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Research report

Dementia care 2: exploring how nursing staff manage challenging behaviour

The national dementia strategy calls for care homes to adopt a person centred approach to care planning. This study looks at whether this is being implemented

Authors

Nicola L Wheeler, PGCert, BSc, is assistant clinical and research psychologist, mental health services for older people, Birmingham and Solihull Mental Health Foundation Trust; Jan R Oyebode, PhD, MPsychol (Clinical), BA, is director of the clinical psychology doctorate, University of Birmingham, and consultant clinical psychologist, mental health services for older people, Birmingham and Solihull Mental Health Foundation Trust.

Abstract

Wheeler NL, Oyebode JR (2010) Dementia care 2: exploring how nursing staff manage challenging behaviour. Nursing Times; 106: 25, early online publication.

Background This second in a three part series on dementia care explores different approaches to care; part 1 examined communication issues.Dementia care previously used a medical approach to management, which focused on the standard neurogenic disease paradigm, but now many care home staff and healthcare professionals are moving towards a person centred approach, based on biopsychosocial explanations.

Aim This study sought to examine the extent to which care home staff have adopted a person centred approach.

Method Focus groups were carried out with 36 direct care staff from nine care homes.

Results and discussion The study found evidence of both models of dementia care. Three homes mainly used the medical approach, four the person centred approach, and two were moving towards the latter.

Conclusion Training in biopsychosocial approaches to managing challenging/problematic behaviours in dementia is needed for care home staff, family and other healthcare professionals.

Keywords Older people, Dementia, Care home, Person centred approach

  • This article has been double-blind peer reviewed

 

 

Practice points

  • Care home staff should empower residents through assisted living that encourages independence, while offering assistance when necessary.
  • They should also take a “team” approach, allowing members to contribute their own unique skills, be supportive of each other and communicate effectively together.
  • Effective, good quality care and activity planning should be individualised and reflect each resident’s unique social history.
  • Homes should provide a supportive and stimulating social environment, which could include the use of themed corridors, mood lighting, complementary therapies and quiet rooms.

 

Introduction

Dementia care and interventions initially centred on dementia being viewed as a “disease”, so medical interventions grounded in the “standard neurogenic disease paradigm” (Moniz-Cook et al, 2003) were the norm. However, this model does not readily explain the range of individual differences among people with dementia, especially in terms of their different behavioural and emotional responses.

Kitwood (1990) forcefully dismissed this disease centred model of dementia as giving rise to “malignant social psychology”, and gave 17 negative manifestations of how this dehumanises the individual, including:

  • Disempowerment – inhibiting the remaining independence of people with dementia;
  • Imposition – denying people choice;
  • Labelling and disparagement – blanketing people with this condition as cognitively incompetent.

Kitwood (1990) argued that neurochemical and consequent structural changes in the brain cannot solely account for the manifestation of dementia. Rather, he favoured “biopsychosocial explanations” and advocated a person centred approach, based on meeting the physical and mental needs of people with dementia, by analysing the interaction between their neurological deficits, general physical health, personal history and care environment (Kitwood, 1994). By applying behavioural management approaches, for example maintaining daily routines and using reminiscence therapy, Kitwood (1989) maintained that some recovery of cognitive impairment, halting of deterioration and behavioural improvement may be possible. However, this depends on how staff understand their role as carers, and the facilities/interventions available in the care home (Moniz-Cook et al, 2001).

The Alzheimer’s Society (2007a) predicted a 154% increase in the incidence of dementia in the UK by 2052. As it is estimated that over one third of people with late onset dementia live in care homes, (Alzheimer’s Society, 2007a), this increase will mean more care home provision will be needed. 

Kitwood (1990) and Stokes (2000) advocated a new person centred culture in dementia care. Their research is widely accepted in academic circles and underpins the Department of Health’s (2009) national dementia strategy, which requires all care homes to adopt person centred approaches to care planning and ensure that staff receive training in these approaches. Therefore, our study sought to build on this by investigating the extent to which care home staff have adopted a person centred approach.

Method

Nine nursing and residential care homes in the West Midlands specialising in the care of people with dementia participated. Three homes were drawn from each of the following social services categories: privately owned by individuals (P); owned by a chain (C); and run by a charity/voluntarily (C/V). Each home manager provided data on resident numbers, staffing levels, staff training, policies and procedures, and specialist facilities and care provisions for residents with dementia. A focus group discussion lasting around one hour was then held with staff at each home.

Thirty six participants (aged 18-57 years) took part (3-5 per focus group), including healthcare assistants (58%), nurses (14%), activity coordinators (6%) and managers (22%).

These discussions sought participants’ perceptions of caring for residents with dementia, and management approaches to behaviours considered to be challenging or problematic. The findings are presented with quotations from participants, identified by their home number (1-9), home type (P, C, or C/V) and participant number (1-5).

Results

Our findings revealed evidence of the use of the two models of dementia care, that is, the standard neurogenic disease paradigm and the person centred or holistic approach. Care homes were categorised into three groups according to their predominant approach to dementia care, as perceived by focus group participants:

  • Those that described instances of malignant social psychology, where the standard neurogenic disease paradigm tended to underlie the care culture (n=3);
  • Those using a biopsychosocial approach (n=4);
  • Those moving towards the latter (n=2).

Consensus between participants in each focus group was evident in their perceptions of their home’s approach. This consensus was both verbal, such as seeking affirmation from colleagues, and non verbal, such as head nods, and confirmed in responses given by their care home manager.

Three of the nine homes (1C, 5C/V and 8P) showed a reliance on the standard neurogenic disease paradigm, characterised by their frontline use of drug therapy for managing challenging/problematic behaviours: “We tend to use quetiapine” (home 8P, participant 4). The remaining homes showed the culture shift towards person centred care. For example, staff in home 3C described using medication as a “true last resort” (Stokes, 2000):

“If it’s appropriate, if they are extremely agitated and anxious, for them, we may use a small sedative” (home 3C, participant 3).

Indeed, three homes (4C/V, 7P and 9P) echoed this view, reporting that drug therapy for behavioural management was “unnecessary medications. They just complicate things and aren’t needed” (home 4C/V, participant 3). Four homes (2C, 4C/V, 6C/V and 9P) showed strong evidence of a person centred approach, relying on psychosocial and behavioural management strategies. Social history, for example, was used to develop individualised care and activity plans:

“Another group of ladies like to sit in the middle lounge and do some knitting or sewing as they used to make clothes for their families, so we use information from the families… to get to know the residents and things they enjoy doing and then we cater for their specific needs” (home 9P, participant 2).

Social history was also used to maintain daily routines:

“We’ve had some residents who didn’t want to go [to] bed at night and then we found out that was because they used to work night shifts, so we just adapt to it. If they want to walk the corridors at night, then we will walk with them, and if they want breakfast in the middle of the night, then they will have breakfast in the middle of the night” (home 6C/V, participant 3).

Homes following the standard neurogenic disease paradigm

Kitwood (1997; 1990) described how malignant social psychology arises as a result of seeing dementia as an organic mental disorder for which nothing can be done (Stokes, 2000). This characterised the care environment of homes following the standard neurogenic disease paradigm.

While all participants acknowledged their work was mentally tiring (“It’s hard and it does wear you out,” home 4C/V, participant 1), in homes using medical behavioural management, staff showed evidence of low morale:

“They [residents with dementia] can’t communicate with you, so you end up finding it frustrating” (home 5C/V, participant 1).

In such homes, staff also showed evidence of disempowering residents:

“They are quite severe like, dementia patients are. They won’t be aware of what’s happening. They haven’t got a clue really” (home 7P, participant 1).

Consequently, their work was described as being task orientated, towards caring for residents’ physical needs: “You have the washing, cleaning and cooking to do” (home 8P, participant 1).

In these homes there was a clear demarcation of roles between carers (healthcare assistants), nurses and management:

“Even when there is only three of you [carers] on, the nurses still don’t come out and help you…They aren’t on the floor as often as they should be. We shouldn’t say that about nursing staff and management really, but they don’t help us carers” (home 5C/V, participant 4).

Such high levels of stress and frustration seem symptomatic of burnout (Kitwood, 1997; Maslach, 1982). This, in turn, may lead to staff sickness and lack of job satisfaction, perhaps resulting from residents’ non compliance:

“If you have someone who is constantly wandering, you have your other residents to look after which makes them agitated… so you end up finding it frustrating” (home 5C/V, participant 1).

This may also result from residents’ physical or verbal aggression:

“If you have someone on the odd day who is high that day… they might be more physically or verbally aggressive… towards us” (home 1C, participant 1).

While acknowledging that staff undergo mandatory training including health and safety, and manual handling, staff in these homes talked of a lack of career opportunities to improve qualifications and pursue professional development interests:

“Companies won’t pay out for training when it’s like £100 per person, and they have a large number of staff and a high turnover” (home 5C/V, participant 4).

Staff seemed to lack motivation to do a good job, often describing their work negatively and referring to residents as “them” or “they” or colloquially as “the rezzies” (home 8P, participant 1). Such attitudes may hinder staff in forming valuable relationships with residents with dementia through interaction and reminiscence.

Homes that adopted person centred care and those moving towards it

Homes where care was described as being more person centred relied on “a good working team” (home 9P, participant 2) who communicated well with each other, using the unique skills of each team member to provide optimum dementia care.

There was also evidence of colleagues supporting each other at difficult times in these homes:

“You need your team mates there with you, just like to take some of it away from you… if you’re stuck in the middle and you have three or four [residents] that are bombarding you, if a colleague comes one or two can toddle off with her or summat” (home 4C/V, participant 1).

Teamwork seemed to help empower both residents with dementia and staff, improving quality of life for both parties and leading to a celebration of achievements:

“It [dementia care] is very, very rewarding, and I think that side of it is frequently missed out, because… when you do make a breakthrough, it just gives you the feeling of, ‘Oh gosh, I’ve really achieved something here!’” (home 9P, participant 3).

Focus group participants emphasised the need to talk with residents and empathise with them:

“Coz talking to them does really help you connect with them a bit better, if you understand them as a person” (home 4C/V, participant 2).

Homes also made physical changes to their care environments. One had a dedicated floor where residents with dementia lived, called the “reminiscence floor”:

“On the reminiscence floor, we all know what their needs and wants are and we are better able to deal with them” (home 2C, participant 2).

Others had themed corridors (“We have a movie corridor and it’s the old film stars,” home 3C, participant 3), quiet rooms, soft lighting and therapy lights. Some staff spoke of paying attention to seating and eating arrangements:

“We have a separate lounge and dining room. As a result, mobility is improving, eating is improving, residents are enjoying their food more and they are getting some social stimulation as well when walking down the corridors together or with carers” (home 6C/V, participant 4).

Participant 3 in home 6C/V talked about using complementary therapies to enhance the holistic approach to managing dementia care, allowing residents to feel secure in a friendly, relaxed and stimulating setting:

“I am doing reflexology… which helps them relax better and sleep better… and aromatherapy baths.”

Here behaviours were phrased in terms of needs to be satisfied, rather than problems to be dealt with, and staff talked about dementia as a neurological impairment affected by the social environment, so they looked for reasons for residents’ challenging behaviour:

 “He was always playing with the doors, opening and closing them, and testing the handles… and you think ‘why is he doing that?’ But then we looked in the care plan, through his social history and found out he used to be a carpenter. He’s checking all the doors to make sure they are hanging properly and ensure he has done a good job” (home 6C/V, participant 4).

When asked to recall memories of residents with dementia for whom they had cared, participants from homes that had embraced the person centred approach typically spoke affectionately about all of them, even challenging ones:

“They are all so individual. They have all got a special place in your heart. There are very few that I can’t remember and I have been doing this job for 22 years…. You remember them all for different things, different reasons, whether it be for good or bad….” (home 3C, participant 3).

However, in homes where malignant social psychology was evident, participants almost invariably recalled residents who were aggressive and showed challenging behaviours, and commented on their use of medication to manage such behaviours:

“For me it was ‘Matron’…. When she first came, she was dreadful…. Nasty, violent, aggressive, and she would kick you and everything… later she was lovely…. It was the drugs in the end though that they gave her. That one little tablet just changed her entirely….’ (home 8P, participant 1).

Discussion

Focus group members in two thirds of the homes sampled found that using a biopsychosocial approach to managing challenging behaviour enabled some residents with dementia to function at their optimum level, reducing the need for medication as a first line management approach.

However, other homes were still using medical management as a primary strategy. This reliance on medical behavioural management may stem from lack of knowledge/experience of biopsychosocial interventions and their potential benefits.

Our results, although representative of our research sample, may not be representative of care homes generally. These nine homes may have had their own agendas for participating. Some participants regarded their home as providing optimum dementia care and were keen to share good practice – for example, those in homes 3C, 6C/V and 9P. For others, participation may have been a means of addressing problems they were experiencing.

Our research supports the Alzheimer’s Society’s (2007b) report, which emphasised the need for dementia awareness training for care home staff. Training in biopsychosocial approaches to dementia is needed for care home staff, family and other healthcare professionals. However, such provision is seen as costly, leading a healthcare assistant (participant 4) in home 5C/V to suggest:

“Perhaps the lottery fund could give money to care homes for this kind of training, like for staff and relatives, like a grant.”

Conclusion

Our findings suggest that optimum dementia care relies on staff having confidence, competence and special qualities, such as “a lot of patience” (home 4C/V, participant 2) and “understanding” (home 3C, participant 2), which enable them to interact positively with residents. This ensures they are seen as “PEOPLE with dementia” (Stokes, 2000), and that their individual needs are met by empowering both carers and residents:

“… it always helps to have higher [staff] numbers, but not always necessary. As long as the staff that you have really do understand what dementia is… it’s not just a disease… the person is still there. As long as you treat the residents with respect and dignity. It’s all about understanding how to cope/deal with the residents, not the number of staff that you’ve got. As long as they’ve got the training, I think that’s the main point” (home 3C, participant 3).

  • Part 3 of this series, to be published in next week’s issue, examines resident wellbeing reviews

Readers' comments (5)

  • All well and good but having worked in carehomes staffing levels are generally so low that person-centred care is something trotted out for CQC inspections and research like this rather than actually being put into practice.
    When you've two, or at best three staff half of which will be agency and probably unfamiliar with the setting, to look after 20, mostly doubly incontinent, dementing residents then you tell me where you get the time to walk around with the many "wanderers" at all hours of the day and night, let alone provide them with mental stimulation they need. Your entire day is taken up with toileting and changing, feeding, washing, turning and trying to keep residents from falling or hurting themselves or others. Add to that the enormous amount of paperwork, dealing with relatives and members of the MDT, then where do we find time for all these wonderful initiatives which in themselves are quite time-consuming? I would love to give residents one to one time but until a minimum staffing level of, at the very worst, 1 member of staff to 4 residents, day and night, is enshrined in law then our most vulnerable people will continue to receive sub-standard care from managers more interested in maximising profits than giving the care human beings deserve.

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  • Peter Goble

    I agree with Anonymous's comments overall and, although there are rare moments moments of serendipitous 'connection' and 'grace' in dementia care, it is generally a desolate and demoralising enterprise, for all the reasons given. I've spent nearly twenty years of my nursing life in care homes for people with dementia, and it's a great relief not to be doing it any more.

    I don't know how I feel about articles like the one rendered above. I think, without disparaging the authors, that they are trying to find a jewel in rubbish, cherry-picking the occasional heart-warming generalisation about aromatherapy and reflexology, or sketches of reminiscence rooms or blitz-era singalongs. Heaven preserve me from such stuff. I'm 72, I use a computer, maintain a website, listen to an iPod and fly easyjet to Munich for a few beers and pretzels. I don't still live in the era of Gracie Field, George Formby or Winston Churchill, and neither do most people my age, dementia or no dementia.

    Where do these tired "reminiscence" ideas come from? If ever I visit a home as a prospective tenant and find a room plastered with old Ration Books and pictures of the sinking of the Graf Spee I'll throw a real wobbly, Haloperidol or no Haloperidol!

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  • Oh dear,now you've done it.Aren't you aware fellow respondants that you are just supposed to blindly and unquestionably follow the so called research produced in the main by psychologists who would be unable run a ward or care home for one day.

    The fact is that a care home generally an under resourced,task orientated hellhole staffed by poorly trained teenagers.Jeremy Kyle or Radio one blasting out at ridiculous levels and a lack of stimulation other than to be herded from room to room at different parts of the day in a monotonous cycle of sameness between waking and sleeping.

    Do I sound depressed?Of course I do I have worked in the real world of dementia care in the private care sector and have seen some really exceptional care given by those young carers.But the fact remains that such establishments will never be resourced to a level required in this poor piece of research.

    It is fantasy and the authors should be ashamed of themselves for peddling such tosh.

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  • As the second author of this piece, I thought I would make a brief response to those who've taken the trouble to respond to our article.

    I whole-heartedly agree that low staffing levels preclude high quality care. Most of the care staff I have worked with would love to provide more person-centred care if they only had the time, although as Nikki's focus groups bear out, sometimes care will not be person-centred if people have not had a chance for education about dementia or are not working in an atmosphere that encourages it.

    The issue about reminiscence is well made - reminiscence activity should be personal and appropriate to each individual. If I were caring for Peter in 20 years' time, and if I had sufficient resources, I might be encouraging him to sit back with a well chosen German beer and reminisce about those Munich beer festivals, and we might get that old i-pod out and see if it still played.

    The post that is most perplexing to me is David's. If Care Homes are 'hellholes', is that not all the more reason to try in whatever way we can to raise the game, rather than sinking into despondency? Nikki may be a psychologist (thank goodness the Nursing Times carries out blind reviews!), but she is one of the most committed and energetic undergraduates I have worked with. How many young people take the trouble to disseminate the work they have done for a degree project. I think she is to be congratulated on getting her findings into print and I think we need people of all disciplines who have fire in their belly for change when it come to the quality of dementia care.

    Jan O

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  • Jan O - I couldn't agree more with your comment.

    In response to the others - not all care homes are "hellholes" that are poorly staffed by 'teenagers'. I have commenced work at a nursing home this month and, having worked in a poorly staffed, low morale, hospital ward for the last 10 years it is nothing short of wonderful to have moved to the care home setting.

    At the care home (inclusive of residents with dementia) we have adequate levels of staff, excellent resources and access to more training than I ever did at the NHS. I now have time to sit with the residents and chat with them about their past and care can be personalised and resident centred. Of course some aspects are task orientated, such as the turns and drug rounds but show me a place where there are no task orientated routines?

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