Lynn Chenoweth

Staff outcomes from the Caring for Aged Dementia Care REsident Study (CADRES): A cluster randomised trial

BACKGROUND Dementia care mapping and person centred care are well-accepted as processes for improving care and well-being for persons with dementia living in the residential setting. However, the impact of dementia care mapping and person centred care on staff has not been well researched. OBJECTIVES The impact of person centred care and dementia care mapping compared to each other and to usual dementia care on staff outcomes was examined in terms of staff burnout, general well-being, attitudes and reactions towards resident behavioural disturbances, perceived managerial support, and quality of care interactions. DESIGN A cluster-randomised, controlled trial. SETTINGS The study was conducted between 2005 and 2007 in 15 residential aged care sites in the Sydney metropolitan area, Australia, with comparable management structures, staffing mix and ratios, and standards of care. PARTICIPANTS 194 consenting managers, nurses, therapists and nurse assistants working in the participating sites. METHODS Intervention care sites received training and support in either person centred care (n=5) or dementia care mapping (n=5); control sites continued with usual dementia care (n=5). Staff outcomes of those three groups were assessed before, directly after the four month intervention (post) and after a further four months (follow-up). The primary outcome measures were the Maslach Burnout Inventory-Human Services Survey and the 12-item General Health Questionnaire. Analysis involved repeated measures analyses of variance for each of the outcome measures and adjustment for potential confounders to limit bias. RESULTS The Maslach Burnout Inventory-Human Services Survey results showed that change over time in emotional exhaustion scores differed between the three groups. Post-hoc analyses for each group separately revealed that the only significant time effect was in the dementia care mapping group (p=0.006), with emotional exhaustion scores declining over time. At baseline, more perceived support from management was associated with less emotional exhaustion (r(s)=0.26, p=0.004, n=122) and less depersonalisation (r(s)=0.21, p=0.023, n=122), but not for any of the other outcome measures. CONCLUSIONS This study has shown that person centred approaches of care, in particular with dementia care mapping, may contribute to reducing staff job related burnout. The findings also highlight a potentially important role of managerial support and a whole of system approach.

Facilitating the process of critical thinking for nursing

An exploratory study was conducted during 1995 to examine the degree to which critical thinking was encouraged in nursing education throughout New South Wales (NSW), Australia. The study identified whether a sample of graduate nurses and nurse educators at 12 faculties of nursing in NSW shared similar ideas about what critical thinking entails, the best ways in which to develop critical thinking processes and whether critical thinking is a reasonable way for nurses to achieve skilled and effective nursing interventions. The findings indicate that both nursing students and nurse educators favour the facilitation of critical thinking for nursing for very practical reasons. These refer to improving professional standards of practice, stimulating inquiry and promoting sound reasoning in practice, as well as contributing to personal and professional development. Study participants were found to favour a variety of teaching and learning strategies for critical thinking, and this finding is the focus for this discussion paper. The majority of participants stated that nurses would perhaps be better able to abstract principles of thinking from the specific contexts in which they are practised. Strategies found effective for nursing practice included a variety of approaches: direct learning of skills that contribute to critical thinking, such as analysis; infusion, or integration of critical thinking in all areas of learning; and learning to think critically within distinct disciplines of thought. Analysis of the findings, therefore, suggests that critical thinking is thought to be an important component of nursing practice and that in nursing it is a complex activity, requiring a combination of dispositions, abilities and approaches that can be developed by drawing on a range of learning strategies.

Self-management in older patients with chronic illness

Chronic illness causes the majority of disease burden and health costs in developed countries; however, this could be substantially reduced by optimal patient self-management. This study examined the levels of self-management in patients (n = 300) with chronic illness (chronic heart failure, chronic respiratory disease, Parkinsons disease and chronic schizophrenia) of moderate severity who had experienced an illness exacerbation in the last month. Patients perceptions of self-efficacy in relation to their self-management and their sense of coherence were also assessed at baseline and 1 month later. No changes occurred in self-perceptions or self-management from baseline to follow-up. Patients at risk of poor self-management included people with low self-efficacy, poor sense of coherence, older age and a primary diagnosis of chronic schizophrenia. As self-efficacy is the only predictor known to be amenable to intervention, self-efficacy enhancing support should be promoted.

The Sydney Multisite Intervention of LaughterBosses and ElderClowns (SMILE) study: cluster randomised trial of humour therapy in nursing homes

Objectives To determine whether humour therapy reduces depression (primary outcome), agitation and behavioural disturbances and improves social engagement and quality-of-life in nursing home residents. Design The Sydney Multisite Intervention of LaughterBosses and ElderClowns study was a single-blind cluster randomised controlled trial of humour therapy. Setting 35 Sydney nursing homes. Participants All eligible residents within geographically defined areas within each nursing home were invited to participate. Intervention Professional ‘ElderClowns’ provided 9–12 weekly humour therapy sessions, augmented by resident engagement by trained staff ‘LaughterBosses’. Controls received usual care. Measurements Depression scores on the Cornell Scale for Depression in Dementia, agitation scores on the Cohen-Mansfield Agitation Inventory, behavioural disturbance scores on the Neuropsychiatric Inventory, social engagement scores on the withdrawal subscale of Multidimensional Observation Scale for Elderly Subjects, and self-rated and proxy-rated quality-of-life scores on a health-related quality-of-life tool for dementia, the DEMQOL. All outcomes were measured at the participant level by researchers blind to group assignment. Randomisation Sites were stratified by size and level of care then assigned to group using a random number generator. Results Seventeen nursing homes (189 residents) received the intervention and 18 homes (209 residents) received usual care. Groups did not differ significantly over time on the primary outcome of depression, or on behavioural disturbances other than agitation, social engagement and quality of life. The secondary outcome of agitation was significantly reduced in the intervention group compared with controls over 26 weeks (time by group interaction adjusted for covariates: p=0.011). The mean difference in change from baseline to 26 weeks in Blom-transformed agitation scores after adjustment for covariates was 0.17 (95% CI 0.004 to 0.34, p=0.045). Conclusions Humour therapy did not significantly reduce depression but significantly reduced agitation. Trial registration Australian New Zealand Clinical Trials Registry -ACTRN12611000462987.

Leadership and management in the aged care sector: A narrative synthesis

The aim of this study is to examine the issues and the progress being made in leadership and management with relevance for the residential aged care workforce. A systematic review was conducted using scientific journal databases, hand searching of specialist journals, Google, snowballing and suggestions from experts. After a seven‐tiered culling process, we conducted a detailed review of 153 papers relevant to leadership and management development in aged care. Strong, effective leadership and management promotes staff job satisfaction and retention, high care quality and the well‐being of care recipients, and reduces associated costs. Good leadership and effective management also play a key role in bringing about a successful change to a positive workplace culture through innovative programs and research projects. Organisational investment in improving leadership and management skills and capabilities can only improve outcomes for staff stability and productivity, care quality and budgets, and better prepare the aged care sector.

New approaches to health and well‐being for dementia day‐care clients, family carers and day‐care staff

Kilstoff K, Chenoweth L. International Journal of Nursing Practice 1998; 4: 70–83 New approaches to health and well-being for dementia day-care clients, their family carers and day-care staff This study was conducted in one multicultural dementia day-care centre over a period of 18 months. It introduced a gentle hand treatment for clients using three essential oils. The study evolved out of the process of action research where the family carers and day-care staff participated with the researchers to choose, design, develop and evaluate a hand treatment programme. Data was collected through in-depth interviews pre-and post-treatment, focus group discussions, client observation logbooks and a disability scale. The findings indicate a positive strengthening of the relationship between the person with dementia and their family carer, and an improvement in feelings of health and well-being for both. The specific improvements for clients include increased alertness, self-hygiene, contentment, initiation of toileting, sleeping at night and reduced levels of agitation, withdrawal and wandering. Family carers have reported less distress, improved sleeping patterns and feelings of calm. They also found the treatment useful in helping them manage the difficult behaviours exhibited by their relative with dementia. The benefits of this treatment for nursing practice are that it is safe, effective and easily administered by staff in any setting.

Implementing Person-Centered Care in Residential Dementia Care

Person-centered care (PCC) for people with dementia is a system of care that is based on the belief that personhood can be maintained despite cognitive impairment. A recently conducted cluster randomized trial (Chenoweth et al., 2009) demonstrated that PCC was effective in reducing agitation in people with dementia who were in residential care. This article provides a detailed overview of the PCC intervention arm of the study and describes the training and procedures used to facilitate implementation of PCC. Training emphasized the impact of the social world on the person with dementia and promoted the skills of interpersonal engagement, especially in relation to feeling expression. Facilitated on-site learning involved care planning that included obtaining a life story of the person with dementia and observing social interactions. The success of the PCC intervention was related to this two-pronged approach, which included support from managers. Implementation of PCC requires a whole-of-system approach, which includes formal and informal learning.

PerCEN: a cluster randomized controlled trial of person-centered residential care and environment for people with dementia

BACKGROUND There is good evidence of the positive effects of person-centered care (PCC) on agitation in dementia. We hypothesized that a person-centered environment (PCE) would achieve similar outcomes by focusing on positive environmental stimuli, and that there would be enhanced outcomes by combining PCC and PCE. METHODS 38 Australian residential aged care homes with scope for improvement in both PCC and PCE were stratified, then randomized to one of four intervention groups: (1) PCC; (2) PCE; (3) PCC +PCE; (4) no intervention. People with dementia, over 60 years of age and consented were eligible. Co-outcomes assessed pre and four months post-intervention and at 8 months follow-up were resident agitation, emotional responses in care, quality of life and depression, and care interaction quality. RESULTS From 38 homes randomized, 601 people with dementia were recruited. At follow-up the mean change for quality of life and agitation was significantly different for PCE (p = 0.02, p = 0.05, respectively) and PCC (p = 0.0003, p = 0.002 respectively), compared with the non-intervention group (p = 0.48, p = 0.93 respectively). Quality of life improved non-significantly for PCC+PCE (p = 0.08), but not for agitation (p = 0.37). Improvements in care interaction quality (p = 0.006) and in emotional responses to care (p = 0.01) in PCC+PCE were not observed in the other groups. Depression scores did not change in any of the groups. Intervention compliance for PCC was 59%, for PCE 54% and for PCC+PCE 66%. CONCLUSION The hypothesis that PCC+PCE would improve quality of life and agitation even further was not supported, even though there were improvements in the quality of care interactions and resident emotional responses to care for some of this group. The Australian New Zealand Clinical Trials Registry Number is ACTRN 12608000095369.

Recommended Measures for the Assessment of Behavioral Disturbances Associated With Dementia

OBJECTIVE The study reviewed all the published instruments used for the assessment, diagnosis, screening, and outcomes monitoring/evaluation of behavioral disturbances associated with dementia (BDAD) to recommend a set of psychometrically valid measures for clinicians and researchers to use, across a range of different practice settings. METHODS The study involved a broad scoping search, followed by a series of in-depth literature reviews on 29 instruments using scientific literature databases (MEDLINE, PsycINFO, CINAHL, and the Cochrane Library) and various national, international government, and government agency websites and professional organization websites. External consultations from measurement, clinical and research experts in dementia care, consumer representatives, and policy/decision makers, were sought in selecting the best instruments and in making the final recommendations. FINDINGS Key attributes and psychometric properties of a short list of five instruments were measured against prespecified criteria. The Neuropsychiatry Inventory (NPI) and the Behavioral Pathology in Alzheimers Disease Rating Scale (BEHAVE-AD) were rated as the best measures for assessment of behavioral disturbances, followed by the Consortium to Establish a Registry for Alzheimers Disease-Behavior Rating Scale for Dementia (CERAD-BRSD), the Dementia Behavior Disturbance Scale, and the Neurobehavioral Rating Scale. CONCLUSION The use of valid and standardized outcome measures for the assessment of BDAD is critical for epidemiological studies, prevention, early intervention and treatment of dementia conditions, and funding for relevant healthcare services. The review recommends the NPI and BEHAVE-AD as the most appropriate measures for both clinical and research, whereas the CERAD-BRSD is suited better for research. The review was designed for the Australian context; however, the findings are applicable in other developed countries.

Determining the efficacy of Dementia Care Mapping as an outcome measure and a process for change: A pilot study

Dementia Care Mapping (DCM) is increasingly being promoted world-wide as a useful approach in assisting staff to improve the well-being of residents with dementia. While DCM is employed as an outcome measure of well-being and as a process to assist staff improve quality of care, it has not been subject to the rigorous scrutiny of a controlled trial to establish its efficacy as an outcome measure, or as an intervention. In 2005 the authors were awarded an Australian Health Ministers Grant to conduct a randomised control trial of DCM in 15 residential dementia care units across the city of Sydney, Australia. This paper reports on a pilot study conducted with 35 dementia care residents in three secure residential care units in the state of New South Wales, Australia, prior to the controlled trial. The main aims of the pilot were to determine the sensitivity of DCM against the validated baseline and outcome measures selected for the trial and to evaluate the utility of the research plan. The utility of the research plan was established. Whilst a significant improvement was shown in staff interactions with residents over time, there was no evidence that DCM improved the residents’ quality of life and well-being in relation to physical and cognitive functioning, although there was a reduction in the residents’ levels of agitation and depression. While as a research tool DCM needs further refinement to match the strength of validated outcome measures that more accurately assess the residents’ well-being, DCM procedures improved staffs attention to monitoring and attending to the residents’ well-being.