Johns Hopkins University School of Nursing, 525 North Wolfe Street, Suite 316, Baltimore, MD 21205; e-mail: [email protected]. Received: March 24, 2014 Accepted: July 28, 2014 Posted: September 30, 2014 doi:10.3928/00989134-20140905-01
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HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE
ABSTRACT Hospital clinical staff routinely confront challenging behaviors in
Instructions
patients with dementia with limited training in prevention and
1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must:
management. The authors of the current article conducted a survey
1. Read the article, “Knowing Versus Doing: Education and Training Needs of Staff in a Chronic Care Hospital Unit for Individuals With Dementia” found on pages 26-34, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.
(SD = 2.61), reflecting high level of disease knowledge. However,
2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until November 30, 2016.
Contact Hours This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
of staff on a chronic care hospital unit concerning knowledge about dementia, perceived educational needs, and the care environment. The overall mean score for a 27-item knowledge scale was 24.08 staff indicated a need for more information and skills, specifically for managing behaviors nonpharmacologically (92.3%), enhancing patient safety (89.7%), coping with care challenges (84.2%), and involving patients in activities (81.6%). Although most staff (i.e., nurses [80%] and therapists [86.4%]) believed their care contributed a great deal to patient well-being, approximately 75% reported frustration and being overwhelmed by dementia care. Most reported being hit, bitten, or physically hurt by patients (66.7%), as well as disrespected by families (53.8%). Findings suggest that staff have foundational knowledge but lack the “how-to” or handson skills necessary to implement nonpharmacological behavioral management approaches and communicate with families. [Journal of Gerontological Nursing, 40(12), 26-34.]
Activity Objectives 1. Discuss the learning needs of staff on a dementia care unit. 2. Describe challenging behaviors that occur in patients with dementia.
Disclosure Statement Neither the planners nor the authors have any conflicts of interest to disclose.
D
ementia, a disabling, costly, and challenging disease, affects approximately 5 million individuals in the United States and 15 million families who provide dementia care (Alzheimer’s Association, 2013). The number of individuals with dementia is expected to increase by 300% by 2050 (Hebert, Weuve, Scherr, & Evans, 2013). For those with dementia, age and disease progression, medical comorbidities, neuropsychiatric behav-
Katherine A. Marx, PhD, MPH; Ian H. Stanley, BA; Kimberly Van Haitsma, PhD; Jennifer Moody, RT; Dana Alonzi, OTR; Bryan R. Hansen, MSN, RN, FNE-A; and Laura N. Gitlin, PhD
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© 2014 Shutterstock.com/john gomez
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iors, physiological instability, and safety concerns result in increased risk of hospitalizations (Callahan et al., 2012; Toot, Devine, Akporobaro, & Orrell, 2013). In the hospital, staff often confront behavioral challenges, for which little formal training is provided. Common behavioral challenges include medication refusal, rejection of needed assistance, fearfulness of medical procedures, heightened confusion, agitation, and verbal/ physical aggression toward staff (Galvin et al., 2010). Managing behaviors is associated with low job satisfaction and burnout (Brodaty, Draper, & Low, 2003; Miyamoto, Tachimori, & Ito, 2010). To manage behaviors, staff
frequently rely on pharmacological agents, which have limited benefits and present risk for adverse events (Gitlin, Kales, & Lyketsos, 2012; Kales, Gitlin, Lyketsos, & Detroit Expert Panel on the Assessment and Management of the Neuropsychiatric Symptoms of Dementia, 2014; Sadowsky & Galvin, 2012). Although nonpharmacological approaches to managing behaviors are endorsed by medical organizations as frontline treatment, they are not typically used because of a lack of knowledge of their evidence, a lack of training in using nonpharmacological strategies, the perception that such strategies require more time, and a lack of supportive clinical environments for their use
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(Kolanowski, Fick, Frazer, & Penrod, 2010). Central to the nonpharmacological approach is the principle of person-centered care, in which strategies are tailored to the specific needs and preferences of patients (Cohen-Mansfield, 2001; Sadowsky & Galvin, 2012). Identifying strategies requires knowledge of the patient and a problemsolving approach for which health providers are not typically trained. To inform the development of training programs in nonpharmacological strategy use in hospital settings, the authors of the current article conducted a staff survey to evaluate disease knowledge, perceived education needs, and the care environment.
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METHOD Procedure and Participants A three-part, anonymous, crosssectional, institutional review boardapproved survey was conducted from August 2012 to September 2012 with staff on a unit specializing in geropsychiatry at an urban hospital. Surveys were distributed at nursing staff meetings (morning and evening shifts) and unit rounds, as well as individually to therapy and social work staff over 2 weeks by research staff. Supervisors distributed surveys to nursing staff not in attendance. Staff placed completed de-identified surveys in envelopes, which were handed to research staff. Measure The survey was developed by an expert panel of researchers, administrators, health providers, and unit staff. The first section focused on staff knowledge and included a modification of the Alzheimer’s Disease Knowledge Scale (Carpenter, Balsis, Otilingam, Hanson, & Gatz, 2009), a 30-item true/false self-report questionnaire. The authors’ modification eliminated 14 items (e.g., “It has been scientifically proven that mental exercise can prevent a person from getting [Alzheimer’s disease] (AD)”; “After symptoms of [AD] appear, the average life expectancy is 6 to 12 years”; and “Having high cholesterol may increase a person’s risk of developing [AD]”) because pretesting revealed that items were confusing or the science has evolved such that a true/false response was not completely accurate. The authors added 11 items culled from research, as well as statements that were made by unit staff and presented to the authors by the staff’s clinical supervisors. Items reflected behavioral challenges and use of nonpharmacological strategies (e.g., “If a person with [AD] feels threatened by you, he/she will be more cooperative”; and “It doesn’t matter if you introduce yourself to a person with [AD] because they can’t remem-
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ber your name”) (Griffiths, Knight, Harwood, & Gladman, 2014; Teri et al., 2009). The final scale included 27 true/false items. A total knowledge score was derived by summing the number of correct responses; higher scores reflect greater knowledge about AD (range = 0 to 27). The second part of the survey focused on staff perceptions of educational needs in dementia care and included the following 11 yes/no items: (a) communicating with family members; (b) commu-
Providing hands-on skills training in using nonpharmacological, person-centered, tailored interventions is an important step toward providing dementiaappropriate care.
nicating with medical staff or care team; (c) communicating with patients; (d) managing behaviors nonpharmacologically; (e) involving patients in activities; (f) managing patients’ resistance to care; (g) enhancing patient safety; (h) preventing injury to self; (i) identifying and managing patients’ pain; (j) coping with challenges of caring for patients with dementia; and (k) other. The third part of the survey examined the care environment (i.e., confidence, frustrations, and challenges). Items were co-constructed by examining unpublished staff surveys previously used by project team members and at project team meetings in which clinical staff identified care challenges. Three items asked staff to rate (i.e., very, some-
what, or not at all confident) their confidence in care provision concerning their abilities to (a) identify needs and provide care, (b) identify capabilities, and (c) use problem solving to manage behaviors. Four items asked staff to rate (i.e., not at all, somewhat, or a great deal) frustration levels. Questions included: ● To what extent does your care contribute to patients’ wellbeing? ● Do you enjoy providing care for patients? ● Do you feel frustrated or overwhelmed when caring for patients? ● Do you raise your voice or lose patience with patients? For care challenges, staff rated (i.e., not at all, somewhat, or very difficult) difficulty level on six items: (a) communicating with patients with dementia; (b) communicating with family members; (c) communicating with coworkers; (d) helping patients perform activities of daily living; (e) managing patient behaviors; and (f) engaging patients in activities. Another seven yes/no items asked if staff (a) experienced being hit, bitten, or physically hurt by patients with dementia; (b) know who a supervisor is to report patient challenges; (c) are comfortable reporting challenges; (d) feel their supervisor listens; (e) have been disrespected by family members; (f) have been disrespected by coworkers; and (g) are able to perform their job effectively. Data Analysis All analyses were conducted using IBM SPSS Statistics version 20. Continuous variables (i.e., age, months working with patients with dementia, and total knowledge scale score) were assessed using measures of central tendency (i.e., mean, standard deviation, and range). Group differences between nursing and therapy staff were assessed with independent t tests. The remaining categorical variables were examined by running frequency distributions.
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Pearson chi-square tests examined group differences between responses by nursing and therapy staff.
DEMOGRAPHICS OF SURVEY RESPONDENTS (N = 39)
RESULTS
Characteristic
Of the 62 staff on the unit during the survey period, 39 (62.9%) completed and returned questionnaires. Only one survey from nursing staff was completed outside of staff meetings. In addition, one of six physicians completed the survey, although all were invited to participate.
Sex (female)
Participant Characteristics Most participants (94.9%) were female and 35 or older (64.1%) (Table 1). Overall, 15 (38.5%) were nursing staff (i.e., RN, licensed practical nurse, geriatric nursing assistant, or patient care technician), 22 (56.4%) were therapy staff (i.e., occupational therapist, physical therapist, recreational therapist, or speech-language pathologist), and 2 (5.1%) were other (i.e., nursing unit secretary or medical doctor). Staff worked on the unit for an average of 48.9 months (SD = 49.1 months, range = 0 to 252 months). Most (82.1%) had prior experience working with patients with dementia, primarily in skilled nursing homes (61.5%) or hospitals or rehabilitation facilities (53.8%). Eleven staff (28.2%) indicated that they either had been or are informal caregivers. The physician and the unit secretary were not included in further analyses, given that their professional backgrounds did not fit the two possible analytic groups (i.e., nursing or therapy) and differences in schooling and professional activities would render it impossible to include them as their own group. The final sample was 37. Knowledge About Dementia The overall mean score for the knowledge test was 24.08 (SD = 2.61, range = 15 to 27), reflecting high knowledge levels with no statistically significant difference (p = 0.705) between nursing
TABLE 1
n (%) 37 (94.9)
Age (years) 18 to 24
2 (5.3)
25 to 34
11 (28.9)
35 to 44
11 (28.9)
45 to 54
7 (18.4)
55 and older
8 (18.4)
Position RN
9 (23.1)
Physical therapist
8 (20.5)
Occupational therapist
7 (17.9)
Recreational therapist
6 (15.4)
Licensed practical nurse
2 (5.1)
Geriatric nurse assistant
2 (5.1)
Patient care technician
2 (5.1)
Speech-language pathologist
1 (2.6)
Nursing unit secretary
1 (2.6)
Medical doctor
1 (2.6)
Months on unit (mean [SD], range)
48.9 [49.1], 0 to 252
Prior experience with patients with dementia (yes)
32 (82.1)
Prior work settings with patients with dementiaa Skilled nursing home
24 (61.5)
Hospital/rehabilitation facility
21 (53.8)
Assisted living facility
6 (15.4)
Home care
5 (12.8)
Adult day care center
5 (12.8)
Clinical experience with patients with dementia (months) (mean [SD], range) Informal caregiver (yes) a b
b
155.6 [115.6], 3 to 360 11 (28.2)
More than one answer was possible. Staff indicated they either had been or are informal caregivers.
(mean = 23.93, SD = 1.79) and therapy staff (mean = 24.27, SD = 3.10). Several questions approached statistically significant differences between the two groups. For example, “When people with AD repeat the same question or story, it is helpful to remind them they are repeating themselves” was correctly answered false by 100% (n = 22) of therapy staff but
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only 86.7% (n = 13) of nursing staff (χ² = 3.10, df = 1, p = 0.078); “One symptom that can occur with AD is believing other people are stealing one’s things” was correctly answered true by 100% (n = 22) of therapy but only 86.7% (n = 13) of nursing staff (χ² = 3.10, df = 1, p = 0.078); and “When a person has AD, using reminder notes is a crutch contributing
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TABLE 2
STAFF EDUCATIONAL NEEDS (N = 37) Nursing Staff (n = 15)
Therapy Staff (n = 22)
Yes, n (%)
Yes, n (%)
Communicating with patient?
9 (60)
17 (77.3)
Communicating with family?
10 (66.7)
11 (50)
9 (60)
8 (36.4)
Managing behaviors nonpharmacologically?
13 (86.7)
21 (95.5)
Involving patients in activities?
13 (86.7)
17 (77.3)
Managing patient resistance?
12 (80)
16 (72.7)
To be more effective, would you like to learn more about:
Communicating with medical staff?
Enhancing patient safety?
13 (86.7)
20 (90.9)
Preventing injury to oneself?
12 (80)
17 (77.3)
Managing patient pain?
9 (60)
16 (72.7)
13 (86.7)
18 (81.8)
3 (20)
2 (9.1)
Coping with care challenges? Othera a
Topics dealt with difficult families and psychiatric medications.
to decline” was correctly answered false by 95.5% (n = 21) of therapy staff but only 73.3% (n = 11) of nursing staff (χ² = 3.73, df = 1, p = 0.053). Overall, staff had a mean accuracy of 90.9% (SD = 9.80). Individual responses to the following three questions fell below one standard deviation of the mean (i.e., ≤81.1% of staff responding correctly to the item): “Once people have AD, they are no longer capable of making informed decisions about their care” (79.5% answered correctly); “When changing location or routine of persons with AD, it is best to prepare them several hours in advance” (57.9% answered correctly); and “When persons with AD are screaming curse words at you, a good practice is to say that you will give your attention to them when cursing stops” (71.1% answered correctly). Perceived Educational Needs Most staff identified wanting more information about nine of 10 areas (Table 2). Managing behaviors nonpharmacologically was
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endorsed the most (91.9%, n = 34), followed by enhancing patient safety (89.2%, n = 33), coping with care challenges (83.8%, n = 31), and involving patients in activities (81.1%, n = 30). Care Environment All nursing and therapy staff similarly reported being either very or somewhat confident in caring for patients with dementia (Table 3). Most nursing (80%) and therapy (86.4%) staff perceived that their care contributed a great deal to patients’ well-being. However, frustration and being overwhelmed was indicated by most (75.7%, n = 28). Regarding care challenges, two areas most frequently listed as somewhat or very difficult were communicating effectively with patients with dementia (69.2%) and engaging patients with dementia in activities (69.2%). Small, but not statistically significant, differences were found between nursing and therapy staff responses (Table 4). Most reported being hit, bitten, or physically hurt
by patients (66.7%) (Table 5). More than one-half reported being disrespected by family members (53.8%), and 43.6% reported that other staff had been disrespectful toward them. However, most staff reported being able to perform their jobs effectively (79.5%). Of eight staff indicating otherwise, primary reasons cited for being unable to perform their job effectively were staff shortages (87.5%, n = 7), stress (50%, n = 4), and poor teamwork (37.5%, n = 3). Pearson correlation revealed that despite most staff indicating having been physically hurt by patients, no significant association existed among those expressing a desire to know more about preventing injury to self (r = –0.010, p = 0.951). In addition, no significant association existed between reporting being disrespected by families and wanting more information on communicating with families (r = 0.152, p = 0.363). However, a significant association, albeit weak, existed with wanting more knowledge about managing patient resistance to care (r = 0.337, p = 0.045).
DISCUSSION As the number of individuals living with dementia increases, a pressing need exists to prepare a healthcare workforce with new knowledge and skills. The current study examined staff knowledge, self-described educational needs, and the care environment on a geropsychiatric hospital unit to inform training. Regarding dementia knowledge and consistent with other surveys, staff appeared to have adequate foundational knowledge, with a 90.9% mean accuracy for staff overall (Page & Hope, 2013). However, three items fell one standard deviation below the mean, suggesting a need for additional education and skills training. The first item (i.e., “Once people have AD, they are no longer capable of making informed decisions about their own care”) relates to how patients are involved in directing their own care. Staff appear to need hands-on skills
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TABLE 3
CONFIDENCE AND FRUSTRATIONS CARING FOR DEMENTIA PATIENTS (N = 37) Nursing (n = 15), n (%)
Confidence How confident are you that you can:
Therapy (n = 22), n (%)
Somewhat Confident
Very Confident
Somewhat Confident
Very Confident
Identify needs and provide care to patients with dementia?
5 (33.3)
10 (66.7)
8 (36.4)a
13 (59.1)a
Identify what a patient with dementia is still capable of doing?
9 (60)
6 (40)
10 (45.5)
12 (54.5)
Use problem solving to manage a challenging behavior?
9 (60)
6 (40)
13 (59.1)
9 (40.9)
Nursing (n = 15), n (%)
Frustrations To what extent do(es):
Therapy (n = 22), n (%)
A Great Deal
Somewhat
12 (80)
3 (20)
0
19 (86.4)
3 (13.6)
0
10 (66.7)
5 (33.3)
0
13 (59.1)
8 (36.4)
1 (4.5)
You feel frustrated/overwhelmed when caring for patients with dementia?
1 (6.7)
11 (73.3)
3 (20)
0
17 (77.3)
5 (22.7)
You raise your voice or lose patience when individuals with dementia do not follow instructions?
0
3 (20)
12 (80)
0
4 (18.2)
18 (81.8)
Your care contribute to the wellbeing of patients with dementia? You enjoy providing care to patients with dementia?
a
Not at all A Great Deal Somewhat
Not at all
One therapy staff answered not applicable.
to effectively involve individuals with dementia in daily care routines. The second item (i.e., “When changing the location or routine of persons with AD, it is best to prepare them several hours in advance”) has enormous implications for best practices for informing patients of impending therapeutic procedures or discharge. Typically, it is not helpful to inform patients with dementia too far in advance; as such, a better understanding of how to handle this common clinical scenario is needed. The third endorsed item (i.e., “When a person with AD is screaming curse words, a good practice is to say that you will give your attention to them when the cursing stops”) reflects the possibility that staff are inadvertently reinforcing behaviors they want to avoid by reacting and paying attention to negative verbalizations and not supporting positive, prosocial behaviors.
Endorsement of this item reflects a fundamental misunderstanding of dementia-related challenging behaviors and that such behaviors are typically consequences of an unmet need or inappropriate environmental stimuli. Regardless of a strong knowledge base, staff wanted to know about four key areas. Each of these areas (i.e., managing behaviors nonpharmacologically, enhancing patient safety, coping with care challenges, and involving patients in activities) require new skills in problem solving, nonpharmacological strategy use, and the tailoring of approaches to patients’ abilities and interests. The high endorsement of patient safety is similar to the culture of safety in nursing homes and hospitals (Bonner, Castle, Perera, & Handler, 2008) and may reflect tension between the need of staff to ensure safety but also preserve autonomy
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(Edberg et al., 2008). The third highest identified need (i.e., coping with challenges) is also supported by previous research (Edberg et al., 2008; Kolanowski et al., 2010). The emotional and physical stresses of caring for individuals with behavioral challenges is well documented in the formal caregiving literature (Brodaty et al., 2003; Schmidt, Dichter, Palm, & Hasselhorn, 2012; Zwijsen et al., 2014). Consistent with prior research, the authors of the current article found that staff members wanted to obtain a better understanding of how to actively involve patients with dementia in their own care and adopt new skills for managing behaviors (Kolanowski et al., 2010; Page & Hope, 2013). Staff appeared to have insight that they needed more handson skills training. The discrepancy between high knowledge scores and
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TABLE 4
DIFFICULTY OF DAILY CARE CHALLENGES (N = 39) Total Group, n (%)
Nursing (n =15), n (%)
Therapists (n = 22), n (%)
Not at all Difficult
Somewhat Difficult
Very Difficult
Somewhat/ Very Difficult
Somewhat/ Very Difficult
Communicating effectively with patients with dementia
12 (30.8)
26 (66.7)
1 (2.6)
10 (66.7)
15 (68.1)
Communicating effectively with family members
18 (46.2)
19 (48.7)
2 (5.1)
8 (53.3)
12 (54.6)
Communicating effectively with coworkers
28 (71.8)
10 (25.6)
1 (2.6)
2 (13.3)
9 (40.9)
Helping patients with dementia perform ADLs
11 (28.9)
18 (46.2)
3 (7.7)
9 (60)
11 (50)
Managing patient behaviors
11 (28.2)
25 (64.1)
2 (5.1)
9 (60)
16 (72.7)
Engaging patients with dementia in activities
12 (30.8)
27 (69.2)
0 (0)
9 (60)
16 (72.7)
Area
Note. ADLs = activities of daily living.
TABLE 5
CARE ENVIRONMENT (N = 39) Yes, n (%)
Item Know who supervisor is
39 (100)
Feel comfortable reporting challenges to supervisor
39 (100)
Feel that supervisor listens and supports you
37 (94.9)
Feel you can perform the job effectively
31 (79.5)
Been hit, bitten, or physically hurt
26 (66.7)
Have been disrespected by family member of a patient with dementiaa
21 (53.8)
Have been disrespected by staff member
17 (43.6)
a Of those disrespected by family members, 71.4% reported it to supervisors, and 100% were comfortable reporting the incident.
feelings of frustration, as well as the expressed need for skills, reflects the “knowing versus doing” gap; that is, staff appeared to have the requisite knowledge but lacked the repertoire of strategies and techniques necessary to deliver better and more effective care to individuals with dementia and engage their families. Prior studies have found that staff trainings that use less academic di-
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dactic and more hands-on, on-thejob approaches are preferred and highly valued by staff (Griffiths et al., 2013; Teri et al., 2009). Handson methods can include interactive Webinars (e.g., essentialAlz [access http://www.alz.org/essentialz] and Nurses Improving Care of Healthsystem Elders [access http://www. nicheprogram.org]), role-playing, shadowing experts, hands-on coach-
ing, and problem solving around active cases. Behavioral symptoms are complex and occur because of multiple factors, some of which are modifiable (Steinberg et al., 2008). These factors may include unmet care needs, emotional distress, unaddressed pain, lack of appropriate structure, boredom, and/or social and physical environmental complexity. Because pharmacological treatments do not address the most pressing care challenges staff confront, nonpharmacological approaches are essential. However, these approaches require a different method than the method in which staff are traditionally trained; specifically, nonpharmacological approaches include problem solving and tailoring strategies to patient needs, interests, and capabilities. These strategies have been successfully taught to informal caregivers to manage behavioral symptoms (Gitlin et al., 2008; Gitlin, Winter, Dennis, Hodgson, & Hauck, 2010; Teri et al., 2012) and, similarly, could be taught to hospital staff. Regarding care environment, staff members were confident in the care
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they provided and most believed that their care contributed to patient well-being. However, with 75.7% expressing frustration, 66.7% being physically hurt by patients, and more than one half being disrespected by family members, this group may be at high risk for low job satisfaction and burnout (Choi, Flynn, & Aiken, 2012). In addition, 20% of staff reported they could not perform their job effectively due to shortages, stress, and poor teamwork.
LIMITATIONS The results from the current cross-sectional survey conducted on one hospital unit may not generalize to other settings or staff. In addition, the majority of completed surveys were returned by day-shift nursing staff and therapy staff; therefore, views of night-shift and other staff are not well represented. Future studies could potentially increase participation by having the survey available online or providing more time to complete the survey. Important questions not asked on the survey related to whether staff had knowledge of the roles of others and whether they perceived themselves as part of an effective team, both of which are important concepts in dementia care (Mitchell et al., 2012).
IMPLICATIONS FOR NURSING PRACTICE Providing nursing care to individuals with dementia is complex and highly demanding. Addressing behavioral symptoms can be challenging, even when nursing staff are highly skilled and have a strong knowledge base about dementia. When nursing staff lack necessary skills or knowledge to address behavioral symptoms, the challenge of providing patient care is even greater. Providing hands-on skills training in using nonpharmacological, personcentered, tailored interventions is an important step toward providing dementia-appropriate care. Although traditional didactic educational
KEYPOINTS Marx, K.A., Stanley, I.H., Van Haitsma, K., Moody, J., Alonzi, D., Hansen, B.R., & Gitlin, L.N. (2014). Knowing Versus Doing: Education and Training Needs of Staff in a Chronic Care Hospital Unit for Individuals With Dementia. Journal of Gerontological Nursing, 40(12), 26-34.
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Staff on a chronic care unit had good foundational knowledge of dementia. Staff reported needing more training on how to use nonpharmacological strategies for managing difficult behaviors in individuals with dementia. Hands-on, on-the-job training is preferred to a more didactic, prescriptive approach to training.
offerings on building knowledge about dementia are important, equal consideration should be given to actively engaging nursing staff in mentored and guided hands-on learning experiences that allow them to safely explore and practice tailoring nonpharmacological approaches to the needs of individuals with dementia. For example, use of simulated roleplay, expert coaching, and case presentations with feedback from interprofessional teams may advance care skills for this clinical population.
CONCLUSION Clinical staff members are on the frontline treating patients with dementia, many of whom experience challenging behaviors. Training staff to understand behavioral symptoms as expressions of unmet needs and other modifiable factors (e.g., environment), as well as providing them with the skills to effectively communicate with and involve patients with dementia in care, is desperately needed. Knowledge of and opportunities to practice basic nonpharmacological strategies are typically not part of staff training. The current study’s findings suggest that staff have foundational knowledge about dementia but do not have the know-how to provide nonpharmacologically based care. Novel learning approaches that provide (a) hands-on opportunities to learn and
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practice skills in behavioral management and (b) an opportunity for staff to receive coaching and feedback are required. Future staff education programs should include interactive, skill building, and opportunities for case sharing. REFERENCES Alzheimer’s Association. (2013). 2013 Alzheimer’s disease facts and figures. Retrieved from http://www.alz.org/ downloads/facts_figures_2013.pdf Bonner, A.F., Castle, N.G., Perera, S., & Handler, S.M. (2008). Patient safety culture: A review of the nursing home literature and recommendations for practice. Annals of Longterm Care, 16(3), 18-22. Brodaty, H., Draper, B., & Low, L.F. (2003). Nursing home staff attitudes towards residents with dementia: Strain and satisfaction with work. Journal of Advanced Nursing, 44, 583-590. Callahan, C.M., Arling, G., Tu, W., Rosenman, M.B., Counsell, S.R., Stump, T.E., & Hendrie, H.C. (2012). Transitions in care for older adults with and without dementia. Journal of the American Geriatrics Society, 60, 813-820. doi:10.1111/j.15325415.2012.03905.x Carpenter, B.D., Balsis, S., Otilingam, P.G., Hanson, P.K., & Gatz, M. (2009). The Alzheimer’s Disease Knowledge Scale: Development and psychometric properties. The Gerontologist, 49, 236-247. doi:10.1093/geront/gnp023 Choi, J., Flynn, L., & Aiken, L.H. (2012). Nursing practice environment and registered nurses’ job satisfaction in nursing homes. The Gerontologist, 52, 484-492. doi:10.1093/geront/gnr101 Cohen-Mansfield, J. (2001). Nonpharmacologic interventions for inappropriate behaviors in dementia: A review, sum-
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missions for people with dementia: A systematic review and meta-analysis. Journal of the American Medical Directors Association, 14, 463-470. doi:10.1016/j. jamda.2013.01.011 Zwijsen, S.A., Kabboord, A., Eefsting, J.A., Hertogh, C.M., Pot, A.M., Gerritsen, D.L., & Smalbrugge, M. (2014). Nurses in distress? An explorative study into the relation between distress and individual neuropsychiatric symptoms of people with dementia in nursing homes. International Journal of Geriatric Psychiatry, 29, 384-391. doi:10.1002/gps.4014 ABOUT THE AUTHORS
Dr. Marx is Senior Research Program Coordinator, Mr. Stanley is Health Educator, and Dr. Gitlin is Professor and Director, Center for Innovative Care in Aging, Johns Hopkins University School of Nursing; Ms. Moody is Recreational Therapy Manager, and Ms. Alonzi is Rehabilitation Services Clinical Coordinator, Bayview Hospital; Mr. Hansen is Doctoral Candidate, Johns Hopkins University School of Nursing, Baltimore, Maryland; and Dr. Van Haitsma is Director, Polisher Research Institute of the Madlyn and Leonard Abramson Center for Jewish Life, North Wales, Pennsylvania. The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was funded in part by a grant from the Alzheimer’s Association. The authors would like to thank the staff of the Lakeside Medical Unit at the Johns Hopkins Bayview Medical Center who graciously took the time to participate in this study and who succeed daily in providing excellent care for individuals with dementia and other diseases. They would also like to acknowledge the work that Andrea Nelson and Carletta Betz contributed to developing the survey. Address correspondence to Laura N. Gitlin, PhD, Professor and Director, Center for Innovative Care in Aging, Johns Hopkins University School of Nursing, 525 North Wolfe Street, Suite 316, Baltimore, MD 21205; e-mail: [email protected]. Received: March 24, 2014 Accepted: July 28, 2014 Posted: September 30, 2014 doi:10.3928/00989134-20140905-01
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