An evaluation of the effectiveness of Dementia Care ......the effectiveness of Dementia Care Essentials in improving the quality of residential and community aged care . ... 8 Target

An evaluation of the effectiveness of Dementia Care Essentials in

improving the quality of residential and community aged care Sites de-identified

Volume One. Report

Commissioned by Alzheimer’s Australia Vic.

Conducted by

Bernie McCarthy MAPS

McCarthy Psychology Services

May 2012

Evaluation of the effectiveness of Dementia Care Essentials 2012

2

Table of Contents

List of Tables 3

List of Figures 4

Executive Summary 5

Background 7

Introduction 9

Methodology 17

Sample 17

Instruments 19

Analysis 22

Results 23

Demographics PAS 23

DCM/QUIS 25

Organisational Review 39

Surveys 42

Comparison with Competencies 43

Discussion 45

References 53

List of Appendices (Full appendices in Volume Two) 56


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List of Tables

1 Positive (Personal Enhancers)and negative (Personal Detractors) care actions identified in Dementia Care Mapping

12

2 VIPS Framework – Brooker 2007 15

3 QUIS care interaction types 20

4 Mood scale for adapted QUIS 22

5 Existing data for residents at Residential Site 1 and Residential Site 2 at Time 1

23

6 Dementia Care Mapping for Time 1, 2, and 3 for both residential sites

26

7 Detailed analysis of PDs and PEs related to each of the five Fundamental Needs at Residential Site 1 at Times 1, 2, and 3.

28

8 Target behaviours for Residential Site 1 Action Plan 32

9 Detailed analysis of PDs and PEs related to each of the five Fundamental Needs at Residential Site 2 at Times 1, 2, and 3.

33

10 Action Plan items from Residential Site 2 at Time 3. 36


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List of Figures

1 Cornell scores at Residential Site 2 at Times 1 & 3 24

2 Cornell scores at Residential Site 1 at Time 1 & 3 25

3 Personal Detractors and Personal Enhancers at both sites at Time 1 & 3 27

4 Personal Detractors and Fundamental Needs for Residential Site 1 at Times 1, 2 & 3

29

5 Personal Enhancers and Fundamental Needs for Residential Site 1 at Times 1, 2 & 3

30

6 Personal Detractors and Fundamental Needs for Residential Site 2 at Times 1, 2 & 3

34

7 Personal Enhancers and Fundamental Needs for Residential Site 2 at Times 1, 2 & 3

35

8 QUIS observations (rate per minute) of care provided by one care workers with the same client at Times 1, 2, and 3.

38

9 QUIS ratings during two types of care interaction (rate per minute)

39


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Executive Summary

This report was commissioned by Alzheimer’s Australia Vic. to examine the effectiveness of

Dementia Care Essentials training delivered at Certificate III and IV levels to aged care

residential and community care staff, in improving the quality of aged care provided to

people living with dementia. The evaluation had a dual focus on the effectiveness of the

training delivered by Alzheimer’s Australia Vic. and also the impact of organisational culture

and change efforts on this effectiveness.

The evaluation was a multi-method repeated measures action learning design conducted in

three aged care sites in metropolitan Melbourne, Victoria. Two sites were residential and one

delivered community aged care. Measures were taken pre-training, immediately post-training

and 3-months post-training. Variables measured included staff, resident and organisational

aspects of the care context. Instruments included Dementia Care Mapping (DCM) and

Quality of Interventions Schedule (QUIS) adapted to community care, and the VIPS

Framework (Brooker, 2007) to measure the organisational context supporting person-

centred care.

With the two residential aged care providers Dementia Care Mapping was utilised as an

outcome measure and as a stimulus for reflection on the feedback that was provided post-

training and after 3 months. With the community aged care provider QUIS was utilised as an

outcome measure and stimulus for reflection on the feedback that was provided post

training. An action plan was devised by each site on the basis of the feedback following a

Plan-Do-Study-Act model of change.

Results of the data show that there is a mixed effect of the training immediately post the

training with improvement in some indicators and worsening of others. It is only after the

organisation commences its action planning phase that more consistent changes emerge.

The data show that the process of change has begun at 3 months and is moving in the

direction of improved care but is not sufficiently developed even after 3 months to provide

convincing evidence of the effort to improve quality of care practice. Given that 3 months is a

relatively short period to see organisational change it would be beneficial to do further follow

up.

Conclusions are that the Dementia Care Essentials training is an effective and necessary

stimulus to promote improved dementia care. However on its own without efforts at an


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organisational level to embed this learning in a way that is consistent with the culture of the

organisation will not produce change in the quality of care on its own. Multiple cycles of

action planning and implementation are essential for sustained change. Providing the

training as part of a broader organisational approach to improving the quality of care is more

likely to produce changes that are specific and show improvement in the care experience of

the residents and clients.


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Background

The Dementia National Health Priority Initiative, known as the Dementia Initiative

was funded in 2005 by the Australian government to improve the quality of dementia

care experienced by Australians with the condition and their carers. One of the

programs funded as part of the initiative was Dementia Care Essentials (DCE). This

program was to provide nationally accredited training to aged care staff who wished

to improve their skills and further their aged care careers. In 2011 it was approved

for further funding. This current round of DCE is funded by the Australian

government (Department of Health and Ageing) under the Aged Care Workforce

Fund.

DCE is a program of nationally accredited training delivered locally by a range of

agencies across the nation and in slightly varying formats. The format in Victoria is a

program of three days, face-to-face training including workplace assessment and

completion of tasks by participants in fulfilment of the criteria for unit competency.

The first round of DCE included only the Certificate III level dementia competency

from the Certificate III in Aged Care Work from the Community Services Training

Package CHC02. This unit was CHCAC15A Provide care support which is

responsive to the specific nature of dementia. This changed in 2010 to CHC08 and

the unit became known as CHCAC319A Provide support to people living with

dementia.

The second (current) round of DCE includes both Certificate III and IV levels of the

dementia competency both of which have been designed by Alzheimer’s Australia

and are from the CHC08 Community Services Training Package qualifications

Certificates III and IV in Aged Care Work. They are the unit CHCAC319A Provide

support to people living with dementia at Certificate III level and the Certificate IV

level unit CHCAC416A Facilitate support responsive to the specific nature of


8

dementia. The former unit is advertised to participants as Dementia Care Essentials

and the latter unit is advertised as Dementia Care Essentials – Support Planning.

The specific requirements of each unit from the Community Services Training

Package are identified in Appendix 1.3


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Introduction

The current study is a selective evaluation of the effectiveness of the second round

of Dementia Care Essentials (DCE) training provided by Alzheimer’s Australia Vic.

by sampling two residential aged care homes and one community services team in

metropolitan Melbourne, Victoria in 2011 that participated in the program.

Dementia is the greatest single contributor to the cost of care in nursing homes and it

is estimated that 60% of people in Australia in high care and 30% in low care

residential care facilities have dementia, with some 90% and 54% respectively

having an obvious impairment (AIHW, 2004). Equally it is acknowledged with the

ageing of the population that 69% of people living with dementia, live in their own

home in the community. Consequently the majority of people living with dementia are

not living in residential aged care. However the proportion of those people living with

dementia in residential aged care has increased. Hence the importance of this study

focusing on both residential and community aged care.

Dementia is a growing health concern for our society with increasing numbers of

people diagnosed and requiring care now and in the decades ahead. Best practice

dementia care is recognised as person-centred (Alzheimer’s Australia, 2009). This is

identified by Brooker as value-based, individualised, respecting the perspective of

the person with dementia and supporting their social needs and skills (Brooker,

2007). Practice evaluations have demonstrated that this is far from the truth in

practice (Cohen-Mansfield & Bester, 2006; Rabig, Thomas, Kane, et al., 2006).

Aged care provider organizations around the world still struggle with the transition

from task oriented approaches to effective person centred dementia care.

The provision of training to aged care staff has been long regarded as an essential

component for improving the quality of care (Stevens, et al., 1998). Training is also a

mandated and funded element of the Aged Care Act (1997).

Training staff in aged care homes in an effort to improve the quality of care provided

is an endeavour however, fraught with difficulties not least of which are the following:


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the need to work in a constantly changing environment with people who have a

combination of physical and cognitive decline, whose conditions progressively

worsen, amid a tightly controlled regulatory and compliance environment, with a mix

of bio-medical and person centred bio-psycho-social health care paradigms, low paid

staff who are mostly part-time, with low staffing levels, whose education may be

minimal and whose command of English may be poor and add in management

whose priorities may not be care quality but more financial (return on investment for

proprietors/ shareholders) and organisational.

In the community aged care sector these issues are added to by issues of isolation

as workers rarely come together as a team creating problems around ongoing

support and professional development. There are also often problems of

communication with direct care workers often not involved in or aware of support

plans that are developed for the person they are supporting. They may also be

employed by a number of different community care organisations and are sub-

contracted in to deliver the care.

This critique presents only part of what is a more balanced view that includes the

frequent efforts of talented and dedicated staff to implement cultural practice

changes in care environments that improve the quality of care. There are also many

generous well-motivated care staff whose values are person centred and whose care

behaviour provides a person centred model for their colleagues. Many managers

and aged care leaders establish and manage high quality care environments that

provide experiences of hope and meaningful living for those with dementia in their

care.

The DCE program, based in the national competency as described above was

designed to improve skills for aged care workers based on the person-centred

approach to dementia care which has become synonymous with “best practice”

(Brooker, 2007). This person centred approach is predicated on the notion that the

person with dementia remains a social being who has a personal individual


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perspective, can contribute to their care, remains a social participant and is more

than the sum total of their neurological impairment (Kitwood, 1997).

It is often difficult to measure the effectiveness of such training interventions

(Hughes, Bagley, Reilly, et al., 2008). It requires a dual focus on both the skills of the

caregiver and on the effect of these skills in improving or sustaining the quality of

lived experience of the person receiving the care. Many methods are employed, from

exit surveys of satisfaction and attitude change, through to direct observation of

employees in the exercise of their duties (Norbergh, Helin, Dahl, et al., 2006).

An initial focus on the skills the participants are learning in the DCE courses at

Certificate III and IV levels identify essential skills (essential knowledge is also

identified and is evaluated for competency, but is less observable and therefore not

the focus of this review) that are required for competency in dementia care. A

competent student would display a set of skills as listed in Appendix 1.3.

These criteria may be used to identify markers for competency but should be

accompanied by indicators of the quality of lived experience of the person with

dementia.

The measurement of quality of life in people with dementia received little attention

until the past decade (Zimmerman, et al., 2005). Several studies have examined a

range of definitions of the concept of “quality of life” itself (Droes, et al., 2006;

Gerritsen, et al., 2007; Gerritsen, Steverink, Ooms, et al., 2004) and range of

methods (Edelman, Fulton, Kuhn, et al., 2005) for responding to the contextual

difficulties associated with validly and ethically assessing this domain including self-

report (Gerritsen, Steverink, Ooms, et al., 2007; Smith, et al., 2005); qualitative

interview(Cahill & Diaz-Ponce, 2011) and observational measures involving ratings

by proxy such as Dementia Care Mapping (Brooker, 2005; Edvardsson & Innes,

2011; Sloane, et al., 2007) or the environmental rating tool TESS-NH (Sloane, et al.,

2002).


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One tool that encapsulates the dimensions of staff skills and resident experience is

Dementia Care Mapping (DCM). DCM is an observational tool and quality

improvement process created by Professor Tom Kitwood and Kathleen Bredin to

measure and evaluate the quality of dementia care in residential and day care

settings (Kitwood & Bredin, 1992).

DCM involves a trained observer noting systematically every five minutes what the

person with dementia is doing and what they appear to be feeling during this period

(the quality of their lived experience). The mapper also notes the positive and

negative care actions by aged care workers that have an impact upon the wellbeing

of the person with dementia (University of Bradford, 2005). Positive care actions

(Personal Enhancers - PEs) improve wellbeing and negative care actions (Personal

Detractions – PDs) decrease wellbeing or create illbeing. A list of these care actions

as identified in the DCM manual (Brooker and Surr, 2005) are located in Table 1.

below.

Table 1. Positive and negative care actions identified in Dementia Care Mapping.

Positive care actions (Personal Enhancers) Negative Care Actions (Personal Detractors) Warmth Intimidation Holding Withholding Relaxed pace Outpacing Respect Infantilization Acceptance Labelling Celebration Disparagement Acknowledgement Accusation Genuineness Treachery Validation Invalidation Empowerment Disempowerment Facilitation Imposition Enabling Disruption Collaboration Objectification Recognition Stigmatization Including Ignoring Belonging Banishment Fun Mockery


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These positive and negative care actions are measurable indicators of care quality.

As such, they can be utilised as indicators of change in the quality of person-centred

care provision. They may also be used as indicators of the “essential skills” noted

above for competency.

DCM was designed as a tool for the improvement of quality of care and quality of life

in clinical settings rather than as a research instrument (Kitwood & Bredin, 1992).

The evidence for its effectiveness as a valid and reliable research tool for the

measurement of quality of care and life in aged care is regarded as well established

(Brooker, 2005; Fossey, Lee, & Ballard, 2002; Innes & Surr, 2001). It has been used

in quality audits (Younger & Martin, 2000) and as an outcome measure (Fossey, et

al., 2002).

The current evaluation includes staff working with community dwelling elderly with

dementia as well as those working in residential settings. This section of the aged

care workforce has increased significantly in size in recent years (Productivity

Commission, 2011). Research into the experience of people with dementia living in

their own homes, specifically focussing on quality of life, is relatively new. There are

no observational tools designed specifically for this setting. Some have been

adapted for the community setting, including Dementia Care Mapping (in

development as DCM-SL by Bradford Dementia Group and not available for use in

Australia).

One tool that lends itself readily to adaptation to the community setting is the Quality

of Interactions Schedule (QUIS) (Dean, Proudfoot, & Lindesay, 1993). This

observational tool was developed for the residential aged care setting as a measure

of the quality of social interactions between residents and care staff. These were

coded as positive social, positive care, neutral, negative protective or negative

restrictive.


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The original observations were conducted in a residential setting by dividing the

working day into four sections and making observations over a two week period to

obtain a representative sample of the social interactions occurring in the care

environment. This is clearly not possible in a community care setting where care staff

provide care in brief focussed interactions that may be up to one hour in duration but

rarely longer. The type of work carried out may be housework, cleaning, or tidying, or

it may consist of personal care such as showering, dressing or assistance in the

toilet. This latter type of care is generally not visually observable due to privacy

considerations and the impracticality of having a “third person” in the small space

afforded by most domestic bathrooms and toilets without influencing the behaviour of

the elder and the carer.

The QUIS may be utilised for the domestic setting, however, as it can be adapted

readily for short observations and is simple to learn and use. The adaptation is

outlined in the Method section below.

Organisation culture

In addition to measuring the wellbeing of the individuals living in residential care

environments and the skills of those caring for them, increasing attention has been

paid to the organisational culture within which care is provided. Organisational

typologies from a wide range of industries abound in the literature (Hawkins, 1997).

However, the application of organisational theory to health care and specifically to

aged care is attracting attention only relatively recently. Kirkley, Bamford, Poole, et

al. (2011) in a study of the opinions of staff and managers providing respite services

to people living with dementia in the community, identified five themes in relation to

organisational culture that influence person-centred care: understandings of person-

centred care, attitudes to service development, service priorities, valuing staff and

solution-focused approaches. They interviewed 49 staff and operational managers of

community based respite services in the UK and found that views of person centred

care were diverse reflecting a lack of common understanding about the nature of

person centred care. Participants also identified barriers and facilitators to person


15

centred care in the knowledge, attitudes and personal qualities of care staff.

Leadership style was also implicated. The way managers support and value staff

and the way they manage risk were influential, i.e., a controlling management style

was not associated with person centred care.

Other organisational models have included the V.I.P.S. Framework (Brooker, 2007)

in which Brooker uses the well-known acronym for “Very Important People” to

identify four elements to person-centredness: V=Value base and value of the person

regardless of disability; I=Individualised care; P=care provided from the Perspective

of the person themselves rather than shaped by institutional imperatives; S=the

Social dimension of the person is sustained.

Table 2. VIPS Framework – Brooker (2007).

Element Indicator Value V1 Vision V2 Human resource management V3 Management Ethos V4 Training and staff development V5 Service environments V6 Quality assurance Individual I1 Care planning I2 Regular reviews I3 Personal possessions I4 Individual preferences I5 Life history I6 Activity and occupation Perspective P1 Communication with service users P2 Empathy and acceptable risk P3 Physical environment P4 Physical health P5 Challenging behaviour as communication P6 Advocacy Social S1 Inclusion S2 Respect S3 Warmth S4 Validation S5 Enabling S6 Part of the community


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Philosophically this model is based in the work of Tom Kitwood and draws on the

work of (Rogers, 1961) whose client centred psychotherapy and the philosophical

approach that is derived from it, underpins many changes in modern health care

initiatives to enhance patient wellbeing in acute hospitals (Doherty & Doherty, 2005),

disability services (McCarron, McCallion, Fahey-McCarthy, et al., 2011), and

dementia care (Kitwood, 1997; Kitwood & Bredin, 1992).

Brooker built a 24-indicator organisational review on this model to assist aged care

providers (residential care homes) to identify areas of excellence in person centred

care delivery and areas for improvement. These are listed in Table 2. above.

The review may be self-rated on a four point scale: Excellent, Good, OK and ‘Need

to work on this’. Brooker identifies three uses for this tool: Raising awareness of

person centred care across the organisation; Evidence collection and benchmarking;

and action planning for improvements in key elements.

In this evaluation there is a focus both on facilitating a change and measuring that

change at an organisational level. It is believed that by stimulating skill and

knowledge improvement (with DCE training) and then supporting this with reflection

on practice (using DCM/QUIS and the organisational VIPS Framework) there may be

positive shifts in the indicators for person centred care at an individual staff and

organisation level.


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Methodology

The current report builds on our experience of evaluating the effectiveness of DCE

training, offered by Alzheimer’s Australia Vic (AAV) in 2009-10. This evaluation of

DCE uses a multi-method repeated measures action learning approach to identify

differences at three time points: Pre-training, Post-training and 3-months Post-

training.

All sites have been de-identified.

Sample

Of the organisations participating in the Dementia Care Essentials training program

conducted by AAV, a sample of two residential sites and one community site

participated in the evaluation. These were a convenience sample of sites that were

willing to engage in the evaluation on approach from AAV. The scale of the

evaluation was limited by financial and time considerations.

Residential Site 1

Residential Site 1 is a not-for-profit aged care home that has a philosophy of ageing-

in-place, providing serviced apartments, mixed and high care to 90 residents. They

have a 15-bed dementia specific secured unit where the evaluation observations

took place..

Staff that attended training from Residential Site 1 were:

Certificate III: 15 (13 completed assessment)

Certificate IV: 10 (all completed assessment)

Residential Site 2

Residential Site 2 is part of a not-for-profit aged care organisation that provides

residential and community services. At Residential Site 2 there are 96 beds with


18

mixed care and high care and a 32 bed dementia specific unit that is secure. This is

where the observations took place. During the project period the Nurse Unit Manager

resigned and the unit was without a permanent leader for several months. Proposed

physical division of the 32-bed unit into two 16-bed units did not take place as

planned in the project period.

Staff that attended training from Residential Site 2 were:

Certificate III: 10 (9 completed assessment)

Certificate IV: 27 (27 completed assessment)

Community Care Site

Community Site 1 hosts the community services team that provides Community

Aged Care Packages (CACPS), Extended Aged Care in the Home (EACH) and

Extended Aged Care in the Home – Dementia (EACH-D). This team provided direct

care staff and care managers (one senior care manager, 2 care managers, 2

Community Support Workers (CSW) (Carers) and one Team leader) who

participated in the training at Certificate IV level only and who were observed during

their work. They have an integrated model in which there is direct communication

between care workers and the care managers. Clients were observed with workers

in in three locations where their clients lived. These interactions consisted of

discussion between care managers and clients/carers or between direct care

workers and clients/carers. Only one observation involved provision of direct

personal care (showering). The observer rated the interaction from outside the

bathroom to preserve privacy.

Staff that attended training from Community Site 1 were:

Certificate IV: 6 (5 completed assessment)


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Instruments

The methods used include: direct observation (DCM and QUIS), compilation of in-

house data (Falls, Skin Tears, Behavioural incidents, response times), survey self-

report (participants survey), proxy reports (Cornell, PAS).

Dementia Care Mapping

Dementia Care Mapping is an observational tool as described above that is used as

both a tool for measurement of person centred care and for the improvement of

person centred practice within a continuous cycle of Mapping-Feedback-Action

Planning-Mapping. Observations are made every five minutes for up to six hours by

a trained mapper who records data in four domains: Resident actions (alphabetical

Behaviour Category Codes, e.g., A=Articulation: Interacting verbally or nonverbally;

B=Borderline: Passively observing interactions of others; C=Cool: withdrawn),

Resident wellbeing (ordinal scale +5, +3, +1, -1, -3, -5 where +5=extremely high level

of wellbeing, pleasure or happiness, +3=Moderate levels of wellbeing, pleasure and

enjoyment, +1=no signs of wellbeing or illbeing observable, -1=small signs of

illbeing, distress or irritation, -3= Moderate signs of illbeing, upset or agitation, and -

5=Extreme distress, anger or upset), Personal Enhancers and Personal Detractors

(listed in Table 2), and a narrative of events throughout the map. All domains are

shown in detail in the Appendices.

DCM was conducted according to the British standard PAS800: Use of Dementia

Care Mapping for improved person-centred care in a care provider organization –

Guide. This involves pre-mapping meetings with stakeholders, obtaining consent

from participants on the day of mapping, conducting mapping in a person centred

manner, providing feedback to staff and management and conducting an action

planning meeting to enable practice improvement.

Data available from the mapping at each time point includes:

• Individual and Group WIB scores and profiles • Individual and Group Behaviour Category Profiles


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• Personal Detractors (PDs) • Personal Enhancers (PEs) • Potential for Positive Engagement • Passive Engagement • Occupational Diversity • Agitation • Withdrawal

The Quality of Interactions Scale (QUIS)(Dean, et al., 1993) was modified by

(Procter, et al., 1998) to avoid ceiling effects of the original and further modified in

this study to form the basis for the measurement of social interactions between older

people living in their own home in the community and the care workers who visited

them in their own homes. The original version was designed for use in residential

aged care homes as outlined above.

The QUIS is an observational instrument for recording the number of times a target

social interaction occurs in a time period. Target staff interactions identified in the

original QUIS are: positive social, positive care, neutral, negative protective or

negative restrictive. These are defined in Table 3 below.

Table 3. QUIS staff interaction types

Positive Social Interaction principally involving good, constructive, beneficial conversation and companionship

Positive Care Interactions during the appropriate delivery of physical care

Neutral Brief indifferent interactions not meeting the definitions of other categories

Negative Protective Providing Care, keeping safe or removing from danger but in a restrictive manner, without explanation or reassurance

Negative Restrictive Interactions that oppose or resist residents’ “freedom of action” without good reason, or which ignore participants as a person.


21

The Proctor adaptation added to the above descriptions of staff behaviour by

including the following categories of resident behaviour to capture the activity of

residents during the observation period.

(1) Disengaged. Resident is inactive, sitting passively or sleeping, or involved in

unpurposeful activity such as fiddling with clothes, smoking or aimless walking.

(2) Non-social engagement. Resident is engaged in purposeful activities which do

not involve social interaction with others; for example, combing hair, reading,

watching television, actively listening to music, knitting. If it becomes clear that the

resident’s engagement is not functional (e.g. they repeatedly vacuum or

wipe the same place, wander aimlessly), then change code to disengaged or

challenging behaviour, whichever applies.

(3) Social engagement. Resident is engaged in some form of communication with

others where there is a state of reciprocity with at least one other person or the

resident is initiating contact with another person. This includes recognizable speech,

attempts to speak, vocalizations, signs or gestures, physical prompting in a

manner which gains, attempts to gain or maintains the attention of another person. It

also includes clearly giving attention (as evidenced by eye contact or orientation of

the head) to another person who has begun to interact with the subject.

(4) Challenging behaviour. Resident is engaged in solitary repetitive, non-

functional motor activity (e.g. body rocking, pacing), verbal activity (e.g. crying out,

grunting, continuous swearing), self injury, aggression to others, damage to property

or other inappropriate behaviour such as spitting, pestering others or stripping.

The author added a mood rating scale to determine the nature and range of mood

change during the interactions. This is detailed in Table 4 below.

The time period for recordings was reduced to five minutes due to the short period of

time community workers are with their clients. The original 15 minutes would not

have provided sufficient sensitivity as home visits may only last 30-60 minutes,

providing too few time periods for study


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Table 4. Mood scale for adapted QUIS.

+3 High positive mood +2 Considerable signs of positive mood +1 Mild signs of positive mood 0 Neutral or lack of positive or negative signs of positive mood -1 Mild signs of Negative mood -2 Considerable signs of negative mood -3 High signs of negative mood

Resident measures of quality of life included depression (measured with Cornell

Scale for Depression), falls, skin tears, behavioural incidents, bruises and rate of call

bell uses. Level of cognitive impairment (measured with Psychogeriatric Assessment

Scale – PAS) was included as an indication of the level of disability experienced by

residents. These were taken at Times 1 and 3.

Organisational Review

The VIPS Framework by (Brooker, 2007) was selected to measure change in person

centred organisational markers. As described above in Table 2 the framework

consists of 24 markers that are rated on a four point scale. Ratings were scaled

numerically so that ‘Excellent’ =4, ‘Good’=3, ‘Average’=2 and ‘Needs more work’=1.

Answers to questions within each indicator provided detailed records of

organisational activity that were used to detect change in organisational practices

following the training intervention. This tool was used prior to the training intervention

(Time 1) and at 3 months post-training (Time 3). It was completed by management

personnel at all sites.

Analysis

Due to the small number of sites it is not possible to establish levels of significance

of any change that may be evident. However, descriptive statistics were obtained for

all sites.


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Results

Demographics

Three sites participated in this evaluation. Two sites were residential and one was a

community team. The Unit within Residential Site 1 had 15 residents and the Unit

within Residential Site 2 had 32 residents.

Pre-training Time 1 was 13 June 2011 to 12 July 2011 for DCM. The three months

prior to this period (April-June) was the selected time for resident data at Time 1.

Post training Time 2 was 30 August 2011 to 13 September 2011for DCM. Resident

data was not gathered at this time.

3 month follow up Time 3 was 03 January 2012 to 06 January 2012 for DCM.

Resident data was collected for the period October to December 2011.

In-house resident data

Existing resident data was collated for Times 1 & 3 for both residential sites. This is

presented in Table 5 below.

Table 5. Existing data for residents at Residential Site 1 and Residential Site 2 at Time 1 and 3.

Residential Site 1 Residential Site 2 Time 1 Time3 Time 1 Time 3 PAS 10.57 --- 17.00 16.67 CORNELL 10.89 9.25 11.71 11.18 Falls (per resident)(incl 'found on floor') 0.93 0.73 0.28 0.56 Skin Tears (per resident) 0.20 0.20 0.16 0.09 Bruises (per resident) 0.07 0.13 0.06 0.22 Aggression (per resident) (verbal and physical) 0.07 0.20 0.28 0.16


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Level of cognitive impairment did not change significantly at Residential Site 2

between times 1 & 3 (t(3)=1.00, p=.39). Data for Residential Site 1 were obtained for

Time 1 only and although lower than for Residential Site 2 was only obtained for

residents able to respond verbally to an interview, therefore omitting the more

impaired residents.

Levels of depression were not significantly different between Time 1 and 3 at both

Residential Site 1 and Residential Site 2 (t(5)=2.03, p=.10). For remaining variables

there was insufficient data to conduct analysis of variance.

At Residential Site 2 the pattern of decrease in depression was more consistent for

residents for whom data was obtained at both times (Figure 1.) than at Residential

Site 1 where three out of seven residents for whom data was obtained at both times

had lower Cornell scores at Time 3 than Time 1 and four had higher scores on the

Cornell at Time 3 than at Time 1 (Figure 2). Two residents at each site had Cornell

Scores at Time 3 that indicated they had improved in their depression to below the

threshold for diagnosis (score of 14).

Figure 1. Cornell scores at Residential Site 2 at Times 1&3


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Figure 2. Cornell scores at Residential Site 1 at Times 1&3

It is clear that for some variables such as skin tears there was little change from

Time 1 to Time 3. However, for falls at Residential Site 2 there was a twofold

increase from .28 to 0.56 falls per resident. This relates to an increase in falls for one

resident who was found on the floor several times and died toward the end of the

Oct-Dec period.

Aggression at Residential Site 1 increased from 0.07 incidents of aggression per

resident to 0.20 incidents per resident. This represents an increase from one incident

in three months to three incidents in three months from three different residents.

Bruises increased at Residential Site 1 (0.07 to 0.13 per resident) and at Residential

Site 2 (0.06 to 0.22 per resident). However, levels remained low for each three

month period.


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Dementia Care Mapping

Results for Dementia Care Mapping for Residential Site 1 and Residential Site 2 are

displayed in Table 6. below. The DCM output shows a mixed result for both sites.

Wellbeing scores fluctuated across Time1 to Time 3 remaining modest at both sites.

The level of wellbeing indicates that on average the groups of residents experienced

little above the +1 level of “no signs of wellbeing or illbeing observable”.

Table 6. Dementia Care Mapping results for Times 1, 2, and 3 for both sites

Residential Site 1 Residential Site 2 Time 1 Time 2 Time 3 Time 1 Time 2 Time 3

Wellbeing group score +1.38 +1.61 +1.52 +1.22 +1.19 +1.31 Potential for Positive Engagement 74.19 73.66 65.62 76.50 75.82 60.00 Occupational Diversity (No.) 8.00 8.00 8.00 7.00 9.00 9.00 Passive engagement (%) 17.29 17.66 17.19 6.30 13.13 20.31 Agitation (%) 1.00 0.00 1.00 3.80 3.00 2.00 Withdrawal (%) 5.94 6.62 13.75 14.47 9.67 17.38 Unresponded-to distress (%) 0.00 0.00 1.00 1.00 0.00 0.00 UNMEs (No.) 0.00 0.00 0.00 0.00 0.00 0.00 Rate of PEs (per Time Frame) 0.037 0.019 0.056 0.010 0.004 0.024 Rate of PDs (per Time Frame) 0.041 0.042 0.067 0.120 0.068 0.058

Potential for Positive Engagement (PPE) decreased from Time 1 (74.19%) to Time 3

(65.62%) at Residential Site 1 and from 76.5% to 60.0% at Residential Site 2.

Negative indicators also increased including Passive Engagement which increased

at Residential Site 2 across all three mapping periods from 6.30% to 20.31% but

remained stable at Residential Site 1 (17.29%, 17.66%, 17.19%). Withdrawal

increased across all observations at Residential Site 1 (from 5.94% to 13.75%) and

improved initially at Residential Site 2 (from 14.47% to 9.67%) and then increased to

higher than pre-training levels (17.38%). This pattern across all measures maybe

indicative of increasing burden of disease as residents progress in their dementia.

The period from Time 1 to Time 3 was approximately six months.


27

Rate of Personal enhancers (PEs) initially decreased at both sites (Time 2) and then

improved to almost double at both sites at Time 3. Personal Detractors (PDs) and

PEs are displayed in Figure 3. below for Times 1-3.

Figure 3. Personal Detractors (PDs) and Personal Enhancers(PEs) at both sites at Times 1-3.

Rate of PDs on the other hand remained stable at Residential Site 1 (0.041, 0.042)

and then worsened (0.067), and at Residential Site 2, rate of PDs improved at Time

2 (from 0.12 to 0.068) and then remained low (0.058).

It may be that immediately following training staff were more wary of interacting with

residents and so overall there is decrease in rate of interaction both positive and

negative. By far the greater decrease is for negative care actions at Residential Site

2. As the action plans took effect the rate in interaction increased at Time 3 and

there is an improvement in rate of positive care actions and a continuing decrease in

negative care actions at Residential Site 2 but not at Residential Site 1 where there

was an increase in negative care actions as well as positive care actions.

Detailed Analysis of DCM by Site

Residential Site 1

Table 7 below shows a detailed analysis of PDs and PEs related to each of the five

Fundamental Needs at Residential Site 1 at Times 1, 2, and 3.


28

Table 7. Detailed analysis of PDs and PEs related to each of the five Fundamental Needs at Residential Site 1 at Time 1, 2, and 3.

DETRACTORS Time 1 Time 2 Time 3 ENHANCERS Time 1 Time 2 Time 3 COMFORT Intimidation 0 0 0 Warmth 4 1 2 Withholding 0 1 2 Holding 0 0 0 Outpacing 5 0 2 Relaxed pace 4 0 0 Sub-total 5 1 4 Sub-total 8 1 2 IDENTITY Infantilization 1 0 8 Respect 3 0 6 Labelling 0 1 0 Acceptance 1 0 2 Disparagement 0 0 0 Celebration 0 3 4 Sub-total 1 1 8 Sub-total 4 3 12 ATTACHMENT Accusation 0 0 0 Acknowledgement 0 1 0 Treachery 1 2 2 Genuineness 1 0 0 Invalidation 3 4 2 Validation 3 0 7 Sub-total 4 6 4 Sub-total 4 1 7 OCCUPATION Disempowerment 2 1 2 Empowerment 1 0 0 Imposition 13 14 13 Facilitation 3 1 3 Disruption 3 5 6 Enabling 2 0 2 Objectification 0 0 0 Collaboration 0 0 1 Sub-total 18 20 21 Sub-total 6 1 6 INCLUSION Stigmatisation 0 0 2 Recognition 1 6 2 Ignoring 2 1 2 Including 0 1 4 Banishment 0 0 0 Belonging 0 0 0 Mockery 0 0 0 Fun 4 0 1 Sub-total 2 1 4 Sub-total 5 7 7 TOTAL PDs 30 29 41 TOTAL PEs 27 13 34

Display of these results in Figure form reveals the specific nature of the change from

Times 1-3 for each need at each site. In Figures 4 and 5 the PDs and PEs

respectively for Residential Site 1 are displayed related to each need.

At all three maps Occupation is the need most undermined. The care staff at

Residential Site 1 tended to take over and impose care (cf Table 7). There was a


29

high level of interaction but when it was to provide care it was often done without

permission or informing the person and this remained high at each map. This is

mostly done by failing to ask permission, imposing care upon residents without

asking them if they would like the care to be provided. Instances included putting

aprons on the person or removing them, moving the person, taking plates, disrupting

activity to move the person onto the next activity or to prepare them for mealtime.

The next most commonly undermined need was Identity at Time 3 with eight

instances of Infantilisation (using forms of address like “Darling” and “Eat your lunch,

you’ll make me happy”). There were however, improvements in the care actions that

influence Attachment needs with staff engaging in fewer Invalidating interactions at

Time 2 and Time 3.

Figure 4. Personal Detractors and Fundamental Needs for Residential Site 1 at Times 1-3

Figure 5 below shows the Personal Enhancers for Residential Site 1 at each Time 1-

3. Most notable in Figure 5 is the decrease in rate of positive engagement from staff

across the board for all needs at Time 2 and the increase in support for Identity from

staff at Time 3. At Time 3 there was improvement in the care actions that support

four of the five needs (Comfort, Attachment, Identity and Occupation). Care actions

that support Inclusion increased from Time1 to Time 2 and then remained stable

from Time 2 to Time 3.


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The Time 2 decrease is consistent with the wariness of staff to interact with residents

following the training that may indicate an awareness of what is appropriate

behaviour but some anxiety or lack of confidence to put this knowledge into action.

Figure 5. Personal Enhancers and Fundamental Needs at Residential Site 1 for Times 1-3.

The greatest improvement was for care actions supporting Identity. Specifically this

included Acceptance of a resident’s refusal of care when it was offered; Celebration

of participation in a balloon activity; a guitar-playing musician singing well-loved song

for one of the residents; Respectfully asking permission to take a plate; Respect in

listening to a resident instruct staff about the science and function of batteries and

electrical charge from his knowledge and experience as a university lecturer.

The increase in Identity support is consistent with the specific actions addressed in

the action plan (see below) to remedy high levels of negative care actions detected

in the map at Time 1.

Other needs to receive better attention at Time 3 included Attachment and

Occupation. Mapping at Time 3 showed there were some staff (particularly among

the Activity staff) who were very supportive of Attachment, Identity and Occupation.

However, care staff specifically, tended to maintain patterns of Impostion and

Disruption at all maps. Management of Residential Site 1 reported that they had


31

made a concerted effort to address the Action Plan with the Activity staff but were

aware that more work needed to be done to address with care staff the issues of

Imposition and Disruption that undermine Occupation needs. It may be that these

PDs are driven by cultural expectations of appropriate caring behaviour, i.e. provide

care regardless. However, these PDs show up consistently in most aged care homes

where a traditional style of care is dominant.

The pattern of initial decrease in rate of positive care actions when combined with

the mixed result for PDs at Residential Site 1 indicates that the training did not

initially improve care actions. However, three months later with the support of an

Action Plan targeting specific care actions, the staff care actions improved. This is

supportive of the importance of follow up to face-to-face training with an action plan

that identifies specific behaviour and focuses staff attention to improve specific care

actions.

Action Plan – Residential Site 1

The Action Plan is an integral step in the practice improvement process when DCM

is used to improve care quality over time (BSI, 2010). It consists of the formulation of

a strategy for improvement from specific items at individual staff, group and

organisational levels, and review of the effects of this in subsequent maps.

The Action Plan at Residential Site 1 was developed following the map at Time 2

and is shown in full in Appendix 3.8 and the Action Plan for Residential Site 2 is at

Appendix 3.9. The target behaviours identified in the Action Plan for Residential Site

1 are shown below in Table 8.

This plan relates closely with the outcomes of the mapping and was specific so it

could be taken up by staff in practical actions to improve care. These actions are

listed in the Appendix 3.8. Mapping at Time 3 shows that the plan has been effective

in making a difference to staff behaviour in these areas with higher rates of staff

informing residents before providing care and seeking permission (Items 2-5). This


32

was mostly successful with Activity Staff who adopted these behaviours consistently

at Time 3.

Table 8. Target behaviours for Residential Site 1 Action Plan.

Target behaviour

1. Break the task into small instructions during ADLs

2. Tell residents what you are going to do

3. Ask permission

4. Use of names, affirm identity –residents need to know that you know who they are

5. Use of physical & verbal prompts rather than taking over

6. Focus on creating calm atmosphere. Avoid excessive loud voices, noises which creates more agitation

7. Sessions to be incorporated into Professional Training Day

Residential Site 2.

Table 9. below shows a detailed analysis of PDs and PEs related to each of the five

Fundamental Needs at Residential Site 2 at Times 1, 2, and 3. (see next page)


33

Table 9. Detailed analysis of PDs and PEs related to each of the five Fundamental Needs at Residential Site 2 at Times 1, 2, and 3.

DETRACTORS Time 1 Time 2 Time 3 ENHANCERS Time 1 Time 2 Time 3

COMFORT

Intimidation 0 0 0 Warmth 1 0 0

Withholding 8 0 3 Holding 0 0 0

Outpacing 0 1 1 Relaxed pace 0 0 0

Sub-total 8 1 4 Sub-total 1 0 0

IDENTITY

Infantilization 11 3 1 Respect 1 0 0

Labelling 0 1 1 Acceptance 0 0 1

Disparagement 1 0 0 Celebration 1 0 0


ATTACHMENT

Accusation 0 0 0 Acknowledgement 0 0 1

Treachery 5 2 0 Genuineness 0 0 0

Invalidation 13 4 3 Validation 1 1 1


OCCUPATION

Disempowerment 1 5 2 Empowerment 0 0 0

Imposition 16 2 2 Facilitation 0 0 1

Disruption 8 7 7 Enabling 0 0 5

Objectification 2 6 2 Collaboration 1 0 0


INCLUSION

Stigmatisation 0 0 0 Recognition 1 0 1

Ignoring 6 5 8 Including 0 1 1

Banishment 2 1 0 Belonging 0 0 0

Mockery 0 0 2 Fun 0 0 2


TOTAL PDs 73 37 32 TOTAL PEs 6 2 13

Display of these results in Figure form reveals the specific nature of the change from

Times 1-3 for each need at each site. In Figure 6 and 7 the PDs and PEs

respectively for Residential Site 2 are displayed related to each need.


34

Figure 6. Personal Detractors and Fundamental Needs for Residential Site 2 at Times 1-3.

There is a consistent decrease in PDs from Time 1 to Time 2 for all needs. This

continues for Identity, Attachment and Occupation. PDs that undermine Inclusion

and Comfort increase from Time 2 to Time 3.

The most impressive decrease was in PDs that undermine Occupation (27-20-13).

These were Imposition (16-2-2), Disempowerment (2-5-2) and Objectification (2-6-2).

Observed examples of these care actions include: feeding a person too quickly, and

not waiting for them to swallow before offering the next spoonful; taking a fork from a

person and feeding them because they were slow; and “Come with me – I’ll take you

to the toilet”.

Figure 7 below shows the Personal Enhancers for Residential Site 2 at Times 1-3 for

each Fundamental Need.

Levels of Personal Enhancers were low across all needs in the map at Time 1 and

Time 2. It is not until Time 3 that we see a marked increase in the frequency of

positive care actions in all but care actions that are supportive of Comfort.


35

Figure 7. Personal Enhancers for Residential Site 2 at Times 1-3 for each Fundamental Need.

The most notable increase is for actions that support Occupation. These include

Enabling (1-0-5), Empowerment (0-0-0), Facilitation (0-0-1) and Collaboration (1-0-

0). Enabling contributed most to this increase. Although the level of positive events

was lower than the level of negative events the trend is important for assessing the

effectiveness of the effort for change in care practices. The Enabling care actions

included: staff slowly and patiently supports person with apraxia to stand; staff keeps

the conversation going with the person so he could enjoy the book on Australiana,

asking questions and prompting with comments;

Inclusion increased from 1 event at Times 1 and 2 to 4 at Time 3. This was due to

staff providing Recognition and Inclusion (Person looks lost, staff notice it and invites

her with a gesture to sit with her), and Fun (joking with a resident about the name for

her bear; joking about sleeping in the unit on a hot night).

There was no increase in comforting care actions and little increase in care actions

affirming Identity.


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Action Plan – Residential Site 2

As with Residential Site 1 the Action Plan for Residential Site 2 was developed by

management and staff at Residential Site 2 following the Time 2 map and feedback

session. This is shown in full at Appendix 3.9.

The specific items identified in this Action Plan are listed in Table 10 below.

Table 10. Action Plan items from Residential Site 2 at Time 3.

Ensure all residents have " what matters to me " completed Reduction of large 32 bed unit to more home like environment Monthly visit by DCC to each site La Trobe unit team meeting Improved sensory boxes established " All about me " poster Residents family meetings Person Centred Care framework Sunshine Club - Daily sensory stimulation group Improve knowledge and understandings of PCC Lower level of stimulation during meal times Address outpacing during meal times New staff program Improving staff communication to residents Improve holistic care / shift from task focus culture

There are specific actions identified in this plan that address the documentary,

environmental and organisational supports that facilitate change to improve resident

experience and also changes that directly address staff behaviour to improve

resident experience. An example of this is the environmental change of turning the

television off during meals to address the need for “Lower level of stimulation during

meal times”. A documentary support was to conduct an annual random audit of files

to “ensure all residents have " what matters to me " completed”. A staff behaviour

change was to improve “staff communication to residents”. The specific behaviours

to be improved are not identified in either the item or the strategy (staff education).


37

However, it is clear from the results of mapping at Time 3 that there has been an

improvement in the number of personal Enhancers supporting an improvement in the

behaviour of staff toward residents.

Comparison of the Residential Site 1 Action Plan with the Residential Site 2 plan

shows that most of the latter items are ‘higher order’ items than the specific

behavioural items identified in the Residential Site 1 Action Plan. Although the

Residential Site 1 Plan does identify one organisational item (“Sessions to be

incorporated into Professional Training Day”) most items are focussed on specific

staff behaviours that can be improved. The Residential Site 2 items predominantly

address the organisational dimension of care improvement. Residential Site 1

focussed on changing specific staff behaviour through training and feedback to

groups of staff, particularly Activity staff. Residential Site 2 have focussed on

organisational actions that enable different staff behaviour such as “provide more

time for staff to assist during meals” as an action to address staff outpacing residents

during meal assistance.

QUIS – Community Site 1

Observations were conducted in the homes of clients of Community Site 1. The

logistic difficulties of observing the same dyads of client and care worker (and a care

worker who attended the training) meant that there were limited opportunities for

observations of care workers.

As detailed above, the observations were predominantly of social conversations

around the dining or kitchen table rather than of personal care interactions. Only one

dyad of client and direct carer was observed at each of Times 1, 2, and 3. The

results of this series of observations is shown in Figure 8 below.

It is clear that with three separate observation times there is marked variation. On

each occasion the client, a divorced elderly male gentleman living alone (except at

Time 3), was observed sitting at his kitchen table. The care worker proceeded to


38

engage in checking the client’s welfare with a discussion over a cup of tea about his

bills, any events that needed to be followed up from her discussions with the Care

Manager, and any shopping that needed to be done. She did not take him shopping

during each of these observations but constructed a shopping list with him for a

future visit, checked the fridge and assisted him to sort his bills.

Figure 8. QUIS observations (rate per minute) of care provided by one care worker with the same client at Times 1, 2, and 3.

At Time 2 his dog had just died and he was digging a hole to bury it when the care

worker arrived. He was distressed and tearful as indicated by the Mood scores at

Time 2. She provided social support by sitting with him rather than engaging in

checking bills, fridge and shopping. She successfully adapted her approach to his

needs.

At Time 3 his son and the son’s partner had moved back to live with him and there

was concern that the client may be exploited by this. However, the client was very

positive and enjoying the company of his son. The care worker did not impose her

concerns on the client but validated his perspective. She later expressed her

concerns to the care manager.

The same care worker was observed showering a client who had refused a shower

for several weeks. The care worker used her knowledge of client preferences to


39

purchase four chocolate muffins that she knew her client liked. She strategically

opened the muffins on arrival and said that the client could have one warmed up

after she had a shower. The client was initially sceptical but walked with her to the

bathroom where the care worker quickly turned on the water and engaged her in

conversation that kept the process going until she was showered and dressed. They

returned to the kitchen where she ate her warm muffin with enthusiasm.

This episode reflected the skills of the care worker in using strategic thinking and

knowledge of the person to sensitively and skilfully overcome a growing problem for

the person’s care.

Figure 9 Rate per minute of QUIS ratings during two types of care provision.

Figure 9 above shows the two types of interaction with the two clients mentioned

above at Time 3.

The care worker adapted her care work to the activity that was necessary in each

circumstance. During showering she provided more Positive care enticing the person

with the muffins and did not engage in Negative Restrictive or Negative Protective

actions to achieve her goal. In the kitchen table interaction she provided more

Positive Social interaction, conversing, asking questions to maintain connection with

him and to ascertain his views about his son’s presence in the house. There was


40

less Social Engagement from the showering client than the kitchen table client

although there was considerable talking by the care worker during the shower as she

kept the person oriented to and engaged with the task.

Community Site 1 Action Plan

The Community Site 1 Action Plan was developed following the QUIS observations

and staff attendance at the DCE training. It consists of items that are strategic plans

for future action rather than actions that focus on specific staff behaviour for change

now. These items are found in Appendix 4.2 The items are related to the

Organisational Review. A composite list of these items listed as changes to the

organisational review from Time 1 to Time 3 for all sites located in Appendix 1.2.

Organisational Review

The organisational review was completed using the VIPS Framework at all three

sites at Times 1 and 3. This 24-part tool provides a comprehensive assessment of

the provision of person centred care from an organisational perspective (D. Brooker,

2007). As stated above the period from Time 1 to Time 3 was three months. This is a

brief period in which to expect noticeable changes to have occurred given that the

literature on organisational change suggests that longer periods up to three years

may be necessary

The method of completion varied between sites. At Residential Site 1 the Quality

manager completed the review, at Residential Site 2 several senior staff completed

the review and it was approved by executive level managers for sign-off, and the

same process occurred for Community Site 1.

Table 3 above lists the four domains and the 6 areas per domain that comprise the

VIPS Framework indicators. A table of changes and proposed changes made by


41

each site is included in Appendix 1.4. The full organisational reviews are available

from the author.

All three sites rated their organisations the same at Times 1 and 3. As the rater at

Residential Site 1 explained, “The scores didn’t change but what we did in some of

the areas was different”. Scores for Residential Site 1 and Community Site 1 did not

change. Scores for Residential Site 2 changed from an average of 2.33

(representing OK-Good rating) to 2.95 with increases in 10 of 24 indicators.

Most ratings are “Good”. There were 8 ratings of “Needs more work” for Residential

Site 2 at Time 1 and only three at Time 3. All 8 indicators that needed more work

were addressed with actions or proposed actions that involved regular activities that

had not yet taken place but for which there was a plan. This activity in the action plan

had an effect that brought the rating up to “Good” in all five cases where

improvement was made. There was one “Needs more work” rating for Community

Site 1 at Time 1 and one for Residential Site 1 and these did not change at Time 3.

Appendix 1.2 contains a table of changes that were recorded against each indicator

of the VIPS Framework. The pattern of changes is different for each site. Residential

Site 1 engaged as evident in the Action Plan in more staff-focussed changes and

Residential Site 2 engaged in a broad range of changes including organisational and

staff-focussed and incorporated the organisational review into the Action Plan so that

each action was allocated to an indicator of the VIPS Framework. This integrated

approach enabled them to connect the specific actions with the organisational

consequences.

The Residential Site 1 changes focussed on the “Social” dimension of the VIPS

Framework emphasising the actions that affected the relationships staff had with the

residents in aspects such as warmth and inclusion. They recorded that there was

“more emphasis” on these indicators without identifying specific strategies as they

did in the Action Plan (see Table 9 above).


42

Residential Site 2 took a more broad ranging approach addressing all four

dimensions of the VIPS Framework with only five of the 24 indicators not addressed

by the Action Plan in actual or proposed changes. 14 indicators contained proposed

changes that were more long-term projects such as “Structural separation of 32-bed

unit into two 16-bed units” and “Quarterly family meetings for information and

education”. Residential Site 1 had 19 indicators in which there was no changes

made and did not identify proposed changes.

Community Site 1 utilised the ‘residential’ focus of the VIPS Framework and

successfully completed it for Time 1. They reported at Time 3 that on review nothing

had changed. The only area that needed more work was individualising care

planning. No further information was provided.

Staff Surveys

A survey was sent to all participants in the DCE training from all three sites in both

online (a link in an email) and hardcopy. Of the 62 participants 21 responded to the

survey. Of these, 18 were hardcopy responses and three online. The survey

questions are located in Appendix 2.

The training was viewed overwhelmingly positively by respondents with 100% rating

it “Extremely high quality training” or “High quality training”. What was most

memorable varied widely from “how we can handle people with dementia”, “working

together as a team” to” Creating our own person and then working together to

organise the help they needed to live a fulfilling life”. What the participants learned

included “stop and listen”, “ask for consent before providing care” and “never

underestimate what a person with dementia can do”. All agreed they were doing

things differently as a result of the course and gave examples such as “giving the

person my uninterrupted time” and “looking at the person past life history”. They

believed the training was consistent with the approach taken by their organisation to

supporting people with dementia and that this increased the extent to which hey


43

were able to apply the learning from the course to their work. All respondents

believed the course has changed the way their organisation provides support for

people with dementia. Examples included more communication among staff, better

team work, and “Trained staff are happier to work with people with dementia

because they have more clear idea of their psychological needs- they are more

sensitive to the needs of people with dementia”.

Overall the survey results indicate that the subjective experience of the participants

in the DCE training course were very positive and believed they and their

organisations benefitted from the course and were able to make improvements to the

way they provide care to people with dementia.

Comparison with Competencies

The national competencies for the two units that comprised the Dementia Care

Essentials training course at Certificate III and IV levels were mapped to the

instruments that were used in this evaluation to establish if there was evidence for

the competencies in the care behaviour of staff in the three care groups.

The PEs and PDs of DCM and the positive and negative care behaviours of the

QUIS provided a ready list of indicators that were used to show such evidence

outlined in Table 11. below.

For instance for the competency, “Adapt activities to individual needs” evidence may

be obtained from levels of PEs and PDs related to the needs for Comfort and

Identity. Using this measure the competency may be regarded as present at

Residential Site 1 by Time 3 and at Residential Site 2 with low PDs for these needs

but not with high PEs for these needs.

The QUIS may also be used to provide evidence for the competency by examining

the presence of Positive Care and Positive Social care worker behaviour and the

absence or low levels of Negative Restrictive and Negative Protective care worker

behaviour. In this instance the interactions with the male client over three Times


44

provides good evidence for the ability of the care worker to adapt to the changing

needs of the person by providing Positive Care when needed and Positive Social

interactions when needed.


45

DISCUSSION

The aim of this evaluation was to measure the effectiveness of Dementia Care

Essentials training at both Certificate III and IV levels in improving skills of aged care

staff in both community and residential settings. The evaluation utilised a multi-

method repeated measures approach that incorporated action learning.

There were mixed results for depression scores which on average remained

unchanged but when examined for individual residents revealed some improvement

in their levels of depression. Several residents showed slightly more signs of

depression. Without also noting changes to antidepressant medication it is not

possible to attribute such improvements to the effectiveness of the training.

However, improvements of the magnitude noted in the data suggest that there were

significant improvements in quality of life for some residents during the period of the

training and action planning and changes in the way staff act, particularly

attentiveness to emotional wellbeing, may be a contributing factor.

Levels of incidents (bruises, falls, skin tears, aggression) were low across both

residential sites and varied without any perceivable pattern that may be attributed to

any effect of the training.

The evidence of Dementia Care Mapping shows a mixed picture of partial

effectiveness of the training in the residential sites that improved following

implementation of the Action Plan by both sites. The QUIS showed that the staff

member observed over three times showed skills consistent with competency in the

DCE units. However, there is no evidence that this is attributable to the effect of the

training program.

As a general comment it may be said that the training did not have a consistent

effect on care staff behaviour or resident experience in the weeks immediately

following completion of the course. This is consistent with (Nolan, et al., 2008) who

suggest that training on its own is not sufficient to bring about desired improvements

in quality of care.


46

However, we can see improvements specifically related to the stimulus that training

provides once they are focussed and elaborated in an action planning and

implementation process. The action planning that took place following DCM at Time

2 led to specific improvements in targeted care behaviour, particularly at Residential

Site 1. Levels of PEs supporting most fundamental needs increased at Residential

Site 1 and levels of detracting care actions did not increase supporting the view that

by targeting specific care behaviour and providing a rationale and context for it with

training can enable care staff to embrace appropriate care behaviour and so improve

the quality of care provided. At Residential Site 2 the same improvement following

the action planning and implementation in targeted behaviours in lower levels of

most PDs and higher levels of most PEs at Time 3. This trend indicates that if further

cycles of action planning and mapping were conducted PEs would be greater than

PDs in one or two cycles.

Training is an integral component of this quality improvement process. It stimulates

the use of knowledge and improvement in skills by exposing staff and management

to new ideas and models of care. However, this evaluation indicates that training

should to be followed up with practical application and reflective analysis of the

practical care situation so that the knowledge and skills can be integrated and

applied to the current situation, thus causing improvement in care and care

experience.

The DCM practice improvement process is typical of such processes. It is built on

the Plan-Do-Study-Act model of stepwise systematic action based on evidence. The

development of the British Standard (PAS800) for DCM has provided a succinct

process for aged care homes to follow to implement this simple but powerful process

that supports the work of training with data gathering, reflection on practice in the

feedback and identification of specific change targets for implementation and then

further data gathering in subsequent cycles of DCM.

The standard identifies training as an essential precursor to the implementation of a

person centred approach to caregiving. It prepares the ground as it were and


47

provides the participants with a language for caregiving that includes notions of

empathy and personhood, validation and attachment. It sensitises staff to the

importance of being empathically reflective about their practice so that they can take

advantage of the data that can be obtained by DCM. It also stimulates staff

members’ imagination for what care could be like, what is possible in their work.

It is clear that there is not only one type of activity that can be the focus of an action

planning process. The two residential sites in this evaluation had very different

processes and foci for their effort. Residential Site 1 focussed tightly on the feedback

from the mapping at Time 2 and made a short list of specific behaviour that staff

were to focus on and improve. Residential Site 2 used the feedback as a stimulus for

reflection that focussed broadly upon improvement but across several dimensions.

This gave them the opportunity to address individual staff care actions, program

improvements, organisational scheduling and physical structure changes,

incorporating these actions into the ongoing and existing quality improvement

procedures of the organisation. Senior executives were involved in sign-off of the

organisational review and in monitoring and contributing to identification of the action

plan indicating an organisational readiness to engage with the feedback provided by

DCM and an organisational capacity to embrace information and take action upon it.

Residential Site 1 has expressed interest in taking this process further. The success

they experienced with a focussed approach to the feedback and action planning has

added impetus to an organisational thrust for improvement in care quality that has

been under way for several years.

The organisational review with the VIPS Framework was useful to draw the attention

of participating organisations to the corporate and procedural dimension of person

centred practice improvement. All sites incorporated the action plan into the

organisational review, noting changes that were related to specific indicators.

Residential Site 2 and Community Site 1 both incorporated the action plan into their

review in a systematic manner that reflected an existing practice of integrating

actions into a process and seeing the implications of those actions for care quality.


48

Residential Site 1 as an organisation has an active quality improvement process and

focussed their efforts on specific behaviour of staff. The organisational and program

dimension of quality improvement was not the focus of their attention during this

period, having already made significant inroads in recent years.

However, they have noted that this experience has provided added impetus to their

intention to roll out such a focussed approach across all areas of the organisation.

They are also intending to address the problems that were identified as a result of

the feedback from the DCM Time 3. This included awareness that the improvements

in care behaviour were taken up by some staff and not others. Once this was clear it

became a matter of identifying the reasons this occurred and now making further

action planning to address this issue. This will lead to further cycles of mapping,

feedback and action planning.

Such insight into the real situation, based on the data from direct observation that

DCM provides gave the Residential Site 1 executive the direction and impetus for

accurate and effective future action. In this way future training can be targeted

accurately and effectively to the topic that will produce needed wellbeing benefits for

residents. This is an efficient use of funds for training.

Both sites found that even though they made specific organisational, programmatic

or staff behaviour changes, this did not necessarily alter the rating they gave

themselves for each indicator. So despite effort in one area the rating may remain

“Needs more work”. This is often the case with benchmarking tools when the real

focus is on making the specific changes rather than achieving an improvement rating

from one categorical rating to another. It is also important to take into account that

three months is not a long time to bring about lasting organisational change.

It is important that each site integrated their action planning efforts into the

organisational review of their work. By doing this they were able to see where they

were located in terms of progress toward a goal of developing a more person

centred organisation and not just address discrete staff actions.


49

The VIPS Framework is a means of maintaining attention on the multifaceted

experience of implementing quality improvement in care and helps organisations

avoid the mistake of thinking that providing a training course on its own is sufficient

to achieve any effective change in care quality.

The QUIS was used in this evaluation in an adapted form for the observation of the

care behaviour of staff and care experience of clients in their own homes. In its

modified form with domains that identify both client and carer actions it is more

comprehensive and practical for this community care staff group than in the form it

had when originally designed for observation in residential settings.

We can see from the work of the care worker observed over three time periods in the

community setting that she has the skills to provide effective person centred care

and that there is evidence to support her competence in the requirements for areas

of the DCE training course. However, it is not possible from the data to say that the

training course caused her to improve. The situations were so different that she

acted differently in each situation, quite appropriately, showing adaptability to the

individual in her care. The QUIS was effective in detecting the differences in types of

interactions but was not effective in detecting whether these changes were

improvements from one Time to the next. Perhaps incorporation of elements from

DCM such as PDs or PEs or the ME values to measure client response to care could

improve the sensitivity of the QUIS. There is need for the development of a tool to

reliably measure the quality of care provision and experience in the community

setting.

Limitations

The limitations of this study are several. It is small in size and so limited in the

statistical power and sophistication of any analysis. The small size also restricts the

variability that can be included in the sample, raising the question of generalisability

of these results to aged care organisations that differ from those studied in this

evaluation. It is possible that a “pilot’ study like this may provide direction for a larger


50

study that includes more variation on aged care sites that reflect a more typical

sample of aged care sites.

With only one community care site in the study the conclusions that may be drawn

are tentative at best. Community aged care is a relatively recent phenomenon in the

history of the care of people living with dementia. It is the fastest growing sector of

publicly funded aged care in Australia. The client-care worker dyads that were

observed showed that there are context specific interactions that differ radically from

residential care. Care managers visit to discuss care rather than provide care, often

reflecting on the care needs of the client with the client’s spouse/adult child. Direct

care workers visit to provide specific care in the form of housework and other forms

of housekeeping that include preparation of shopping lists and actual shopping, or

assistance with personal Activities of Daily Living (ADLs). These widely varying

involvements make it difficult to systematise these interactions in a valid metric that

captures the subjective quality of life experience of living at home with dementia.

The QUIS was adapted in this study and sensitively detected the variation in care

activity. It remains to be developed as described above so that the full range of care

activity and the full range of care recipient behaviour can be captured in a measuring

instrument that validly and reliably measures the reality of community care.

The organisational context of community care providers contains inherently complex

relationships between care package providers, direct care providers and care

recipients that make the logistical tasks of organising regularly scheduled

observations difficult. Often the care or case manager works for an organisation that

sets up the care package and engages another organisation to provide the direct

care workers who will visit the client’s home regularly. In this evaluation the direct

care workers were (unusually) employed by the organisation that established the

care packages. This is an integrated model that enables much closer coordination of

care provision and communication of information from direct care worker to care

manager. Even so there are often several care workers rostered to work with an

individual client over a two week roster. An individual care worker may work with a


51

different list of clients each roster period. They work part-time mostly and may work

for several care organisations. This variation makes the observation of dyads rather

unpredictable and introduces a possible source of confusion to data obtained from

community care observations. It also undermines the fundamental need for

attachment that stable caregiving fosters. As community care organisations mature

they are introducing more structure and cohesion into their provision of care (e.g.

integrated model) that may make the conduct of systematic observation in

community care a more predictable task. However, as evident in this set of

observations there remains considerable unpredictability in the care experience.

The study shows after 3 months and one cycle of action planning that changes at all

levels of the organisation are making a difference to care quality. However, as the

graph of PDs and PEs (Figure 3) shows one cycle of action planning is not sufficient

to improve the level of PDs or PEs to the point where PEs predominate. Further

cycles of action planning and further data gathering using tools such as DCM are

required to both broaden and deepen the improvements that have begun to occur.

Residential Site 1 found that one sector of the staff group responded to the action

planning but another sector had not, giving rise to further reflection and problem

solving that will in turn become an action plan for a subsequent cycle of

improvement. Future studies should include multiple cycles of action planning so that

the scope of change over time can be studied. Whatever the source of data (DCM or

QUIS or other multiple sources) these cycles of change are an essential structure

within which to embed staff training. Training then becomes a stimulus for and

reinforcer of change in care practice.

Conclusion

The results of this evaluation indicate support for the effectiveness of Dementia Care

Essentials as a mechanism for quality improvement in provision of care for people

living with dementia in residential and community aged care settings.


52

However, consistent with (Nolan, et al., 2008) who maintain that education is a

necessary but not sufficient condition for success in efforts to improve quality of care,

the evaluation indicates that the training is effective when embedded within a

process of practice improvement that addresses care staff actions and the

organisational dimension of the aged care context, and not as effective in improving

care practices when used as a stand alone intervention.


53

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APPENDICES

1. Organisational Review

1.1. VIPS Framework

1.2. Changes to the Organisational Review from Time 1 to Time 3 for all sites

1.3. Essential skills for participants in DCE

2. Participant Survey Questions

3. Dementia Care Mapping

3.1. Behaviour Category Codes

3.2. Mood Engagement values

3.3. Personal Enhancers and Personal Detractors

3.4. DCM Feedback Residential Site 1 Time 2




3.8. DCM Action Plan Residential Site 1

3.9. DCM Action Plan Residential Site 2

4. QUIS

4.1. QUIS (adapted) data collection sheet

4.2. Action Plan for Community Site 1

5. Mapping of national competencies to DCM PE and PD categories and QUIS

behaviour categories

Documents

An evaluation of the effectiveness of Dementia Care ......the effectiveness of Dementia Care Essentials in improving the quality of residential and community aged care . ... 8 Target