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Working Working TogetherTogether to Enhance to Enhance Understanding of Responsive Behaviours Understanding of Responsive Behaviours

in Longin Long--Term CareTerm Care

Sherry Dupuis, PhDDirector, MAREP

Long-Term Care Association of Manitoba Annual ConferenceMay 29, 2007

Winnipeg, Manitoba

Responsive Behaviours (RB) Responsive Behaviours (RB) in Longin Long--term Care Programterm Care Program• Purpose: on-going program to gain a comprehensive

understanding of responsive behaviours in long-term care settings

• Phase One – examined the nature of RBs in LTC homes (e.g., frequency, triggers, interventions)

• Phase Two – involved the development of a training tool to educate front-line staff on better ways to manage and accommodate responsive behaviours

• Phase Three – examined the meanings and experiences of RBs for staff working in long-term care homes

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What are What are ““ResponsiveResponsive”” Behaviours?Behaviours?

• reflect a response to something negative, frustrating, or confusing in the person’s environment

• place the reasons or triggers for behaviours beyond the disease rather than only within the individual (caused by biological/disease processes)

• persons with dementia chose and prefer this term – a behaviour is a means of communication

• to address behaviours need to look beyond the disease need to change the environment (physical or social aspects)

Phase One

most frequently experienced and most “disruptive” responsive behaviours in LTC settingsstaff members’ perceptions of the triggers of specific types of responsive behavioursmost frequently used interventions to manage specific types of responsive behavioursperceived effectiveness of interventions used to manage specific types of responsive behavioursdifferences between staff groups on selected aspects of responsive behaviours

To gain a comprehensive understanding of staff members’perceptions of responsive behaviours in long-term care settings and the most effective strategies for managing those behaviours

Objectives – to identify:

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1. Constant unwarranted request for attention or help (97.1%)2. Pacing, aimless wandering (96.8%)3. Complaining/whining (96.7%)4. Repetitive sentences or questions (96.5%)5. Trying to get to a different place (95.8%)6. Cursing or verbal aggression (94.9%)7. General restlessness or agitation (94.5%)8. Negativism/sarcasm (89.8%)9. Making strange noises (89.3%)10. Grabbing onto people (88.9%)

Top Ten Responsive Behaviours Experienced by the Most Staff

Other Findings…

non-aggressive verbal behaviours – most common and most intense

highlighted the need for a repertoire of interventions to draw on

negative responses still used by over 30% of staff -- likely due to increasing pressures on staff and staff burnout

health care aides likely to experience the most intense behaviours yet are less likely to have training in responsive behaviours compared to other staff

type of intervention used differs significantly by staff group

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Phase Two

● Development of a training tool to educate front-line staff on better ways to manage and accommodate responsive behaviours

● Based on P.I.E.C.E.S.TM framework

Physical IntellectualEmotional healthCapabilitiesEnvironmental (both physical and emotional) Social and cultural factors

Understanding the Behaviour

1. What is the behaviour? 2. Who is the behaviour affecting? 3. What is the degree of risk? 4. What are the potential triggers of this behaviour?5. What is the meaning behind the behaviour?

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Physical (UTI, Flu, Constipation, Pain or Discomfort, hunger)

Intellectual (Frustration with lack of ability to communicate)

Emotional (Need for touch, love, grief and loss, boredom)

Capabilities (Match between task and remaining abilities)

Environment (Lighting, noise, commotion)

Social and Cultural Factors (Social interactions,

care style, life history and culture)P.I.E.C.E.S. ™ 2006

What are the Possible Triggers?

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The Gentle Persuasive Approaches (GPA) Project: A Standardized Curriculum to Teach Person-Centred Behaviour

Management to Front-line Staff in Long Term Care

Overall Goal

To use a person-centred, compassionate, and gentle persuasive approach, when

responding respectfully, and with confidence and skill to responsive

behaviours of a more escalated nature associated with dementia

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Curriculum

Delivery:2 coaches (PRCs)

7.5 hour day

10-12 participants per session

Multiple education strategies – mini-lecture, reflection, video, small group, practical skill development, role play

Curriculum, Cont’d

Course Content:Module 1:

– Person-centred care– Meaning behind behaviour

Module 2:– Impact of dementia on the brain– Relationship of changes in the brain to behaviour– Care implications

Module 3:– Communication (emotional, environmental, interpersonal)– Communication strategies

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Curriculum, Cont’d

– Module 4:Gentle Persuasive Approaches

– Protective grab

– Individual techniques

– Team techniques

– Role play / Case studies

Phase ThreePhase Three

How do staff think about responsive behaviours? What meanings do staff attach to responsive behaviours? What factors influence the way staff think about behaviours?How do various staff experience responsive behaviours in the long-term care environment? What factors influence the way behaviours are experienced?How do staff typically respond to behaviours? What factors influence the ways in which staff respond?How do the meanings and experiences of responsive behaviours influence how staff respond to behaviours?

To examine the meaning and experience of responsive behaviours for various long-term care staff and how these meanings and experiences influence the ways in which staff respond to behaviours

Guiding Research QuestionsGuiding Research Questions::

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Key FindingsKey Findings

interactionalinteractional and and organizationalorganizational factors more factors more important than pathology/resident factors in the important than pathology/resident factors in the ability of staff to respond effectively to ability of staff to respond effectively to behavioursbehaviours

most important most important interactionalinteractional factor for staff is: factor for staff is: the the ““stylestyle”” by which staff approach their jobsby which staff approach their jobs

““caring stylecaring style”” necessary in responding appropriately necessary in responding appropriately to to behavioursbehaviours and in the prevention of and in the prevention of behavioursbehaviours

““nonnon--caring stylecaring style”” identified as a major trigger of identified as a major trigger of behavioursbehaviours

A Caring StyleA Caring StyleCaring through Voice and Spoken LanguageCaring through Voice and Spoken Language

providing residents with information, providing residents with information, explaining what staff are doingexplaining what staff are doingsimplifying language and taskssimplifying language and tasksreducing amount of information givenreducing amount of information givenbeing gentle/using a calm voice and mannerbeing gentle/using a calm voice and manner

Caring through Body LanguageCaring through Body Languageapproaching residents from the frontapproaching residents from the frontgetting down to residentgetting down to resident’’s eye levels eye levelusing physical affectionusing physical affection

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A Caring StyleA Caring StyleCaring through Relational StylesCaring through Relational Styles

building of close relationships with resident/knowing building of close relationships with resident/knowing the residentthe residentseeing beyond the diseaseseeing beyond the diseaserespecting and believing in autonomy/selfrespecting and believing in autonomy/self--determination of residentsdetermination of residentsbelieving that the person is believing that the person is ““still therestill there””knowing and respecting individual residentknowing and respecting individual resident’’s s preferences and routinespreferences and routinesshowing interest in residentsshowing interest in residentsreally listening to residentsreally listening to residentsbeing patientbeing patient

A Caring StyleA Caring StyleCaring through Being with the PersonCaring through Being with the Person

respecting and being able to move in residentsrespecting and being able to move in residents’’realitiesrealitiesmoving with the residentmoving with the resident’’s rhythms, slowing s rhythms, slowing downdownbeing flexible in routinesbeing flexible in routinesvalidating residentvalidating resident’’s experiencess experiencesbeing able to empathize with residentsbeing able to empathize with residents

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Organizational StructureOrganizational Structure/Systemic Factors/Systemic Factors

Staffing IssuesStaffing Issuesstaff dynamics/conflictsstaff dynamics/conflictsstaff shortagesstaff shortageslack of trained staff/preparedness to respondlack of trained staff/preparedness to respondstaff turnover = lack of consistency in staffstaff turnover = lack of consistency in stafflack of strong, supportive leadership/strong role lack of strong, supportive leadership/strong role modelsmodelsstaff fatigue, stress, and dissatisfaction with jobstaff fatigue, stress, and dissatisfaction with job

Organizational StructureOrganizational Structure/Systemic Factors/Systemic Factors

Limitations of Traditional Service ModelLimitations of Traditional Service Modelheavy workloads/high residentheavy workloads/high resident--toto--staff ratiosstaff ratioslack of time to adopt and use lack of time to adopt and use ““caring stylescaring styles””focus on tasks (bedfocus on tasks (bed--andand--body work) and body work) and paperworkpaperworklack of flexibility in routineslack of flexibility in routines

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RecommendationsRecommendationsensuring strong, supportive leadership is in placeensuring strong, supportive leadership is in placeproviding outlets for emotional support and the providing outlets for emotional support and the release of stressrelease of stressdeveloping a culture of teamworkdeveloping a culture of teamworkadopting a relationshipadopting a relationship--centredcentred approachapproachproviding adequate training for all staffproviding adequate training for all staffadopting a selfadopting a self--reflexive practice approachreflexive practice approachallowing time needed for the adoption of caring allowing time needed for the adoption of caring stylesstylesfocusing on staff wellnessfocusing on staff wellness

Remember!Remember!

Only after we understand the behaviour can we meaningfully manage or accommodate it

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Thank You!

Contact Information:

Murray Alzheimer Research and Education ProgramFaculty of Applied Health SciencesUniversity of WaterlooWaterloo, ON N2L 3G1Telephone: 519-888-4567, Ext. 36188Website: www.marep.uwaterloo.ca