Dementia Dimensions: Efficacy-Based Training in the Assisted Living Directed Care Environment - Dissertation Example

? Dementia Dimensions: A Case Study in Efficacy-Based Training in the Assisted Living Directed Care Environment Submitted by Lisa O’Toole Grand Canyon University Phoenix, Arizona November 4, 2011 Dissertation Prospectus Introduction With our aging population living longer, data shows (Alzheimer’s Association, 2006) that age is one variable that correlates to a person being afflicted with Alzheimer’s disease. Knowing that more people will need specialized care related to cognitive impairment and dementia – there will also be a greater need for specialized care giver training to provide the specialized quality care. This study responds to the rapidly rising dementia population in residential care facilities, the minimum dementia training required by the State of Arizona, and the inconsistency of training offered among facilities, without evidence of efficacy. This research study aims to identify the components of a successful Dementia Training Program, as developed and implemented in a specific Arizona residential facility with a population of residents suffering from dementia, and to identify evidence of efficacy, from five years of structured documentation (facility records), and to subsequently create a dementia training model that can be recommended for use at other residential care facilities with dementia residents. Background of the Study Per Arizona Department of Health Services (2009), the assisted living environment in Arizona consists of three levels of care which is a reflection of the clients’ needs and abilities. The first being Personal care services which provides minimal assistance to the resident that resides there, including reminders for medication administration, assistance with bill paying and possible assistance with transportation . The second level is Supervisory care which provides more assistance with self-administration of medication , may assist with shopping, some food preparation, and activities of daily living (ADL’s) which includes bathing, dressing, and oral care. The third and highest level of care is Directed care services: provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. Care may include incontinent care, administration of medications and full assistance with ADL’s. Clients at this level may need more assistance with walking, eating and have limited verbal abilities to communicate wants and needs. Problem Statement The need for quality care for cognitively impaired individuals is on the rise. According to the 2010 United States Census Bureau data, the population of older adults over age 85 increased by 29.8 percent within the last ten years. The percentage change for to over 90 years old is even higher at 30.2 percent within the same ten year period. According to Mollica (2001), clients are choosing to live in ALF instead of nursing homes which may explain the higher acuity level of resident admissions. The training requirements for an assisted living caregiver consist of a sixty two hour training course (Arizona Senior Housing Institute, 2011) and one hour of continuing education per month. Purpose of the Study The purpose of this qualitative case study is to explore evidence of efficacy of the Dementia Training Program developed and implemented for dementia-affected residents at one Arizona residential care facility and, based on five years of structured documentation, to formalize a model of recommended dementia training protocol, grounded in evidence of efficacy. At this stage in the research, evidence of efficacy of the Dementia Training Program will be generally defined as family and staff satisfaction and patient safety. The Dementia Training Program covers multiple dimensions (interventions, medication administration, wound care, dietary knowledge to prevent weight loss, keeping the environment of care safe for this vulnerable population) Research Questions The following research questions guide this study: 1. What are the key components of the Dementia Training Program under investigation? 2. What evidence is there for the efficacy of the Dementia Training Program? 3. How might the components of the Dementia Training Program be stated in a formalized model that could benefit other residential care facilities with a dementia-affected population? Significance of the Study With a rapidly increasing population of older adults, particularly much older adults, and with the prevention of their rapid cognitive and physical decline relying on knowledgeable providers and dementia-friendly lifestyles, dementia is an escalating international issue. The General Assembly of the United Nations has adopted (September 2011) a declaration that includes Alzheimer’s as a major world-wide priority, citing the primary contributions of lifestyle and the critical importance of prevention in chronic, non-communicable diseases. The Political Declaration Annex, to that declaration, contained item 39, “Recognize that the incidents and impact of non-communicable diseases can be largely prevented or reduced with an approach that incorporates evidence-based, affordable, cost-effective, population-wide and multisectoral interventions (UN General Assembly NCD Summit, 2011).” This research study, proposed here, is an effort in line with these goals, identifying best practices that give dementia residents a lifestyle that will maximally prevent or reduce rapid cognitive and physical decline, and identify a training approach that is evidence-based, affordable, cost-effective, can be shared to spread to other assisted living resident populations, and involves multisectoral interventions. Preliminary Review of the Literature A research investigation of Florida's AD training program review process found that out of 445 curricula received over four and a half years, more than 90% were substandard, and frequently had “content with inaccurate information, language that was not person-centered, and missing required training components” (Hyer, Molinari, Kaplan, & Jones, 2010, p.864). An analysis of assisted living center inspection data, over a two year period in seven states, noted that 25% of the centers had been cited for training violations, and concluded that “staff shortages and insufficient training place elderly residents at risk with inadequate care, delayed diagnosis and treatment and even death” (McCoy & Appleby, 2004). This is complicated by the annual staff turnover rates at about 40%. Yet a recent review of papers on staff training for elders with mental illness found that most focused on behavior skills training (Moyle, Hsu, Lieff, & Vernooij-Dassen, 2010, p.1097). There is a need for more multifaceted training, In an innovative experiential training program in UK, caregivers’ glasses are smeared with Vaseline, to blur vision, and movement is inhibited by binding an arm. They are spoon-fed boring food and violations of dignity are the order of the day, all in an effort to promote empathy in those who care for dementia patients (Davis, 2010). Australia’s Victorian Government Health Information advises that dementia-friendly environments require staff to be trained in “helping people gain personal satisfaction in their lives” (Victorian Governemt, Australia, n.d.). A dementia coalition in Michigan lists “enriching people’s lives” as a dementia staff training core competency (Dementia Competencies Workgroup, 2008, p.21). There is also a need for definitive training standards. There is little consistency in the standards, topics, hours, and level of dementia staff training from state to state (Yee-Melichar, Boyle, & Flores, 2011, p.102). Furthermore, although the literature supports the critical role of caregiver training in improving quality of life for those with dementia, there is still a gap in the practical implementation and application of training (Beer, et al., 2010). Following are some key topics and theories in the literature: Providing a dementia-friendly environment Person-centered care The Green House concept Learning Circles Model for training The Hospitality Model of service Maslow’s Hierarchy of Needs Erikson’s Stage Theory: Integrity vs Despair Lifestyle interventions Computer-Assisted cognitive interventions Computer-assisted reminiscence training Promoting dignity and resident rights ADL (Activities of Daily Living) Responding to medical issues Infection Control Coping with early and later stages of memory loss Wandering safety Depression and suicide in Older Adults Preventing falls (leading cause of injury and death in the elderly) Pressure Sores Communicating effectively Privacy Preventing abuse Pharmacological management of dementia Caregiver Stress Nutrition and Dietary Issues Psychosocial Health Research Methodology This research prospectus is in support of a qualitative case study. It is based on a single case, a Phoenix area, Arizona residential care facility, Huger Mercy Living Center, serving residents with dementia (Catholic Healthcare West, 2011). The residential care facility, attached to St. Joseph’s Hospital, currently has 48 residents (including Sandra Day O’Conner’s husband) and 40 staff members. This care facility was selected due to researcher knowledge of, association with, and access to said facility and its innovative services and particularly with respect to researcher access to five years of structured documentation. Researcher is Assisted Living Manager of the Huger Mercy Living Center. The five years of structured documentation, routinely collected, stored and available in this facility, includes the following of research-targeted interest: dementia training curriculum, frequency, duration and delivery methods; patient family satisfaction reports (for both general residents and palliative care residents); fall reports (to calculate incidents and frequency of resident falls) and hospitalization incident reports; staff satisfaction reports; staff termination and retention information. Researcher intends to examine records of dementia training administered in the facility and note (list) topics covered (example: wound care) and curriculum delivery styles (example: lecture with handouts and practical application rehearsal) and annual training hours per employee. Researcher will organize this information into a table. Researcher will examine 50 randomly selected files to identify and note records of patient falls, acute care and hospitalizations and records of family satisfaction (general and palliative care) and staff satisfaction ratings, and staff loss vs retention records, and will organize this information, with annual percentage averages, into efficacy tables. Researcher will also list pertinent family and employee comments (positive and negative), with year of comment. Cross-referencing the curriculum table and the efficacy tables, Researcher will construct a model Dementia Training Program that can be recommended and made available to other residential care facilities. Researcher expects to identify the components of the Dementia Training Program utilized at the Huger Mercy Living Center. Researcher expects to find strong evidence of its efficacy in this successful facility. Researcher expects to eventually have an efficacy-based, multi-dimensional model of quality dementia-care training, with a specified curriculum and delivery system for use with training staff in other residential facilities with dementia-affected populations. Research Design The research design, used here, is a descriptive case study. It is descriptive in that it is Researcher’s intention to identify and make note of the approach to dementia training taken by a well-reputed residential care facility, as well as to make note of and describe various evidence of efficacy and, thirdly, to describe a Dementia Training model that can be made available to other assisted living residential centers with dementia-affected populations. A case study design has been chosen as being the most appropriate venue for describing what will be identified in the facility records. A case study design is appropriate for descriptive research. The facility under proposed investigation has five years of structured records from which data can be extracted. Furthermore, Researcher has unlimited professional access to that data. It was decided to focus on efficacy evidence of dementia training because there is an increasing population of dementia-affected residents in assisted living residential centers and the available literature indicates a strong need for better dementia training, in particular. Researcher professional observation and experience, in the field of residential assisted living care for dementia-affected residents, confirms what the literature indicates. While the disadvantage of a case study is the small population sample and concern about its generalizability to non-represented persons or facilities of interest, the advantage of a case study design is the capacity to look in depth and to identify patterns of information that can be used to construct an experiential description, in the context of which others can be later compared. This is especially appropriate when working with multiple dimensions of information, as happens when analyzing safety of patients, satisfaction of families and employees, and training program components. I have no research agenda calling for distinction of causality, so experimental designs are not indicated. I have a treasure trove of data to analyze, so there is no need to generate more, with other research designs. Sources of Data The data source consists of routinely-collected facility records extending back five years. These are in the form of documents. These documents consist of family and employee satisfaction ratings, comments and retention records, patient medical records (incident reports for falls, reports on incidents requiring acute medical intervention, such as bedsores or conditions requiring hospitalization. These also include records and reports of dementia training for staff, including topics covered, hours logged, frequency of training, and delivery methodology. Data Collection Procedures This research is a case study of a single assisted-living residential facility. Five years of routinely-collected facility records are available. Ten patient files from each of the five years will be randomly selected for review. A total of 50 patient files will be reviewed. Researcher will note evidence of resident safety (injury incidents, medical care and hospitalization reports), and evidence of family satisfaction (ratings and retention rates), Researcher will identify dementia training curriculum components, for the five year period, and will review records of staff satisfaction ratings and staff loss and retention for five years. Data Analysis Procedures To address the first research question, “What are the key components of the Dementia Training Program under investigation”, information on dementia training topics covered, type of curriculum used, method of delivery, frequency and duration of training for each employee at the facility will be extracted from the records and organized into a summary table. To address the second research question, “What evidence is there for the efficacy of the Dementia Training Program”, records of patient falls, acute medical care and hospitalization incidents, and records of family satisfaction (general and palliative care) and staff satisfaction ratings, and staff loss vs retention records will be examined. This collected data will be compiled into efficacy tables. A Resident Safety Efficacy table will indicate, for each year, the number of falls, percentage of residents who experienced falls, number of incidents of acute medical care (example: bedsores requiring medical intervention) and percentage of residents involved, number of hospitalizations necessitated and percentage of residents involved. A Satisfaction Efficacy Table will indicate for each year the mean rating for family satisfaction, the mean rating for staff satisfaction, and the percentage of staff retained. Pertinent family and employee comments (positive and negative, with year of comment) will also be noted and reported in the findings. . To answer the third research question, “How might the components of the Dementia Training Program be stated in a formalized model that could benefit other residential care facilities with a dementia-affected population”, the identified training program components will be listed and considered in light of the literature about important factors in dementia-friendly environments and dementia training programs, in USA, UK and Australia. The model will be contextualized by the literature in the field and supported by evidence of efficacy compiled from facility records. Ethical Considerations Resident confidentiality is protected by the assisted living center, and confidentiality will be protected in the data collection, analysis and any report released of this research; Patient files will be continue to be accessed only by authorized personnel. No facility records will be taken off-site during the course of review. Since Researcher is Assisted Living Manager of the facility, she already has fully authorized access and will need no additional site authorization. Resident Safety and Satisfaction Efficacy tables will report data without identifying information. Comments will be reported discretely and anonymously, so as to eliminate any source identifying feature. A copy of the final dissertation will be made available to the facility, for the interest and benefit of families and staff. Names will not be used in any publication, conference presentation, media release or interview, nor in the final dementia training model made available to other facilities. Securing informed consent will not be necessary as no new data will be gathered. Source data, already gathered, is covered by informed consent in facility records. This study involves no risk to humans or animals. Foreseeing the possibility that there may be questions about Researcher bias, in view of the Researcher’s position at the investigated facility, in this case study, Researcher has made full disclosure of her position, here in the Prospectus, and will continue to make full disclosure of her position in any presentation of findings. Complete objectivity in scientific endeavors is an ideal and never a reality, something to strive toward and never something to be certain about. In a quantum universe, the mere act of observing alters the “laws” of reality and the actions of the observed. Researcher values the scientific ideal of objectivity and will be ethically bound to report the facts, irrespective of personal desires. References Beer, C. D., Horner, B., A, O. P., meida, Scherer, S., Lautenschlager, N. T., et al. (2010). Dementia in residential care: Education intervention trial (DIRECT); protocol for a randomised controlled trial. Trials Journal, http://www.trialsjournal.com/content/11/1/63. Catholic Healthcare West. (2011). Huger Mercy Living Center. Retrieved November 3, 2011, from St. Joseph's Hospital and Medical Center: http://www.stjosephs- phx.org/Who_We_Are/188537 Davis, R. (2010, November 2). Dementia Training Puts Care Staff in Residents' Shoes. Retrieved November 4, 2011, from The Guardian: http://www.guardian.co.uk/society/2010/nov/02/dementia-training-care-staff- antipsychotics Dementia Competencies Workgroup. (2008). Knowledge and skills needed for dementia care in everyday language. Michigan Dementia Coalition. Eric M. Carlson, E. (2005). Critical Issues in Assisted Living: State Summaries. Washington, DC: National Senior Citizens Law Center. Hyer, K., Molinari, V., Kaplan, M., & Jones, S. (2010). Credentialing dementia training: The Florida experience. International Psychogeriatrics, vol 22:6 , 864-873. McCoy, K., & Appleby, J. (2004, May 26). Problem With Staffing, Training, Can Cost Lives. Retrieved November 4, 2011, from USA TODAY: http://www.usatoday.com/money/industries/health/2004-05-26-assisted-day2_x.htm Moyle, W., Hsu, M. C., Lieff, S., & Vernooij-Dassen, M. (2010). Recommendations for staff education and training for older people with mental illness in long-term aged care. International Psychogeriatrics, Vol.22:7 , 1097-1108. UN General Assembly NCD Summit. (2011, September 16). Declaration on Non- Communicable Diseases. Retrieved November 4, 2011, from United Nations General Assembly: http://alzheimerontario.org/local/files/Web%20site/Public%20Policy/UN% 20Declaration%20NCD%20Summit%20Sep%202011.pdf Victorian Governemt, Australia. (n.d.). Staff: Culture Change, Education and Support. Retrieved November 4, 2011, from Dementia Changes: http://www.health.vic.gov.au/dementia/changes/staff.htm Yee-Melichar, D., Boyle, A. R., & Flores, C. (2011). Assisted living administration and management: Effective practices Model Programs in elder care. New York: Springer Publishing Company References Alzheimer’s Association (2006). Know the top 10 signs [Web Blog Post]. Retrieved from http://www.alzheimers.org/know_the_10_signs.asp. Arizona Department of Health Services, Division of Licensing Services: Assisted Living Homes/ Centers, Adult Foster Care Homes & Adult Day Health Care Facilities. (2009). Retrieved from http://www.azdhs.gov/als/hcg/index.htm. Arizona Senior Housing Institute (2011). Caregiver Training Course Catalog. Retrieved from http://www.srhousing.org. Brands, H.W. (2000). The First American: the Life and Times of Benjamin Franklin. New York: Doubleday. Calabrese, R. L. (2006). The elements of an effective dissertation & thesis: a step-by-step guide to getting it right the first time. Lanham, MD: Roman & Littlefield Education. Creswell, J.W. (2003). Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Thousand Oaks: Sage Publications. Mollica, R. L. (2001). State policy and regulations. In S. Zimmerman, P. Sloane & J.Eckert (Eds.), Assisted Living: (Needs, Practices, and Policies in Residential Care for the Elderly. Baltimore: Johns Hopkins University Press. Nock, A. J.. (1943). The Memoirs of a Superfluous Man. New York: Harper & Brothers. Publication Manual of the American Psychological Association. (2010) Washington, DC: American Psychological Association. (6th edition) (ISBN 10: 1-4338-0559-6; ISBN 13: 978-1-4338-0561-5; ISBN 10: 1-4338-0561-8). Sprague, J. and Stuart, D.. (2000) The speakers's handbook, Harcourt College Publishers. U.S. Department of Commerce Economics and Statistics Administration U.S. CENSUS BUREAU (2010). 2010 Census Data. Retrieved from http://census.gov/2010 census/data/ Appendix A Variables, Phenomena, and Data Analysis Table 2 Research Questions Phenomenon Sources of Data Analysis Plan 1. What are the key components of the Dementia Training Program under investigation? Dementia Training Program curriculum Five years of records of training curriculum and hours invested Examine records of dementia training administered in the facility and note (list) topics covered (example: wound care) and curriculum delivery styles (example: lecture with handouts and practical application rehearsal) and annual training hours per employee. Organize this information into a table. 1. 2. What evidence is there for the efficacy of the Dementia Training Program? Evidence of efficacy (patient safety, family and staff satisfaction) Five years of documentation: patient fall reports, patient acute care and hospitalization records, family satisfaction reports, family satisfaction palliative care reports, staff satisfaction ratings, staff loss and retention records Randomly select 10 resident files from each of the five years, for a total of 50 files. Examine records of patient falls, acute care and hospitalizations and records of family satisfaction (general and palliative care). Examine staff satisfaction ratings, and staff loss vs retention records. Organize this information, with annual percentages and averages, into resident safety and satisfaction efficacy tables. Also list pertinent family and employee comments (positive and negative, with year of comment. 3.How might the components of the Dementia Training Program be stated in a formalized model that could benefit other residential care facilities with a dementia-affected population? Organization and presentation of the Dementia Training Program Documentation of curriculum organization and presentation implemented over past five years at facility under investigation Cross-referencing the curriculum table and the efficacy tables, construct a model Dementia Training Program that can be recommended and made available to other residential care facilities. Appendix B Arizona State Assisted Living Facility Staff Training Requirements “All direct-care staff members must have training in first aid and CPR. If the facility provides supervisory care services, a direct-care staff member prior to employment must complete 20 hours of training, or the amount of time necessary to verify that he or she demonstrates competency in each of the following topics: promoting resident dignity, independence, self-determination, privacy, choice, resident rights, and ethics; communicating effectively with a resident, a representative and relatives, individuals who appear angry, depressed, or unresponsive; managing personal stress; preventing abuse, neglect, and exploitation and reporting requirements; controlling the spread of disease and infection; recordkeeping and documentation; following and implementing resident service plans; nutrition, hydration, and food services; assisting in the self-administration of medications; developing and providing social, recreational, and rehabilitative activities; and fire, safety, and emergency procedures. If a facility is licensed to provide personal care services, a direct-care staff member must comply with training requirements in addition to those required of staff members providing only supervisory care services. Prior to employment a staff member must complete 30 hours of training, or the amount of time necessary to verify that he or she demonstrates competency in each of the following areas: the aging process and medical conditions associated with aging or physical disabilities; assisting residents in activities of daily living and taking vital signs; and medications. If a facility is licensed to provide directed care services, a direct-care staff member must meet training requirements on top of the requirements applicable to supervisory care services and personal care services. Prior to employment, a staff member must complete 12 hours of training, or the amount of time necessary to verify that he or she demonstrates competency in each of the following topics: Alzheimer’s disease and related dementias; communicating with a resident who is unable to direct self-care; providing services, including problem solving, maximizing functioning, and life skills training for a resident who is unable to direct self-care; managing difficult behaviors in a resident who is unable to direct self-care; and developing and providing social, recreational, and rehabilitative activities for residents who are unable to direct self-care. Training must be conducted by one of the following: a nurse, physician, physician assistant, or related medical professional with at least 2 years of health-related experience; an individual with at least a bachelors degree in social work, gerontology, or closely-related field and at least 2 years of health-related experience; an instructor employed by an accredited junior college, college, university or health care institution to teach health-related courses; or an assisted living facility manager with at least 2 years experience serving as a manager in a residential care institution. At least six hours of continuing education is required annually, with an additional two hours for providing personal care services, or an additional four hours in directed care services. A facility shall ensure that there are sufficient staff members, consistent with the level of service the facility is licensed to provide, to provide services established in each resident’s service plan, and to meet the needs of each resident including scheduled and unscheduled needs, general supervision, and the ability to intervene in a crisis 24 hours a day” (Eric M. Carlson, 2005). Read More