Training healthcare assistants from nursing and therapy teams to pick up the early signs of dementia and offer one-to-one support is reaping benefits in a large acute hospital
One in four inpatients in general hospitals has dementia care needs, and faces worse outcomes if these needs go unrecognised. One large NHS trust has introduced an enhanced dementia care role for healthcare assistants, offering training in how to recognise dementia and providing one-to-one support. This article outlines the content of the training and its impact on practice and teamwork at the trust.
Citation: Goodwin C (2015) Enhancing healthcare assistants’ dementia role. Nursing Times; 111: 9, 21-23.
Author: Carole Goodwin is nurse lead, dementia pathway at University Hospitals of North Midlands Trust - Royal Stoke University Hospital (formerly University Hospital of North Staffordshire).
- This article has been double-blind peer reviewed
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There are approximately 670,000 people in England living with dementia, and this number is predicted to double over the next 30 years; this increased incidence is having profound effects on patient care in hospitals. An estimated 25% of hospital beds are occupied by people with dementia; these patients also stay in hospital for longer and are more likely to be readmitted (Department of Health, 2013). On average 40% of patients aged over 75 admitted to general hospitals have dementia; only half have a prior diagnosis.
Dementia is a generic term used to describe a range of conditions that affect the brain and result in an overall impairment of the person’s function (Royal College of Nursing, 2012). It affects everyone differently, but starts with mild symptoms that get worse over time. Many people fail to seek help at an early stage, believing symptoms to be a natural part of ageing.
Despite a high prevalence among older people, dementia in this group is also often overlooked by health professionals as clues to its presence may be subtle and non-specific. However, unrecognised dementia may lead to iatrogenic illness, inappropriate and costly use of resources and poor outcomes for patients (National Chronic Care Consortium and Alzheimer’s Association, 2003).
Dementia in hospital settings
People with dementia come into hospital for the same reasons as older people generally - most commonly due to acute illness, stroke or a fall. Care delivery in general hospital settings is based on the assumption that patients are able to express their wishes, acknowledge the needs of other patients, move through the system, have their acute needs addressed and be discharged as required. However, people with dementia are often unable to do some or all of these things (Archibald, 2003).
When compared with the general patient population, patients in general hospitals who have dementia are known to have worse outcomes in terms of:
- Length of stay;
As such, early diagnosis through assessment is essential.
The effect of going into hospital can be overwhelming for these patients; it can cause confusion and anxiety that often leads to them being viewed as aggressive and challenging. Patients may:
- Harm themselves or others;
- Say or do things that are obscene or offensive and do not reflect their true beliefs;
- Be at risk of falling or wandering off;
- Inadvertently remove intravenous lines;
- Be disruptive and affect ward routines.
Ward staff may have difficulty managing this unpredictable behaviour and feel frustrated with their inability to keep wandering patients safe and at not having enough time to spend with patients to provide one-to-one care. A better understanding of dementia can enable staff to defuse potential disruptive behaviour before it escalates.
The trust’s dementia pathway
Royal Stoke University Hospital, formerly University Hospital of North Staffordshire, is the main provider of acute, general hospital services to a population of approximately half a million people living in and around North Staffordshire; it provides a range of specialist services to a wider population of three million. The trust also operates an accident and emergency department with an average of 120,000 people attending each year. It is engaged with the government’s national dementia strategy (Department of Health, 2009), with a commitment to early diagnosis and good- quality interventions for all.
Although the trust is working to ensure all staff have a fundamental understanding of dementia and the skills required to reassure and support patients, the pressures and pace in the acute setting leave little time to concentrate on developing relationships with patients who have dementia that can positively affect the way they function and interact.
To improve the situation the trust developed a dementia care pathway and produced guidance to inform and help staff to:
- Recognise the individuality and capabilities of people with dementia to ensure they are treated with dignity and respect;
- Help people with dementia to understand and manage their illness and enhance the things they can do;
- Help informal carers to continue caring for as long as possible;
- Have a rehabilitative emphasis to help people with dementia have the best quality of life possible within the limitations of their illness;
- Communicate in a way that people with dementia and their families or informal carers can understand.
Addressing the needs of patients with dementia
The trust identified the need to address the specific needs of patients with dementia, developing the role of HCAs working in nursing and therapy teams who had an interest in the condition. These HCAs would work closely with patients who have dementia, offering one-to-one support, linking with the family and carers and reporting directly to the named nurse.
A person-centred and integrated approach to the provision of care and support is fundamental to the delivery of high-quality care for people living with dementia, as it focuses attention on the individual patient’s needs rather than the system. It is the small considerations in the delivery of care that can create a more positive experience for patients and their families, such as allowing time to offer reassurance, and giving information and support in ways appropriate to the individual. Staff need to see the person and not the dementia and, while it takes time to appreciate patients’ unique history and personality, doing so can have positive effects, as demonstrated by the example in Box 1.
Box 1. A positive example of HCA care
A healthcare assistant on the course worked early shifts and was particularly involved in caring for Matthew James, who had been admitted from a nursing home. Mr Jones had not spoken for a very long time but his history indicated that he had enjoyed socialising and having a “sing along”.
The HCA sang while delivering personal care to him and chatted about all sorts of things. After caring for him for some time, she told Mr Jones that it was her birthday the following day. When she went to him the next morning he wished her a happy birthday.
Developing healthcare assistants
As HCAs already provide day-to-day care to patients they are well placed to notice early symptoms of dementia. They are a significant part of the workforce who come into contact with people with cognitive impairment and, when properly trained in dementia care, can detect early signs and alert the appropriate professionals.
The project to develop HCAs to enhance dementia care was led by two senior nurses, who submitted a successful funding bid to Skills for Health. This supported the training of a cohort of experienced HCAs to meet the care needs of patients with dementia.
With help from Skills for Health and using National Occupational Standards, we developed a transferable role template, which was supported by a competency workbook for each participant, outlining the skills, competencies and learning and development required to provide enhanced dementia care (Box 2). The workbook was based on current NHS policies, national guidelines and established educational projects around the trust, such as its Proud to Care standards, with the main focus on dementia.
Box 2. Dementia competency workbook
The dementia competency workbook includes the following:
- Introduction to dementia
- Reflective practice
- Supervision record
- Early signs of dementia - assessment and diagnosis
- Communication and information
- Nutrition and hydration
- Responding to unmet needs
- Context of care and support for people with dementia and their family or carers
- Promoting independence and activity
- End of life
Reflective practice and supervision were included, as reflection on past experience helps staff to effect positive change. This was particularly relevant given that the cohort engaged with the programme were all experienced care staff.
The trust’s dementia working group, chaired by the deputy chief nurse, approved and provided overall governance for the project.
Each person with dementia is unique, and practices must promote choice, well-being and protection of the individuals concerned while giving due regard to the needs of family members and carers. Box 3 outlines the core principles that shaped the training.
Box 3. Principles of training
- Values based
- Shared capabilities
- Partnership working
- Respecting diversity
- Promoting recovery and wellbeing
- Person-centred care
We advertised the opportunity to participate in the programme across the hospital and some 40 HCAs expressed an interest. The final cohort of 18 was recruited via informal interview, with selection based on personal attributes, support from line managers and work locations.
One aim of the project was to help cascade learning and skills across a broad range of clinical teams, including emergency portals, acute stroke, older people’s care, medical outpatients and the A&E department. Managers and matrons supported their staff wholeheartedly and each participant was allocated a personal mentor from their individual clinical team.
Completing the training programme
The first cohort of HCAs attended training for one day a month from May 2013 to April 2014 and had the opportunity to visit local dementia care settings. Each had to complete a mini-project as part of the training; these were designed to benefit the care of patients with dementia, their families and staff in their individual areas.
Mentors and senior staff supporting the HCAs were brought together at the start of the programme to establish a baseline of information on changes or improvements they hoped to see over the training period. As the enhanced role focused on improving the quality of patient care and patient/carer experience, a small satisfaction questionnaire was developed for carers to complete.
The planned training days covered the elements highlighted in the workbook, with time allowed to complete personal projects. These included:
- Completion and use of memory boxes;
- Development of a dementia information folder for staff in the outpatient clinic;
- A nutritional project to encourage older post-operative fracture patients to eat well;
- Information/training sessions for staff in the A&E department;
- Promoting use of a butterfly symbol and “This is me” document for patients with cognitive problems to help staff recognise patients with dementia and learn something of their background.
Outcomes and impact
Enhancing the HCAs’ skills in caring and supporting people with dementia has enabled the trust to make better use of skill mix, as nurses can focus higher-level skills at more complex cases and broader patient services while being confident in the improved knowledge of their HCA.
One HCA working in A&E is now involved in induction training for junior doctors; another, working on the acute stroke unit, has engaged in delivering dementia awareness training to her team as well as increasing the use of “This is me” documentation and emphasising the importance of involving family and carers. Other sustainable developments include noticeboards and folders with information on dementia for staff, families and carers.
Members of the initial cohort now champion dementia and are the basis of a forum to drive best practice, leading from the bottom up, enabling protocols and procedures to be activated that can bring about change in the cultural views of dementia.
Early identification of people with dementia enables quicker access to treatment, care and support, and should break down barriers to services. For example, a better understanding of the patient with advanced dementia and person-centred care enables staff to approach individuals appropriately and gain their trust. This helps them offer patients appropriate support to adhere to treatment and hopefully speed up their recovery and discharge, increasing their chance of returning to their prior level of ability.
Increased understanding of dementia also results in greater acceptance by staff of patients with dementia and more positive experiences of care overall. Good liaison through knowledgeable, dedicated HCAs should facilitate more timely and effective discharge, thereby promoting a shift in care so that it is proactive, rather than reactive (Box 4).
Box 4. Impact of developing HCAs
- Informed staff with transferrable skills and competencies to care appropriately for people with dementia in any care setting
- Improved one-to-one care and outcomes for people with dementia and their families
- Support through the care pathway for people with dementia
- Enhanced teamwork based on clarity of role responsibilities and levels of accountability
- Improved and skilled staff with time to care and improved job satisfaction
Dementia care begins the moment a patient with dementia arrives at the trust and continues right through to the time they leave the hospital and beyond.
The trust aims to engender a culture that values and supports staff to be able to interact with people who have dementia, and their families, in a caring and holistic way, with an emphasis on high-quality care and best practice. This enhanced dementia care course has enabled a group of staff members to support patients with dementia, as well as their families or carers, with an emphasis on the four elements of person-centred care defined by Brooker (2003):
- Valuing people with dementia and those caring for them;
- Treating people as individuals, appreciating that all people have a unique history and personality;
- Looking at the world from the perspective of the person and listening to their voice;
- Recognising that all human life is grounded in relationships and that people need to live in a social environment that supports their wellbeing.
A second cohort commenced the programme in September 2014.
- One in three people over the age of 65 will develop dementia
- A quarter of inpatients in general hospitals have dementia care needs
- Healthcare assistants are well placed to take on an enhanced role in dementia care
- Healthcare assistants can offer one-to-one support, linking with families and carers and reporting to named nurses
- An enhanced role for healthcare assistants enables better use of nurses’ advanced skills
Archibald C (2003) People with Dementia in Acute Hospital Settings: A Practice Guide for Clinical Support Workers. Stirling: Dementia Services Development Centre.
Brooker D (2003) What is person-centred care in dementia? Reviews in Clinical Gerontology; 13: 215-222.
Department of Health (2013) Dementia: A State of the Nation Report on Dementia Care and Support in England. London: DH.
Department of Health (2009) Living Well with Dementia: A National Dementia Strategy.
National Chronic Care Consortium, Alzheimer’s Association (2003) Tools for Early Identification and Treatment for People with Alzheimer’s Disease and Dementia.
Royal College of Nursing (2012) Dementia: Commitment to the Care of People with Dementia in Hospital Settings.