Dementia is one of the mental disorders whose prevalence is increasing day by day and it is leading to great burden for health care staffs and reduction in quality of life of affected people. According to the World Alzheimer Report (2015) report, an estimated 4.8 million people were living with dementia in 2015 and the number is going to reach 75 million in 2030. The highest rate of increase is most likely to be seen in developing countries and those with the highest number of ageing population such as China, India, South Asia and the Pacific regions. It is also estimated that the prevalence rate will increase to 131.5 million in 2050. Hence, considering this trend, dementia is going to be a major problem in the developing regions of the world. One major issue is that health care professionals are not equipped with the desired skills to understand the complex symptoms of patient and provide optimal care (Baboolal et al. 2018). In such situation, lack of experienced staff is further going to deteriorate health outcomes of people admitted in health care setting. As it is liability of health care workers to reduce symptoms and supporting high quality living in people, taking steps to understand the effectiveness of staff training and education on management challenging behaviours of people with dementia is important.
From my own experience of working at a dementia care ward in an aged care setting in Australia, I have found that both professional as well as family caregiver develop anxiety because of the poor management of people with dementia. Due to increase in complications in patients with dementia (such as delirium, falls and infections), caregivers experience anxiety and chronic fatigue. They struggle to deal with the comorbidities and develop sleep problems too (De Fazio et al., 2015). This indicates that staffs in age care setting are not adequately prepared to deal with people with dementia. Therefore, I think implementing an education and training project for staffs in aged care setting is important so that they have clear knowledge regarding the prognosis, risk factors and the disorder. Training can also educate them about the most effective methods to manage challenging behaviours of dementia patient. The projects aims to give an understanding about the effectiveness of education and training by providing real practice based training to dementia care staffs. The efficacy of the intervention will be evaluated by a before and after survey with patients using the Dementia Knowledge Assessment Tool (DKAT 2) version two. A brief insight into the gaps found in current literature will also be explored.
The main rationale for implementing project in an aged care setting is understood from the fact that gaps exist in the quality of dementia care currently. A qualitative research paper has revealed several issues in the care of people with dementia. Research with health care staffs working with people with dementia has revealed a need to improve care pathways, address resources and pay attention to education of staffs. This recommendation has been given because many staffs have reported about their inability to provide optimal care because of lack of understanding about the care of older people and its impact on dementia care (Houghton et al., 2016). Another research paper investigated about the competency of professionals in dementia care and revealed that health care professionals are experience burden and moral distress because of cognitive impairment in dementia patients. To efficiently handle such patients, they need to be aware about self management skills. Special training regarding special communication skills and method to empower client is needed (De Vriendt et al., 2018). Hence, proper education is considered necessary as capacity can be increased through education and proper leadership. Presence of issues and several gaps in delivering care to people with dementia indicates the rationale behind implementing this project. Education and training has the potential to address care giving burden.
The main aim of the project is to evaluate the effectiveness of staffs training and education in improving confidence and knowledge in managing challenging behaviours in dementia care in age care setting. By implementing training and education session for staffs in aged care facility, the project aims to get answer to the following research question:
‘Is care-staff training and education effective in improving confidence and knowledge in managing challenging behaviours in dementia care in aged care setting?’
The project aims to achieve the following objectives:
The main outcomes expected from this project are as follows:
The setting chosen for the implementation of this project included aged care setting in Australia. This setting has been chosen because dementia is mainly diagnosed in older people and aged care setting has large rate of admission for people with dementia. Apart from community care and hospital services, aged cared setting handles large number of people with dementia. Caregiver distress has been reported for staffs caring for dementia patient and this has a negative impact on health and quality of life of staffs too (Cheng, 2017). Dementia care givers have also reported about higher level of stress, more depression and anxiety symptoms (Sörensen & Conwell, 2011). Hence, delivery of the project in dementia care setting is important so that issues faced by staffs can be identified and they are given adequate training and education to become competent in managing patients with different comorbidities and challenging behaviour.
To get an idea into the gaps found in dementia care currently and the effectiveness of education in improving symptoms of dementia patient, search for literature was done in database like CINAHL, MedLine and PubMed. The key words used for the literature search included dementia care, education and dementia care, training and management of dementia, challenges and dementia.
For health care staffs, one of the major challenges in dementia care is the management of challenging behaviours like aggression in patients. Cohen-Mansfield et al. (2015) argues that problems behaviours develop in people with dementia because of unmet needs and these unmet needs emerge because of the inability of patients to communicate these needs to health care staffs. This leads to physical and mental discomfort and imbalance in lifelong habits. In this situation, advanced skills of health care professionals play a role in understanding unmet need of patients. However, they fail to provide for the needs thus leading to manifestations of vocal or verbal behaviours. This evidence implies that developing skills of staff in identifying unmet needs is important as this can only promote improvement in the quality of life of residents with dementia. The study can be used to develop programs that focus on addressing social and activity needs of patient or identifying such unmet needs in patient. The values of person centered care can be fulfilled by using the evidence to prioritize care (Brooker & Latham, 2015). .
The review of research literature gave evidence regarding many types of education and training protocol that has been implemented for staffs providing care to dementia patient. McCabe et al. (2015) investigated about the impact of a training program on managing behavioural and psychological symptoms in dementia patient by means of a randomized controlled trial. Behavioural and psychological symptoms like aggression and repetitive questioning are some of the reasons behind admission of dementia patients to age care setting. As many staffs in Australia are inadequately trained and poorly paid, they end up requiring assistance from mental health service. To resolve the issue, the study recruited aged care residents and two hours training session was provided to staffs regarding person centered care and dementia. The analysis of data revealed that structured clinical protocol was effective in helping staffs identify the causal factor behind challenging behaviour in dementia patient. The frequency of challenging behaviour reduced. The training helped to systematically identify risk factor of behavioural issues in dementia patient and manage them in different contextual environment. However, lack of commitment and randomization by facility limited the proper implementation of the interview. High turnover of staff also affected the validity of the study. There is a need to evaluate the impact of these factors on the success of training and education program.
Another cluster randomized controlled trial investigated about the effectiveness of stepwise multidisciplinary intervention addressing challenging behaviour in advanced dementia. The intervention group staffs received stepwise comprehensive multidisciplinary training and the control group received training on dementia management and pain without the multidisciplinary component. The staffs were provided training of five meetings related to physical and assessment skills to identify unmet needs of individual. The positive effect of this intervention was that it improved agitation, depression and other neuropsychiatric symptoms of patient. As depression and agitation are some symptoms that present major challenges to geriatrist, psychiatrist and neurologist, the evidence provides solution to improve the skills of these health care professionals (Pieper et al., 2016). However, despite these findings, certain limitations or gaps in research methodology affected the validity of the study. For example, the residents were unaware of the intervention and only the research assistant was blinded to the intervention. Therefore, the fidelity of the training procedure was doubtful. These limitations need to be resolved in future research.
The review of research study revealed evaluation of the effectiveness of educational programs by means of a systematic review too. The significance of this study was that it looked to examine those studies that reduced the burden of caregivers of elderly patients with dementia. Dementia patients most commonly exhibit behavioural symptoms like agitation, delusions and hallucinations. Dementia caregivers are burdened by the increase in such behavioural changes in patient. Such behavioural and psychological symptoms not just increase prognosis but also worsens prognosis and cost associated with care. Hence, to address the issue, () examined research evidence regarding the effectiveness of educating in reducing care giving burden. Seven randomized controlled trial was evaluated which compared with standard delivery care. The evidences suggested that education and supports have positive effect on reducing caregiver burden. The reliability of the evidence was also understood from low risk of bias in studies. The knowledge level and coping strategies of caregivers improved and it reduced depressive symptoms in patient. Some limitation of the studies was that inappropriate measurement techniques and population composition was used. Hence, this evidence points out to the need for conducting studies with more appropriate research designs and better description about the intervention.
The project that has been selected for staffs in aged care setting of Australia is an educational project. Based on the gaps identified in research literature, this projects first aimed to evaluated types of training needs for staffs and then implement education and training program in the setting. Both survey and observation based research method was chosen. The main purpose of conducting survey was to identify staff’s knowledge related to management of challenging behaviours in dementia care and find out the issues they face while dealing with such patient. Hence, the survey was conducted before the implementation of the intervention. In addition, observation based research and survey method was used to evaluate outcome after the implementation of training and education program. The details of the strategy that I implemented are as follows:
The target population for this project was health care staffs working in aged care setting in Australia. To maintain reliability in research findings, all types of staffs (casual, part-time and full time care staffs) were included in the project. To approach these staffs, approval for the research was taken by managers or the administrative staffs of the aged care facility first. They were informed regarding the purpose and rationale of the project and the type of methods that will be used to interview and observe staffs regarding their performance in dementia. All assurance was also given regarding fulfilling the ethical requirements in research. Resnik (2011) suggest that following ethics or moral rules in research is important as this would help in avoiding conflict and acting in a way that suits professional research standards. Adhering to ethical norms promote the aims of research and prohibits researchers from fabricating research evidence. Hence, in accordance with ethical standards, ethical approval for research was taken and relevant authorities were contacted for recruitment of research participants. Informed consent was also taken by informing all participants regarding the procedure, duration and confidentiality methods used in research and taking consent for research.
After getting approval for my project proposal, I first took the approach to assess the knowledge of recruited samples regarding dementia care and the challenges they face during care. I conducted the survey with research participants by selecting a validated survey based tool called Dementia Knowledge Assessment Tool (DKAT) version two. DKAT is an evidence based tool that has been widely used in research and version two has been developed to assess knowledge of staff and families. The tool has set of 21 item questionnaires to check staff’s foundation level of knowledge related to dementia (Toye et al., 2014). The tool has set of statements related to dementia and participants need to give the answer in ‘yes’ or ‘no’. The tool with questionnaires has been attached in appendix 1. The survey and collection of survey response was completed within 4 days.
In the next phase of the project, the samples were provided patient centred and real practice based dementia care training for two weeks. The duration of each training session was two hours and three sessions were held in a week. During the training, power point slides and visual aids was used to educate staffs. The first session included a introduction on dementia and the prevalence of dementia. The next two session focused on identify challenges or issues faced by staffs in delivering care to dementia patient. The rest of the session focused on educating staffs regarding patient centred care approach to manage behaviour of patient. In the last session, a video was also shown regarding steps to implement person-centred care approach while providing care to patients with dementia. The training focused on developing basic knowledge about dementia care and developing the skills related to patient centred care. Developing patient centred skills was vital part of the program and this content was important because dementia patients develop challenging behaviours because of their unmet needs and poor communication and lack of patient-centred values among staffs is the main reason for high rate of unmet needs (Park et al., 2015). Written materials were also provided regarding person centred approach to manage challenging behaviour in dementia patients. Krishnamoorthy & Anderson (2011) suggest that in contrast to traditional approach like use of environmental restraint to control aggressive behaviour of patients, patient centred care approach can support staffs to decipher subtle messages in patient’s action. In addition, this approach can encourage staffs to focus on core values and activities that build therapeutic relation between patients.
The reassessment of the knowledge of the staffs regarding dementia care was done again by conducting survey using the DKAT 2 tool. The outcome and effectiveness of the education and training session was judged by the outcome of the survey response. In addition, to further understand the effectiveness of training staffs, each staffs were observed regarding how they interacted with patients, managed challenging behaviours and the response of patient. The observation of staff was done 10 days before and after the intervention. I analyzed the video recordings of patients and added comments after seeing the videos.
The initial survey with the staffs using the DKAT tool revealed certain misconceptions related to dementia. The survey response was an important data that helped to plan appropriate intervention to increase competence of staffs and increase patient’s satisfaction with care. The scores given by the tool ranged from 0 to 21 and higher scores indicated greater dementia knowledge. Staffs were also asked regarding their age and work experience. A total of 30 health care professionals completed the DKAT tool questionnaire and the survey before the intervention revealed that only five health care professionals could achieve high score of 20-21. Significant correlation was also found between age, work experience and knowledge of staffs. This is said because high scores were obtained for those health care professionals who had more than three year experience in working with dementia patients. However, in case of experience staffs also, poor conception related to management of dementia was found. For example, for the question ‘Are you confident enough to manage the challenging behaviours in dementia care at your workplace?’, even experienced staffs were reluctant in saying ‘yes’. Very few staffs expressed confidence. In addition, the response of participants related to dementia care such as changing the environment, identify pain in patients also revealed poor knowledge among health care staffs.
The results of the survey post the intervention changed significantly with many positive outcomes. After the education and training session, at least 20 staffs achieve high score of about 18-21. This indicated that training significantly improved knowledge and skills of staffs related to dementia care. In addition, confidence level of staffs also increase as 15 participants reported being confident to challenge behaviours in dementia care. In addition, observation for 10 staffs was done. Out of them more than 7 staffs were found to incorporate the elements of the training program while dealing with challenging behaviours in patient.
While implementing this project, the initial survey revealed that majority of health care professionals was not confident about dealing with challenging symptoms of dementia. The completion of the DKAT tool also suggested low level of knowledge and the most important finding was that senior health care staffs also reported lack of confidence in dealing with aggressive behaviour of patients. Hence, this outcome suggest that health care staffs in aged care setting are not adequate trained to manage complex behaviour of patients. This is also consistent with research literature. George, Long and Vincent (2013) explained that patients with dementia often experience adverse events in hospitals and higher length of hospital stay. This occurs because of contributing factors like lack of staff training, inappropriate intervention and discrimination. Hence, in case of the staffs involved in this project, it is evident they have not received adequate training and knowledge to understand complex needs of patient. Based on the survey response, training session was developed to enhance the knowledge and skills of staffs.
The results post the intervention revealed positive effect of training program in improving skills and performance of health care staffs. The strength of this project is that training session was implemented after evaluating the knowledge of staffs in dementia care. Hence, this approach was responsible for the success of the intervention as it helped to identify exact training needs of patients. This helped to address the gaps found in previous research too. The video based observation also indicated positive practice skills as staffs were able to control challenging behaviour in patients by engaging in patient-centred communication and they could interpret the reason behind challenging behaviour and aggressive attitude of patients. From this result, it is clear that training and extra education related to dementia care is important in aged care setting and training is effective in promoting knowledge and confidence related to management of challenging behaviours in dementia.
I would also like to mention about some limitations in the project. Firstly, the intervention was implemented only in one aged care facility in Australia. Choosing two or three more institutions would have enhanced the reliability of the research data. In addition, the sample size was very low. This also occurred because of time constraint issues. The project was completed within two months. If there was more time, then the above mentioned limitations in the project would have been addressed. In terms of challenges, the review of research literature revealed implementation of multi-disciplinary intervention. However, implementing this intervention was challenged. Hence, I decided to focus on single intervention and took steps to increase the efficacy of the intervention by first conducting survey to identify relevant training needs.
Conclusion:
This project report gave an insight into the manner in which the project was implemented to address care giving burden in dementia and revealed about the outcomes that were achieved after implementing a training and education program in health care setting. Implementing this project was important because as a staff working in age care setting in Australia, I myself have seen many staffs complaining about distress and poor satisfaction with job because of inability to control challenging behaviours of dementia patient. The significance of the project is also understood from the review of research literature. However, certain gaps such as lack of consideration of training needs and assessment of factors contributing to unmet needs reduced the reliability of evidence. Hence, taking cure from the gaps, this project was planned. The education session was found to positively influence skills and confidence of staffs in providing dementia care. Implementing this project also enhanced my report writing skills, critical thinking skills, reflective skills and time management skills.
References:
Baboolal, N., Davis, G., Stewart, R., Ramesar, J., & McRae, A. (2018). Comparisons between different elements of reported burden and common mental disorder in caregivers of ethnically diverse people with dementia in Trinidad. PloS one, 13(7), e0201165. Doi: ps://doi.org/10.1371/journal.pone.0201165
Brooker, D., & Latham, I. (2015). Person-centred dementia care: Making services better with the VIPS framework. Jessica Kingsley Publishers. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=Z8CpCgAAQBAJ&oi=fnd&pg=PA3&dq=Person-centred+dementia+care:+Making+services+better+with+the+VIPS+framework.+&ots=L3DajSoq6Z&sig=vjl5OeRmTGzEsiolBI8yphZ3a4E#v=onepage&q=Personcentred%20dementia%20care%3A%20Making%20services%20better%20with%20the%20VIPS%20framework.&f=false
Cheng, S. T. (2017). Dementia caregiver burden: A research update and critical analysis. Current psychiatry reports, 19(9), 64. https://doi.org/10.1007/s11920-017-0818-2
Cohen-Mansfield, J., Dakheel-Ali, M., Marx, M. S., Thein, K., & Regier, N. G. (2015). Which unmet needs contribute to behavior problems in persons with advanced dementia?. Psychiatry research, 228(1), 59-64. doi: 10.1016/j.psychres.2015.03.043
De Fazio, P., Ciambrone, P., Cerminara, G., Barbuto, E., Bruni, A., Gentile, P., … & Segura-Garcia, C. (2015). Depressive symptoms in caregivers of patients with dementia: demographic variables and burden. Clinical interventions in aging, 10, 1085. doi: 10.2147/CIA.S74439
De Vriendt, P., Cornelis, E., Desmet, V., Vanbosseghem, R. and Van de Velde, D., 2018. Quality in dementia care: A cross sectional study on the Bio-Psycho-Social competencies of health care professionals. PloS one, 13(2), p.e0191440. https://doi.org/10.1371/journal.pone.0191440
George, J., Long, S., & Vincent, C. (2013). How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions. Journal of the Royal Society of Medicine, 106(9), 355–361. https://doi.org/10.1177/0141076813476497
Houghton, C., Murphy, K., Brooker, D., & Casey, D. (2016). Healthcare staffs’ experiences and perceptions of caring for people with dementia in the acute setting: Qualitative evidence synthesis. International Journal of Nursing Studies, 61, 104-116. doi: 10.1016/j.ijnurstu.2016.06.001.
Krishnamoorthy, A., & Anderson, D. (2011). Managing challenging behaviour in older adults with dementia. Progress in Neurology and Psychiatry, 15(3), 20-26. https://doi.org/10.1002/pnp.199
McCabe, M. P., Bird, M., Davison, T. E., Mellor, D., MacPherson, S., Hallford, D., & Seedy, M. (2015). An RCT to evaluate the utility of a clinical protocol for staff in the management of behavioral and psychological symptoms of dementia in residential aged-care settings. Aging & mental health, 19(9), 799-807. doi: 10.1080/13607863.2014.967659.
Park, M., Kim, J., Lee, S. J., Lee, H., & Lee, D. Y. (2015). Unmet needs and satisfaction with the help of patients with dementia and their caregivers at home in korea. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 11(7), P718. DOI: https://doi.org/10.1016/j.jalz.2015.06.1598
Pieper, M. J., Francke, A. L., van der Steen, J. T., Scherder, E. J., Twisk, J. W., Kovach, C. R., & Achterberg, W. P. (2016). Effects of a stepwise multidisciplinary intervention for challenging behavior in advanced dementia: a cluster randomized controlled trial. Journal of the American Geriatrics Society, 64(2), 261-269. doi: 10.1111/jgs.13868
Resnik, D. B. (2011). What is ethics in research & why is it important. National Institute of Environmental Health Sciences, 1-10. Retrieved from: https://www.niehs.nih.gov/research/resources/bioethics/whatis/index.cfm
Sörensen, S., & Conwell, Y. (2011). Issues in dementia caregiving: effects on mental and physical health, intervention strategies, and research needs. The American Journal of Geriatric Psychiatry, 19(6), 491-496. doi: 10.1097/JGP.0b013e31821c0e6e.
Toye, C., Lester, L., Popescu, A., McInerney, F., Andrews, S., & Robinson, A. L. (2014). Dementia Knowledge Assessment Tool Version Two: development of a tool to inform preparation for care planning and delivery in families and care staff. Dementia, 13(2), 248-256. doi: 10.1177/1471301212471960
World Alzheimer Report: The Global Impact of Dementia (2015), Dementia Statistics, viewed on 25 August 2018, https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf
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