Last week the Today Show aired a story on abuse in a nursing home in Minnesota. Two teenage girls are accused of emotionally abusing 15 residents who suffer from Alzheimer's disease. They allegedly spit in residents' mouths, groped, poked and taunted these Alzheimer's residents until they screamed. The abuse occurred over a five month period while these teens worked as nursing assistants on the evening shift. The reports also state that there were other teens who worked with them who knew of the abuse but did not report it. 

I am always saddened by stories of abuse in nursing homes. After hearing of this case I wondered how the family members of the abused residents felt when they heard of the abuse. I wondered why these young girls thought that their actions were funny. 

This story stuck in my head for a few reasons. There are so many people working to protect residents in nursing home, to provide person-centered individualized care and to change the culture of living in nursing homes. Why did this have to happen? How could it happen? 

I am curious to learn of the abuse prevention and identification training programs this facility offers. Do they educate all of their staff on abuse prevention? Do they stress abuse prevention during orientation? Where was their supervisor? Why didn't the other girls come forward? How is the leadership in this facility coping with this unbelievable situation? Was there any indication that this was happening? I wonder about hiring practices, are there questions that can be asked during an interview to see how caring a person is?  

I believe that people with Alzheimer's disease are vulnerable, and we are trusted to care for them with respect, compassion and kindness. Their families have made a very hard decision to place their loved one in our home.  A story like this causes people to generalize their thoughts to all nursing home care. 

I once heard one of our family members say that she knew her mother was "safe, well cared for and respected." Isn't that what we wish for all people living in nursing homes? I believe that ensuring safety and dignity need to be our priorities as leaders. 

I urge you to share this story with your staff. Ask them how it makes them feel. Discuss how this could have happened and whether it could happen in your facility? How can we prevent abuse? Although we all wish that this abuse case never happened, the only good that may come from it is learning how to strategically guarantee that it never happens again. I offer my questions as a way to lead the discussion with your staff on how to prevent abuse in nursing homes. 

Sometimes we may be caring for individuals whose needs challenge us and test our abilities to think creatively or critically. In my role as an educator, I am asked many questions from caregivers looking for solutions to challenges. They share with me their situation and are hopeful that I will give them a list of steps they can take to eliminate their problems. 

But I believe that there are no simple solutions. There are no recipe cards or generic interventions that are successful every time. I believe we need to educate ourselves to the disease process, the stages, how the brain changes, approach needs, validation techniques and communication tips before we can think creatively to problem solve. I also believe that it is vital that we get to know each person and their family individually. Someone once said to me, "If you have met one person with Alzheimer's disease, you have met one person with Alzheimer's disease." Each person suffering from this disease is a different person with unique needs. The dementia care team must use their creativity, knowledge, experience and compassion to care for a person with dementia. 

Last week I taught a seminar on caring for people with dementia. At the end of the class a SNF nursing supervisor approached me and shared a story of a resident with Alzheimer's disease who we will name Ethel. Ethel suffers from Alzheimer's disease and her behavior was causing her caregivers stress. Ethel frequently put her hands into her incontinence brief. When she was incontinent of stool she would "play with it and smear it on the wall, chairs or her clothing." 

They unsuccessfully tried a variety of interventions to prevent this behavior. As I spoke with this supervisor I learned that this situation was becoming very upsetting to her staff. She told me that her staff felt that Ethel was "doing it on purpose" and "could stop if she wanted to." We discussed the information that was covered in the seminar and made plans for her to begin to educate her staff on the disease, the changes in the brain, points of stimulation and communication techniques. I also suggested that she coordinate sensitivity training with her staff to teach empathy. For example, for one hour have everyone wear a brief with a cup of warm water in it then have a guided discussion on how wearing the brief felt. 

This story and other challenging situations are times that test the dementia care team's knowledge of the disease, clinical assessment, abilities to be creative and critical thinkers. They are opportunities for education! Opportunities to build knowledge of the disease, help us to develop understanding of the causes of behaviors and see behaviors as communication. When behaviors are seen as communication, staff can better understand how to meet the needs of people with dementia.  

I once worked with a wonderful woman named Jenny. Jenny was a charge nurse on the night shift. Every morning when I arrived at work Jenny would fill me in on all the things that George did last night, stories of how his behaviors were disruptive and challenging the staff. George had Alzheimer's disease and usually got in and out of bed all night long. He would walk into other residents' rooms looking for his wife. 

This upset Jenny, and she would describe to me the amount of time she was spending with George each night. I knew that Jenny and the other caregivers needed some education on person centered care for people with Alzheimer's disease and arranged for a dementia care consultant to come and teach a daylong seminar. Jenny attended the seminar and brought with her a list of questions and concerns that she had.  The next morning when I arrived and went to see Jenny, I expected to hear more what George did stories. Instead, when I asked Jenny, "How was George last night?"  she said "He was excellent!"  I quickly asked her, "Why? What changed?"  She responded, "I did.  I learned why he does what he does, and I changed how I approached him." 

When we have a situation that challenges us, it is a time to use your resources and seek knowledge.  We can read books, ask others about their experiences, attend seminars, watch videos, search the internet, read blogs, contact people from other facilities and call the experts. You can always find someone who will share with you a similar story and inspire your next intervention. There are many educational resources that you can tap into; some are right in your own facility! 

Ask your staff development nurse, physicians, geriatric psychiatrists or your chaplain to set up a learning opportunity for staff to have an inservice, case review, guided discussion or a time for reflection. Design creative educational programs for your CNAs, such as ladder program, that focus on dementia education. Hire a dementia care consultant to come and offer coaching and mentoring for a day. 

Have you found that education can help your caregiving staff overcome challenging situations?  I would love to hear your stories!

Before you read this blog, I would like you to sit and take a deep breath.  Breathe in through your nose and exhale through your mouth.  Do it two or three times.  Do you feel your shoulders relax?  Do you feel your mind calm?  Now I would like you to imagine yourself sitting by a lake.  It is mid day and the temperature is just perfect.  On the lake you notice a family of ducks float by.  They peacefully float on the water, passing you by.  Occasionally one of the ducks goes underwater and pops back up to glide along the water's edge.  The ducks appear calm and relaxed, effortlessly floating.  Watching the ducks also helps you feel calm and relaxed.  

What you can not see is that underneath the water the ducks are paddling quickly.  Ducks need to have strong webbed feet to propel them where they need to go.  They need to be able to paddle quickly to overcome currents of water and the wind.  A duck's warm feathers and multifaceted bill help in their basic needs for survival.   I find it remarkable how a duck can appear so effortless and tranquil while at the same time they are working so hard.

If you could see how quickly a duck was paddling underwater, would it still be as relaxing of a scene for you?  As people who care for people with dementia, we need to be like ducks.  A person with dementia relies heavily on non-verbal communication.  They can quickly pick up on your body language, your frustrations, and your stress.  We need to become proactive caregivers with the ability to anticipate needs before they arise.  We know that how we approach a person with dementia is vital.  When our approach is rushed, from behind or undignified we cause stress for the person with dementia.  Wouldn't you prefer to be approached by a person who was calm?

Recently in a training program, I asked caregivers to brainstorm why certain events during the day could be sources of stress for the person with Alzheimer's disease.  These sources included bathing and showering, going to the bathroom, dining, activities, dressing and shift change.  Caregivers in this seminar broke up into small groups to discuss why these situations may cause stress and how we could be proactive to prevent as many stressors as possible.  For example the team that was discussing shift change realized that during this time of day there is increased noise, new faces, staff members are getting their coats and saying good bye.  Also at shift change, when the nurses or CNAs are giving report, a person with Alzheimer's may be feeling lonely or being talked about.  What steps can caregivers take to minimize any stress for the people they care for at shift time?

Being proactive means being able to anticipate needs before they happen.  In some situations this means knowing all you can about the people you care for.  Just by knowing the person's spouse or their children's names you can help a person feel calm and safe.  We need to be prepared before a shower or before meal time, with all of the tools, equipment, knowledge and resources at our fingertips.  Once we have everything we need we can relax with our residents and focus on bringing them what they need.  For example before assisting a resident with a shower, be sure you have all the equipment you need with you, be sure you have the time you need so that you are not rushing the person with dementia.  Know ahead of time how independent the person can be, what their likes and dislikes are, what part of their body they usually wash first and do what you can to make the shower environment warm and friendly.

In the book Creating Moments of Joy by Jolene Brackey there is a chapter titled "Be Like a Duck".  Jolene describes in this chapter how important it is to appear calm and relaxed when working with people with Alzheimer's disease.  If you know what their needs are, what their "story" is and if you can anticipate what they will need you will help them have a great day.  "We need to be more like ducks.  On the outside we have everything under control."  Jolene goes on to describe what the person with Alzheimer's disease can not see is how hard you are working behind the scenes to be proactive and bring them joy.

Researchers are constantly studying Alzheimer's disease.  If you google the phrase "Alzheimer's Disease Current Research" you will get almost 500,000 links!  These links offer large amounts of information on studies being done around the world. Alzheimer's disease studies include research on prevention, risk factors, nutrition, genetic links, vaccines, calcium, vitamin E, vitamin B, diabetes, olfactory changes, Chinese herbs, estrogen, new drugs trials, nutrition, exercise and biomarkers for early detection. Let me share with you a glimpse into the wide spectrum of what is going on in the world of research. 

Prevalence of Alzheimer's Disease

According to the 2008 Alzheimer's Disease Facts and Figures report published by the Alzheimer's Association, there are an estimated 5.2 million Americans who have Alzheimer's disease. This number is expected to increase every year as the baby boomer generation ages. This report stated that "every 71 seconds someone in America develops Alzheimer's disease. By mid-century, someone will develop Alzheimer's every 33 seconds." It is estimated that 24 million people suffer worldwide and this number will only rise if a cure is not found. 

Risk Factors

The cause or causes of Alzheimer's disease are still not known according to Better Health. Yet researchers have established only 3 proven risk factors: age, genetic history and genetic conditions.  There are multiple risk factors that are still being researched which include: head injury, head size, vascular risk (including smoking, hypertension and diabetes), and diets high in saturated fats. The Alzheimer's Association reported that due to the fact that women live longer than men, women are more likely to develop the disease. They have also found that the disease is more prevalent in people with fewer years of education. 

Prevention

Multiple publications on the internet, including the Alzheimer's Association, state that social interactions, physical exercise, preventing head injuries, mental exercise and a healthy diet (high in antioxidants and low in saturated fats) are all methods that can help reduce the risk of getting Alzheimer's disease. Yet with the cause or causes of the disease still being unknown the effectiveness of these lifestyle practices are still not proven.  

Many risk factors are being studies with the goal of finding ways to delay or prevent Alzheimer's disease. Risk factors include nutrition, exercise, brain activity, gender, diabetes, high blood pressure, hormones and cholesterol.

Treatments

Researchers are actively working to identify biomarkers in hopes to diagnosis the disease earlier. It was reported at the 2008 International Conference on Alzheimer's disease that these biomarkers can be found in blood and spinal fluids. The development of tests to pinpoint indicators of early Alzheimer's disease are currently be researched. Early detection is essential in slowing the progression of Alzheimer's disease.

Drugs that can delay the onset of symptoms could drastically reduce disabilities and memory loss.  Medications currently used to treat Alzheimer's symptoms include: Aricept, Razadyne and Exelon. According to the University of Southern California News, a Chinese herb, Huperzia serrata, is being studied as a possible treatment to slow the progression of some symptoms of Alzheimer's disease. Currently there are studies are looking at stem cell research, DHA, cholesterol reducing agents called statins, insulin, NSAIDS and other chemical interventions.

According to the Better Health Alzheimer's Disease-Latest Research Fact Sheet, research is focusing on areas of possible treatments including increasing the efficiency of the damaged nerve cells (Aricept and Cognex), preventing the production of beta amyloid proteins and inhibit the buildup of beta amyloid.

Research on Care

Recently researchers in Kansas published results from their study. This study highlights how much people with Alzheimer's disease dislike being patronized or treated like children. Researchers analyzed video tapes of activities of daily living (ADL) care.  They found that when care givers communicated with baby talk residents with dementia became more resistive. They found that residents turned away from the CNA and grimaced when staff used sing-song tones. The more the CNA tried to convince the resident to participate in the ADL, by using a sticky sweet tone, the more resistive the resident became. 

This research reinforces how we should communicate with people with dementia. Naomi Fiel's Validation Method taught us to enter into the person's reality instead of trying to reality orient. All people, not just people with dementia, have a desire to feel validated in their thoughts and feelings. Validation communicates understanding and respect for residents with dementia to help them feel comfortable and safe. Entering their reality can be a time to share a memory with a person with Alzheimer's disease. 

Conclusion

This blog entry is a very small glimpse into the vast world of research that is going on. The hope to find a cure is strong!  The need to understand the cause of the disease is vital to treatment and prevention. As professional caregivers of people with dementia is it important that we familiarize ourselves with the current research and best practices in dementia care. I urge you to frequently search the internet to learn more about the current research in Alzheimer's disease or sign up for newsletters from an Alzheimer's organization.   

What other research studies are you familiar with?  Please share your experiences in participating in studies. 

To read more: www.uscnews.usc.edu

Recently a nursing home administrator asked me for some advice on how to change the culture of bathing in his facility. I asked him to describe his facility's current practice and what areas he felt were in need of change. He stated that the bathrooms in his facility (the location of the showers and the tub) were very plain and felt "cold." 

The shower chairs looked uncomfortable, and it seemed that the bath/shower time was "rushed" because of comfort issues. He wanted to make bathing a pleasant experience for both the residents with dementia and their caregivers. I shared with him three very important things to consider when thinking about a dignified bathing experience for people with dementia. These areas are:

1. Environment

2. Equipment

3. Education

Environment

In the most recent issue of ADVANCE for Long-Term Care Management there is an article titled "A Better Bath" by Jolynn Tumolo.  It states that, "Residents will be more comfortable and less rushed if they can see well, aren't cold, and don't have to deal with unpleasant odors or sounds." 

One of the first steps to promote bathing comfort, is to discuss with team members what they see, and hear and how they would feel if they were to bathe in the shower/bath area of your facility. Take photographs of the bathing environment to share with staff. These photos will magnify things that staff may walk by every day.

For example, is the bathroom used as a storage area for extra wheel chairs and lift equipment?  Would that be pleasant to look at when bathing? Are there bare tiled walls and beige shower curtains or green plants and beautiful paintings? Color and accessories are great ways to "warm-up" the bathroom and make it more welcoming. Decorating with familiar objects also helps the person with dementia remember the activity that is taking place. People with dementia use objects in their environment to remind them of the task that they are doing.

Generate ideas on how to improve bathing by asking team members to consider and discuss the following questions: What do you see? What do you hear? What do you smell? What do you feel? Does the environment promote dignity, respect, and privacy?

When thinking about the bathing environment consider the temperature of the room. Is it too cold? We would not want to ask a person with dementia to take off their clothes if they were chilled.  Close your eyes and listen to the sounds that maybe echoing in the room. Are you hearing the overhead paging system, voices in the hallway, is it peaceful and silent or are you listening to calming music? 

Equipment

"A Better Bath" by Jolynn Tumolo offers many suggestions for equipment and tools to improve safe bathing. The author includes products for safety such as grab bars, bath benches, and shower chairs.  Your therapy department can also be a valuable member of the team when you are researching products that promote safety, comfort, and independence. Here at the Alzheimer's Resource Center of Connecticut we have found that the Carendo shower chair offers a comfortable seat for showering and helps the caregivers effectively was all areas. The Carendo reclines and raises the person being bathed to a height that is comfortable for the caregiver. This promotes better body mechanics for the caregiver.

Other pieces of equipment that would be important during a bath include CD players and towel warmers which would enhance the comfort and calmness of the experience. Leadership needs to ensure that caregivers have quality skin care products because they are an essential part of the bathing experience to promote skin integrity and cleanliness. 

The article also makes suggestions for bed-based baths. For a person with dementia this may be a more comforting experience. More information on solutions for comfortable bathing and bed baths can be found in the video Bathing without a Battle by Ann Louise Barrick and Joanne Rader. 

Education

Change should always begin with education. Educational inservices are opportunities for caregivers to share their knowledge, expertise, and suggestions. It is also time for them to reflect on what it means to have a dignified bathing experience. Try to incorporate video training programs as reflective learning opportunities for staff to share their experiences and their ideas for improving the bathing experience. 

Training videos such as S.A.F.E. Response Techniques in Crisis Situation by the Alzheimer's Resource Center, Bathing without a Battle by Ann Louise Barrick and Joanne Rader or Accepting the Challenge By Teepa Snow offer skills and strategies specifically designed to meet the needs of people with dementia.  Education should focus on communication, approach, and specific care techniques to be used at each stage of the illness to promote independence with care.  Many of the techniques can be used in other activities of daily living (ADLs) besides bathing, such as dining. If you find individual residents pose bathing challenges for staff it is time to pull together the team to brainstorm bathing ideas. 

A Dignified Bathing Experience

Helping people with dementia maintain their personal dignity during bath time is essential. By considering these three areas we can explore ways to create a calm, personal and successful experience for both the resident and the caregiver.

Even the smallest change your team makes to the bathing experience can make a large impact for the residents. Bath time should be enjoyable. It is essential to find solutions to make bathing less rushed and more relaxing. 

I am sure that this is an area many of you have also thought about. There are many important things to consider when transforming the bathing experience. Please share your stories of transforming the bathing experience in your facility. What innovative ideas did you incorporate? How did your residents, families and staff react to the changes?  Do you have any suggestions for the administrator looking for advice on how to change the culture of bathing in his facility? 

How do we show dignity to those we care for? What is dignity? How does it relate to person centered care? These were the questions discussed at the Connecticut Culture Change Coalition Statewide meeting last week. 

As many of us do, I have both a personal and a professional connection to Alzheimer's disease. Professionally, as a nurse and as an educator, I teach professional care givers about dementia care:  the details of the disease process, how to approach residents who have confusion, how to prevent combative behaviors, how to help the person find joy filled moments, clinical issues, and most importantly, how to promote person centered care.

Personally, I lost my grandmother to Alzheimer's Disease. I watched my grandmother progressively forget, fail, die.  I believe that Alzheimer's Disease is one of the worse diseases a person could get!  It takes away so much: your memories, your family, your functioning. It affects all of your loved ones. Your entire family suffers, while watching their loved one slip away. This is why it is so valuable that we learn as much as we can about how to promote dignity for people who are faced with so many uncertainties as they suffer through the journey of this disease. 

What is dignity? For this blog we will define it as being respected and honored. What does it look like to respect or honor a person?  How do you know that you have been respectful?  I asked these questions to the group that gathered at the coalition meeting. Some of their responses included:

            "It is showing kindness."

"Dignity is being welcoming when you see someone in the hall, not acting like you didn't see them."

"It is making sure that things are clean and neat.  It is very undignified to be wearing dirty clothes or have crumbs on your face."

One panelist stated that by discussing things that are undignified in the facility, people may have a better idea of what was dignified. "Having a piece of toiled paper stuck to the bottom of your shoe is undignified," stated Michael Smith Executive Director of the Alzheimer's Resource Center. "How would you feel if no one told you that you had toilet paper stuck to your shoe?"  What other things are done each day that feel this same way? Mr. Smith pointed out the use of paper bibs at meal time as an example. 

The language we use and the words we chose can also promote respect and dignity. One of my least favorite words I hear in skilled nursing facilities is "feed." I have heard people say "I have four feeds today." To me it sounds like a description word that you would hear I believe that there are so many other ways to describe how we assist a person with their meals that promote the dignity of the person and help us remember the joy that people find in eating.  By changing the word we use to describe dining we bring to the meal more meaning. It becomes an event rather than a task. Remember to keep your sentences short, simple, and specific to promote better communication for your residents with dementia. Use phrases like:

• It is time for lunch.
• May I assist you with breakfast?
• Are you ready for dinner?
• Can I join you for lunch?
• What a delicious dinner the cook made for us tonight.

It is amazing how rephrasing what we say can bring about a complexly different meaning.

I once taught a training program called LEAP in which there was an exercise in sensitivity that I asked the group to participate in. The exercise included wearing a wet incontinence brief for about one hour during a training program. I taught this program about a dozen times and each time the reactions from staff members were the same. This reflective exercise really made the nurses and CNAs re-think how they used incontinent products. They talked about how they felt embarrassed to walk down the hall in the "noisy diaper." They complained about how uncomfortable and hot they were. 

Some even stated how they were having a hard time concentrating on the class content, because their minds were distracted by wearing the brief. I worn the brief each time we did this exercise, and it taught me empathy for people who need to use them. This experience made it clear to the participants that bladder assessments and re-training programs were essential to promote dignity for residents. 

I believe that the heart of promoting dignity is person centered care. This can be promoted by truly getting to know the individual with dementia and their family, being empathic by putting yourself in their shoes, using Validation techniques and role modeling these techniques for family members, and most importantly offering yourself as a professional resource or caregiver during this heartbreaking time. There are so many other ways to promote dignity. Please share your stories of the things that you do or that are going on in your facility to promote dignity. I would love to hear them!

Effective October 1, 2008, Connecticut will set regulations requiring nursing homes with special care units and providers that have dementia programs to ensure an annual eight hours of dementia education to all direct staff. This mandatory educational requirement increased from a previous regulation that required providing all staff with three to five hours (depending on job title) of education on dementia yearly and eight hours upon hire. This regulation has always included mandatory education on signs and treatment of pain.

If memory serves me correctly, this new regulation was sparked by the daughter of a woman with dementia who lived in a nursing home. The daughter was concerned about the clinical abilities of staff that care for people with dementia to assess and treat pain. People with dementia communicate their needs very differently from a person who is cognitively intact. This is why it is vital that caregivers who work with people with dementia are able to recognize and respond to pain.

I once heard at a conference, that 80% of people in nursing homes experience pain, and 50% of people in nursing homes have dementia. Unfortunately, research has shown that people with dementia are less likely to receive pain medication then people who are cognitively intact in both the hospital and long term care setting. We cannot let this happen!  I believe that education on indicators of pain, assessment skills, pharmacological and non-pharmacological treatments is vital for anyone who cares for people with dementia.  I was happy to see it in the Connecticut regulation. 

Consequences of pain are massive. Pain can cause a decline in physical functioning, decreased independence, disturbance in sleep, weight loss, depression, and many other changes in daily life. For a person with dementia, already suffering from a progressive debilitating disease, pain can only magnify or increase disabilities.   

There are a variety of assessment tools that can be used to assess pain. Yet, for a person with dementia, commonly used numeric ("rate your pain on a scale of 1-10") or face scale type assessment questions are not useful to determine the true experience of pain. 

The Pain Assessment IN Advanced Dementia (PAINAD) can be found at http://www.geriatric-resources.com/  It assesses pain in the person with dementia by looking at, breathing, negative vocalizations, facial expressions, body language and consolability. Registered nurses rate what they are seeing on a scale of 0-2 the total then determines the level of pain and necessary treatments. 

The American Journal of Alzheimer's Disease (April/May 2007) published research on the use of the Certified Nursing Assistant Pain Assessment Tool (CPAT).  Its goal is to improve the quality of life for nursing home residents with dementia. This tool observed pain indicators with five categories: Facial expression, behavior, mood, body language, and activity level. This tool helped CNAs communicate to the nurse the signs of pain that they were seeing in their residents. This is a very worthwhile tool, because the CNA is the first person who usually notices a change in the people that they care for.

Assessment tools are very helpful when caring for people with dementia. We must also be mindful to recognize diagnosis of painful conditions as a flag for pain. A person in the end stage of Alzheimer's disease may not exhibit indicators of pain that a person in earlier stages would. If a person in the end stage of the disease also has a fracture, cancer, wound issues, arthritis, an infection or another pain causing condition careful assessment by the medical team is essential to providing comfort. 

Fiona was a wonderful young CNA I once had the privilege of teaching and working with. I first met Fiona in a CNA certification course I was teaching. She was then hired by the facility I where I worked. Fiona had a soft way about her, coworkers and residents adored her. At the end of her first year as a CNA I announced that we were going to hold our first CNA Ladders class.

Fiona came to me, curious about the course and inquiring if she could fill out the application. She was a bit hesitant because of her minimal experience as a CNA.  Fiona and I talked about how she would bring a unique perspective to the CNA Ladders class. Her genuine caring nature and her expressed desire to learn made her a perfect match for the CNA Ladders class. Including Fiona there were six CNAs who were selected to participate in the first Ladders class.

The Ladders program was wonderful! I enjoyed learning so much from these fabulous CNAs! As we discussed caring for residents with dementia I encouraged them to share their experiences with the group.  We talked about the disease process, care needs, family needs, Validation, person centered care and how important it is to get to know the residents you are caring for by really listening to them. It was following the section on "recognizing behaviors as communication," that Fiona shared her illuminating story.

Mr. Smith was a resident who challenged many of his caregivers with his sarcastic remarks and his strong will. Since before he was admitted to the nursing home he had been crawling on his hands and knees to get from his bed or chair to the bathroom or just around his room. Nurses and CNAs found him challenging to care for because he was described as being "resistive to care." 

It made staff nervous when he crawled, fears of falls and injuries, yet when they approached him to put him back to bed he would get angry with them. It was on a night during the time Fiona was in the CNA class that she decided to do something different when caring for Mr. Smith. Typically when Mr. Smith was crawling on the floor staff would quickly assist him back to bed, so he wouldn't get hurt. But on this night she thought to crawl with him for a moment before encouraging him to go back to bed. She got down on her hands and knees beside him and asked him what he was looking for. He said he was looking for his wife. 

Fiona asked him what she looked like. When did they get married? What was his favorite memory of her?  As they crawled slowly around the room he spoke of his lovely wife. Eventually Fiona said she was getting thirsty and could she get him some cranberry juice, his favorite. They sat together drinking their juice.  Eventually Mr. Smith took Fiona's hand and said to her, "I know my wife is dead, but I like looking for her.  Thank you, you are a good friend."         

After hearing this story the CNA Ladders group discussed Fiona's approach and how she validated Mr. Smith by entering his reality. The group reflected on the importance of listening, seeing behaviors as communication and how getting to know your residents can make them feel understood and cared about.  This was one of the most memorable discussions of the ladders program, for all of us. Later, I thanked Fiona for how she taught us all and told her how happy I was that she had participated in the ladders program.  In the time that has passed since the ladders experience, it is evident how much Fiona has grown as a CNA and how much she enjoys her work. I believe that Fiona found her true calling in life as a CNA, leader and as a role model for other CNAs. 

I asked Fiona if I could share the story of her experience with others. She was eager to have this story told because she recognized how being able to share her experience with other caregivers would help them learn the value of listening to their residents, especially those with confusion. Storytelling is a very powerful teaching tool!  In teaching, a story is what makes the long lists of bulleted points, definitions, facts, procedure, techniques and policies stick in your mind. I enjoy telling this story Fiona shared with us.  I tell it during dementia training programs or seminars.  It brings to life the definition and steps of validation, communication, understanding behaviors and how to listen to residents. Fiona and Mr. Smith's story always sparks discussions and sometimes tears! 

CNAs have so many meaningful experiences with residents. These moments offer us powerful lessons in care giving. I have learned so much by listening to the wisdom found in the experiences of the CNAs I work with and teach. 

As leaders in long term care, how do we encourage CNAs to take the time to share their experiences, teach others and to learn from the elders they are caring for? How do you elicit stories from your staff? How do you use these stories to teach?  Please share your stories.

The first time I heard of "symbolic interactionism" was when I was writing my master's thesis.  My advisor, Dr. Hartnett, asked me to study how elders react to the meaning of the various symbols in a nursing home.  My thesis research was a grounded theory study that asked the question "how do elders cope when transitioning from home to a nursing home?"  

Dr. Hartnett and I had many long discussions about the many symbols of death and illness that can be found in a nursing home.  Mechanical lifts, blood pressure cuffs, medical professionals and medication carts are all reminders of (symbols of) sickness.  How residents view the other residents can also offer a symbol to consider.  During one of our conversations, we discussed how the nursing home itself is a symbol.  Rereading this research makes me wonder how do people with dementia view the symbols in a nursing home?  How do they make sense of their environment?  Do these symbols just make it harder for them to feel comfortable? 

Symbolic Interactionism: "Individuals form symbols and learn meaning of life situations through interactions with others.  People use symbols to interact with each other and society.  Individuals act according to the meanings that they apply to events based on their interactions with other people (Blumer, 1969).  Symbolism through interaction was evident throughout my research. The symbol of a home means different things to different cultures. Home is usually a place where people feel safe, happy, loved, and independent. 

Yet a nursing home is seen in our culture as the opposite of a home. The nursing home is a place where traditionally most people do not want to be.  During an interview, one resident shared her feelings for the nursing home when she stated; "it's not like home."  To understand why it is not like home it is valuable to examine the symbols and the meanings of the symbols that are in the nursing home.

The symbol of a nursing home and what it means in our society was interpreted by the residents interviewed in my study. One resident articulated how the nursing home was a place she never wanted to have to admit her husband. She shared that she cared for her husband when he was suffering from Alzheimer's disease in their own home; "I did it for him; I always promised I would not put him away into a convalescent home."  Traditionally, in our culture, nursing homes are viewed as places where old people go to die. Like this resident, most people would prefer not to place their loved one in a nursing home. 

The nursing home sites used in my study were filled with symbolic interaction. In the halls of the nursing home many symbols were found. Items such as wheelchairs, walkers, and canes were used by people who could no longer walk independently.  Unfamiliar medical tools such as blood pressure cuffs, medication cart, a poster on cardiopulmonary resuscitation, reminder notices about proper hand hygiene techniques, large linen carts, and a strange looking mechanical lift cluttered the hallways. In the shower rooms there were large unusual looking bathing tubs with doors and many control buttons. 

At meal time some residents are brought adaptive utensils or foods that have been modified to softer consistencies.  Many of these items, which are typically found in nursing homes, are the things that people use when they are handicapped or when they lack the ability to be independent with their activities of daily living.  Items found in nursing homes are not typically found in homes were people are well. These items have been developed with the physical safety of both the care giver and the resident in mind. The staff members, who care for residents who are dependent for all their care, require assistive devices to protect themselves from physical injury. 

To the newly admitted elder resident these items take time to adjust to.  Although these items may be seen by care givers as necessary tools for their jobs, to the elder they are symbols of the loss of independence.  Another resident described her roommate when she said, "Look at her, all she does is sit slumped over in that wheelchair all day. I hope I don't get like that." As seen in this comment, some residents wonder if they will eventually decline to the point where they also will need to use items that are symbols of dependency.  It makes you wonder if this woman would be slumped over if she was sitting in a regular lounge chair. Could she be slumped over because she has been forced to sit in an uncomfortable wheelchair that is actually a tool for her to be transported from her room to the bathroom or dining room?" If you were an elder moving to a nursing home, or a family member touring, what would you think if you saw this woman slumped in her chair?    

As leaders in long term care and in specialized dementia care settings, we need to reexamine the environments our residents live in.  Are they filled with unfamiliar items or symbols of illness? Can the environment be modified to eliminate symbols of illness?  Do we provide opportunities for our residents to share their feelings about their environment, their live in the nursing home? I learned from the many elder residents in my research, that they often are not asked about how they feel about their new home.  In my next blog I will share some of the stories these elders told me. How do you think elders cope with transitioning from home to a nursing home?

Reference

Blumer, H. (1969).  Symbolic interactionism:  Perspectives and method.  Englewood Cliffs, NJ: Prentice-Hall.

"She calls me Honey, because she doesn't know my name."  (No one likes to be patronized.)

During an inservice on resident rights, Mary, a CNA, shared an experience that made her reflect on how she spoke to residents. It has always been very important to Mary to make all of her residents feel welcomed, comfortable and cared about. Mary stated that one day when she introduced herself to a new resident, Mr. Jones, she lovingly said, "Hi, cutie."  

He politely and quickly said, "I am an eighty-five year old man, no one has called me cutie in seventy years!  You can call me Ed." In this moment Mary learned that being loving to her residents did not mean treating them as if they were children. Mary stated that it is important for everyone to remember that residents are adults, deserving of dignity and respect. Mr. Jones had taught her so much by being honest about his feelings.        

As an adult, has anyone ever called you "honey" or "sweetie"? How did it make you feel?  Did it ever make you feel demeaned?  It is one thing when someone we love uses a term of endearment. People in close relationships often use these terms to show their affection. This can make you feel cared about or comforted. Yet when someone you barely know refers to you as "cutie" it can make you feel like a child. 

Recently, researchers in Kansas published results from their study. This study highlights how much people with Alzheimer's Disease dislike being patronized or treated like children. Researchers analyzed video tapes of activities of daily living (ADL) care. They found that when care givers communicated with baby talk residents with dementia became more resistive. They found that residents turned away from the CNA and grimaced when staff used sing-song tones. The more the CNA tried to convince the resident to participate in the ADL, by using a sticky sweet tone, the more resistive the resident became. 

Please click on the following link for a newly published study about the importance of respectful communication with individuals who have Alzheimer's disease.

This research reinforces how we should communicate with people with dementia. Naomi Fiel's Validation Method taught us to enter into the person's reality instead of trying to reality orient. All people, not just people with dementia, have a desire to feel validated in their thoughts and feelings. Validation communicates understanding and respect for residents with dementia to help them feel comfortable and safe. Entering their reality can be a time to share a memory with a resident. For example, Mrs. Green frequently visited my nurses station looking for her children.  When I asked her questions about her daughter, Mrs. Green would share her memories with me. 

I can clearly remember years ago trying to use "reality orientation" on residents with dementia, just as we were taught in nursing school. Yet it always left me feeling like I was causing the person unnecessary frustration. I felt like I won the lottery the day I learned about Validation!  It changed the way I was able to communicate with the residents I care for.               

How can we show that we are treating each person with dignity? A warm smile, eye contact, offering your hand to hold or shake, maintaining personal space and referring to people by their name are all ways of showing your respect. Using Validation techniques, taking time to listen and expressing empathy can also help people feel comfortable, safe and cared for. 

Have you had an experience with communication that you would like to share?  What are your thoughts about the research findings in the Kansas study?

I can clearly remember the day, 15 years ago, when I learned that my Grandmother had Alzheimer's Disease.  I was in nursing school, out of state, when my mother called to tell me about the diagnosis.   Prior to the diagnosis my family had suspected that her forgetfulness was not normal.  We knew something was wrong, but we were not sure of exactly what.  My Grandfather cared for her in their home and my father was always close by when he was needed.  I watched my family try so hard to care for her needs and keep her safe.  Alzheimer's disease was a foreign land to us.  We had no personal experience with the disease process or knowledge as to what the future held for my Grandma.  Eventually she moved into a nursing home for skilled nursing care.  I vividly recall the daily stress my family suffered due to the "unknowns" of the disease.  We worried about leaving her at the nursing home and reassured my Grandfather that she was safe and well cared for.  He was heartbroken that she was there, and not at home.  Within the year he suffered from a stroke and was also admitted to the same nursing home.  They were able to share a room during his short rehabilitation.  Upon discharge his physical therapist asked him if he was happy to be going home.  He said he was sad to be leaving his bride and wished he could stay to be with her.  I will forever remember feeling so sad for my Grandfather.  He died days after my Grandmother did.  My family believes it was from a broken heart.      

In Sandy Keefe's recent ADVANCE article, Alzheimer's Care Twenty-Four Seven, she shared experiences and advice from professionals on having empathy for family members who's loved ones are suffering from Alzheimer's Disease. 

http://long-term-care.advanceweb.com/Editorial/Content/Editorial.aspx?cc=117936 

This article made me wish that my family had had a professional reach out to them with compassion and support.  It reminded me of the professionals who I see everyday who make a difference in the lives of our residents and their families.  Nursing assistants, social workers, nurses, chaplains, volunteers and all staff members offer family members support, guidance, education, security and kindness. 

Do you have a story to share of a staff member who made a difference in the life of a family member?  Does your facility offer family support groups or education? 

"Not every culture change program goes by a formal name and many facilities across the country are embarking on their own methods...in their quest for culture change and quality resident care" stated Maureen McAndrews in her recent article Changing the Culture of Caregiving. Maureen's article describes multiple models used for implementing person centered care philosophies in your organization. Eden Alternative, Wellsping, Plane Tree and others offer us many methods for educating staff on culture change transformation. There are many resources that can help guide leader toward transformational change.

As an officer for the Connecticut Coalition for Culture Change, I have the opportunity to educate leaders and staff members on the variety of culture change models. I also have the opportunity to get to hear many stories of the wonderful person centered care projects that facilities are working on. Staff members beam with excitement when they are able to tell their stories! There is such power in our stories, our experiences and our successes. You can see the pride in a CNA's eyes as she shares how she helped to transform the dining experience for her residents. Stories teach us and inspire us!  We all have a story to share and I encourage you to do so!  Stories of staff implementing culture change and individualized care are great to use as teaching tools in orientation or inservices. These stories are ways to express the mission and vision of your organization and teach people how they personally can get involved. 

I also find it very important when people, especially leaders, are open enough to share stories of "mistakes" they may have made along their culture change journey. For example, one administrator shared that how she returned to her facility, from a seminar on culture change, very excited with all the new ideas. She began to "assign" specific culture change projects to her managers. This administrator openly expressed how she had reflected on what she had done. She didn't allow her staff to express their views on the changes in turn they did not feel any ownership or enthusiasm. 

As leaders we must begin with sharing the vision of the future. Share this with our staff and leaders.  Hear their points of view and ideas for change. We must always keep that vision alive each and everyday. We must work to build a shared vision and celebrate our accomplishments along the way. 

I am curious to hear about your experiences with implementing culture change. Did you use an existing model?  Did you share it with all of your staff?  Did your staff select the model or did administration?  How do you keep the vision alive everyday?  As a leader in long-term care, what have you learned on your path to change the culture of caring in your organization?

Two weeks ago I gave birth to a beautiful baby girl, our first child. In such a short time, we have learned so much from this beautiful, tiny newborn. She has made us so happy and kept us very busy. Prior to her birth, I was told that babies eat every two hours during the night. I never knew what that would feel like on my body and how it would change my routines so drastically until now.  Boy, am I tired! When morning comes I just don't feel rested. My short experience in parenting has given me a new perspective on the importance of sleep for residents in nursing homes, especially those with dementia.

"Residents are healthier and happier if they have a good nights sleep. There are physical, emotional and cognitive benefits from uninterrupted sleep. Why have we been waking people up all these years?" -Jan Fisher & Peg McIssac. 

Uninterrupted sleep is so vitally important to our well being, yet as a nurse I was trained to gently wake people up every 2 hours for incontinence care and/or repositioning. We worry about skin breakdown! We want to follow regulations about offering meals at certain times. By writing individualized plans of care that relate to sleep needs, we are providing residents with restful sleep that will benefit them in multiple ways. Yet how many residents are woken up for breakfast and are actually asleep in their wheel chairs before they even eat?

Advance for Long-Term Management's Buyers Guide offers many product resources for items you can use to promote uninterrupted sleep. Pressure relieving or pressure reducing mattresses, "dry night" briefs, and skin care products can be used to offer residents more hours of sleep. You may want look into doing medication reviews on your residents who have a difficult time sleeping, because many medications cause insomnia. 

Does the environment lend itself to restfulness or is there overhead paging well into the night? Are curtains closed so the lightening is dimmed? What other interventions do you use to promote restful sleeping?  How easily are you able to fall back to sleep if you are woken in the night?  Did you know that elderly have a harder time getting to a REM stage of sleep, especially with multiple interruptions?

When an elder comes to live in a nursing home, how do we welcome them? What do you do to learn about their "body clock?" How do you determine what their "normal" sleeping patterns are? What do you do with that information? My grandma use to love to fall asleep around 2:00 a.m. with a book in her hands. Would this be allowed in your nursing home or would she be put on a schedule that is most convenient for staffing? Is there an assessment tool you use to look for patterns? How do you write this into their care plan? How do you ensure staff are promoting restful sleep? Do you have inservice tips for this topic that you can share? Do you agree that in our efforts to make more person centered care environments, we need to be more attentive to addressing individual sleep needs? 

Please share any research articles you have read on the benefits of sleep for a person centered care environment and any tips for promoting sleep in nursing homes. For more information on sleep, go to ADVANCE for Sleep.

Have you ever heard a staff member say that a resident with advanced dementia can no longer participate in recreational programs? Sure that is true if the programs are not individualized to meet the changing needs of the person with advanced dementia. What types of activities can a person with advanced dementia participate in? What types of activities are beneficial? 

Diane Mockbee, BS, ADC, president of the National Association of Activities Professionals (NAAP), says that meaningful interactions with residents in advanced stages of dementia "should focus on the five senses: smell, touch, taste, hearing, and vision." She recommends using a variety or types of activities such as one on one, small group and large group sessions, depending on the person ad where they function best. Her articles offer a variety of multisensory ideas for stimulation, including using sweet tasting foods, calming videos, animals, and massage. 

Naomi Feil, the creator of the Validation Method, has made a video titled "There is a Bridge." She spends time with a woman who is in the end stage of Alzheimer's disease. Naomi expresses how by getting to know the person you are caring for, really getting to know what is important to them, you can find ways to connect with them. Naomi shares an example of this by learning about the woman who is in the end stages of Alzheimer's disease, she has her eyes closed and appears to have no connection with her surroundings. In the video Naomi learns that this woman loved to sing church music. Naomi used this knowledge and gentle touch to connect with this woman. By rubbing her cheeks and singing "He's Got the Whole World in His Hands" an amazing connection developed. Eventually the woman sang the song along with Naomi, held her hands and kissed her. It was evident to the group, I watched this video with, that this was a women no one expected to be able to connect with Naomi on the level that she did. 

How can we as professionals get to know the people we are caring for on the level needed to truly touch them and connect with them? How can we help family members learn how to also connect? Would sharing this video and others like it be a start? What are some examples of innovation in activity planning that you find to be successful? 

Next week is National Nursing Assistant Appreciation week! It is a wonderful time to let CNAs know how important they are to you, your residents and to your organization. How are you celebrating your CNA staff? Do you have a special meal planned, are you delivering gift of appreciation or did you write personal thank you notes? Have you found a way to include residents and family members in celebrating your CNA staff?

Every day we can find ways to show our appreciation to nursing assistants. Their roles are vital to providing person centered care to residents. Each moment they spend with a resident is a special connection. The more a CNA is supported to build relationships with the residents they care for the better the quality of the day is for both the resident and the CNA. 

Research has shown that "consistent assignments" where the resident has the same CNA at least 80% of the time, the quality of care is drastically improved. Advancing Excellence in America's Nursing Homes has chosen consistent assignments as target area for nursing home improvement.  The more time a CNA spends with a resident, the deeper the relationship can grow and the quicker the CNA is to notice slight changes in the resident. Consistent assignments also offer the opportunity for the CNA to get to know the resident as a person, not just that they like sugar in their coffee, but a deeper knowledge of "who" that person is, who inspires them, what their fondest memories were and who is important to them. 

CNAs who truly know their resident's life stories play an important role as a person progresses through the stages of Alzheimer's disease. Consistent assignments also help family members learn more about who is caring for their loved one. This helps them to build trusting relationships with the staff.  When a resident was once asked how they liked having a consistent CNA she said "I no longer wake up afraid of who will be taking care of me." 

Have you found success implementing consistent assignments in your facility? What has been the staff, resident and family feedback? Do you have a story to share about a CNA who has made a difference in your organization?