Authors

  1. Pizzacalla, Anne
  2. Montemuro, Maureen
  3. Coker, Esther
  4. Martin, Lori Schindel
  5. Gillies, Leslie
  6. Robinson, Karen
  7. Pepper, Heather
  8. Benner, Jeff
  9. Gusciora, Joanna

Abstract

Gentle Persuasive Approaches in Dementia Care (GPA), a curriculum originally designed for long-term care, was introduced into an acute care setting. This person-centered approach to supporting and responding to persons with behaviors associated with dementia was shown to be applicable for staff on an orthopaedic surgery unit where they had reported significant challenges and care burdens when faced with behaviors such as shouting, explosiveness, and resistance to care. Staff confidence in their ability to care for persons with behaviors increased after attending the 1-day GPA workshop, and they reported being highly satisfied with the curriculum, found it to be applicable to their practice, indicated that it was also useful for patients with delirium, and would recommend it to others. Some of the staff on the orthopaedic unit became certified GPA coaches. The passion of those champions, along with demonstrated success of the program on their unit, contributed to its spread to other units, including rehabilitation and acute medicine.

 

Article Content

Increasing numbers of older adults with dementia are being admitted to acute care settings and they often present with behavioral symptoms that are even more prevalent in the presence of delirium (Landreville, Voyer, & Carmichael, 2013). The reported prevalence of dementia in older inpatients who have fractured a hip ranges from 20% to 30% (Scandol, Toson, & Close, 2013; Seitz, Adunuri, Gill, & Rochon, 2011), but some estimates are twice as high because dementia may not be identified on admission (Sampson, Blanchard, Jones, Tookman, & King, 2009). The prevalence of delirium in patients having orthopaedic surgery ranges from 4% to 53%, with higher rates of postoperative delirium in patients with fractured hips than in those undergoing elective surgery (Chaudhry, Devereaux, & Bhandari, 2013). It is, therefore, critical that staff in acute care settings have knowledge particular to the care of patients with behavioral symptoms associated with dementia and delirium.

 

As well as being associated with poorer outcomes such as delayed discharge, dementia and delirium in acute care settings can contribute to perplexing behaviors in patients. The acute care environment can be perceived by these patients as unfamiliar and threatening (Dewing & Dijk, 2014). Behavioral symptoms include pacing, wandering, shouting, irritability, explosiveness, and resistance to care. Many staff report significant challenges and care burdens when faced with these behaviors (Moyle, Borbasi, Wallis, Olorenshaw, & Gracia, 2010) and this can lead to low staff morale and lost time. Few staff members in acute care settings have had formal education in working with patients exhibiting behavioral symptoms of dementia and/or delerium. In turn, managers and other leaders in acute care settings find it challenging to effect improvement in the care provided to patients with dementia and delirium (Dewing & Dijk, 2014).

 

The leadership team on an orthopaedic surgery unit at one hospital site of a large, tertiary care academic teaching center recognized the need for staff education specific to dementia and delirium care. Existing care practices were, at times, not reflective of best practice expectations (Registered Nurses Association of Ontario, 2010) when staff members were responding to behaviors associated with dementia and delirium. The team implemented an innovative educational intervention as a demonstration project. It addressed the need for person-centered and respectful approaches to support and respond to persons with behaviors associated with dementia (Kitwood, 1997). Although originally designed for the long-term care sector, it was hypothesized that the educational intervention would also enhance practice standards of staff in acute care.

 

The purpose of this article is to describe how unit-based nursing leaders (a) thoroughly investigated, implemented, and evaluated a well-established, evidence-based educational intervention to prepare staff to respond effectively and with respect to persons with behaviors associated with dementia and delirium, and (b) used the evaluation data from the demonstration project to gain senior leadership support for a proposal to implement the intervention across the organization.

 

Recognizing the Need for a New Approach to Caring for Patients With Behavioral Symptoms

Agitation and disruptive behaviors were daily issues on the orthopaedic surgery unit specializing in hip fractures, and staff had reported considerable distress with these patient behaviors. In conversation, many staff did not seem to understand that these patient behaviors were linked to the disease process and sometimes interpreted the behaviors as intentional. Nursing leaders on the unit were searching for alternatives to the use of physical and chemical restraints that could be shared with staff. Restraining was one intervention used for managing challenging behaviors associated with dementia and delirium, although its use is associated with adverse physical, psychological, and social effects (Pellfolk, Gustafson, Bucht, & Karlsson, 2010). Along with the importance of staff understanding the disease processes associated with dementia and delirium, a consistent nonpharmacological and person-centered approach that would offer alternative strategies to the use of restraints was also identified as a need.

 

Recognizing that staff could benefit from learning and applying some strategies for working with patients with dementia and delirium in their practice, the nursing leadership team comprising the clinical manager and 2 clinical nurse specialists associated with the orthopaedic surgery unit investigated Gentle Persuasive Approaches in Dementia Care (GPA) (Schindel Martin, Montemuro, Dempsey, & Crane, 2005). It is a standardized curriculum that was developed for staff caring for residents in long-term care homes (LTCHs). This program was designed to prepare point-of-care staff to deliver person-centered care to persons with dementia exhibiting challenging behaviors. While the GPA program had been implemented in more than 600 long-term and complex continuing care settings across the province of Ontario by this time, there was not yet any evidence to support its application to the acute care setting.

 

Investigating GPA for Its Application in an Acute Care Setting

Origins of GPA

Schindel Martin et al (2003) used a mixed-methods randomized controlled trial design in a 60-bed LTCH in southern Ontario to evaluate the effectiveness of an adapted version of a pre-existing aggression management training program. In this study, the original curriculum was enhanced by the inclusion of content related to principles of person-centered care, challenging behaviors as symptoms of dementia-related disease processes, communication techniques specific to dementia, and de-escalation of impending catastrophic behavior without using unnecessary body containment techniques considered inappropriate for older persons.

 

Forty staff members were randomly allocated to either an experimental group that received the curriculum or to a waitlist (Schindel Martin et al., 2003). Quantitative and qualitative findings revealed that study participants gained both knowledge and confidence in the correct application of respectful body containment techniques and had strengthened verbal communication skills during a simulated episode of dementia-related behaviors using three trained actors. The educational program in this study was the first iteration of what was to become GPA.

 

The GPA Intervention in Long-Term Care

An interdisciplinary group comprising educators, clinicians, and researchers from the central south region of Ontario collaborated in the development and testing of a dementia-specific curriculum for its acceptability, feasibility, and sustainability (Schindel Martin et al., 2005). The GPA curriculum that evolved is evidence-based and uses up-to-date content from the best practice and person-centered theoretical literature. Multiple education strategies are used to meet the learning needs and styles of a variety of learners including small group interactions, reflections, practical skill development, and role-playing. These strategies are also designed to facilitate application of the content into practice. The GPA Basics curriculum is delivered in a 1-day workshop by two certified coaches who are also staff members so they can continue after the workshop to be mentors and to reinforce the GPA principles in practice. Each workshop has only 10-12 participants to allow plenty of opportunity for interaction. It is designed for interdisciplinary groups from all departments who work together in an organization (RNs, RPNs/LPNs, HCAs/CNAs, housekeeping, therapeutic recreation, security, etc.). This diverse group adds to the richness of the curriculum and highlights a key component of GPA, the importance of teamwork. The interactive nature of the workshop also facilitates this team building.

 

The educational strategies are based on Bandura's (1977,1986,1997) theory of self-efficacy. Bandura (1993) distinguished between possessing knowledge and skills, and actually being able to use them under stressful conditions. That is, staff not only need to gain skills in caring for patients with challenging behaviors, but require self-belief of efficacy to use them well. During the workshop, staff practice and review skills that have a direct and positive impact on how they support and respond to persons with behaviors associated with dementia. This is done in a nonthreatening environment with the use of positive reinforcement.

 

The GPA Basics workshop consists of four modules. The first focuses on person-centered care and finding the meaning behind the behavior, as well as the importance of reframing behavior traditionally viewed as "disruptive" or "aggressive," so it is interpreted as "self-protective" or "responsive" behavior that occurs as a result of unmet needs (Cohen-Mansfield, 2013). Persons are often attempting to exert control or to protect themselves from something that may be frightening, frustrating, or threatening (Dewing & Dijk, 2014). In Module 2, participants discuss the impact of dementia and delirium on the brain and the relationship of these changes in the brain to behavior, and the resulting care implications and strategies for care. Module 3 explores communication strategies and techniques to use when caring for persons with dementia or delirium. In Module 4, some suitable and respectful self-protective physical techniques, as well as some respectful body containment strategies that might be helpful to use when responding to episodes of responsive behavior, are demonstrated and then practiced by the participants. The importance of teamwork is also emphasized in this last module. The modules are designed to be interactive, with content being shared by coaches who use slides, video clips, demonstration, and experiential exercises. Some of the key strategies covered in the GPA curriculum are outlined in Table 1.

  
Table 1 - Click to enlarge in new windowTable 1. Gentle Persuasive Approaches (GPA): A Few Key Strategies

Evaluation of the GPA Curriculum Designed for LTC

The acceptability and effectiveness of the GPA intervention were studied in seven randomly selected LTCHs in Central South Ontario by using a mixed-methods design (Schindel Martin & Dupuis, 2005). Advanced practice clinicians and educators acted as interventionists and were specially trained to use a standardized delivery approach. Three GPA workshops were delivered to each site with a total of 205 front-line staff participating. A mixed-methods research design incorporated both quantitative measures (i.e., demographics, satisfaction with the curriculum, self-perceived competency) and qualitative approaches (i.e., focus groups and sem i-structured interviews with key informants).

 

Quantitative findings suggested that staff who received training in GPA experienced a significant increase in their self-efficacy to manage episodes of aggression associated with dementia (p < .001) (Schindel Martin & Dupuis, 2005). Qualitative findings that emerged from interviews with the key informants included three themes: (1) building knowledge, confidence, and skill; (2) building relationships and teams; and (3) reinforcing commitment to an organizational vision of care (Schindel Martin & Dupuis, 2005).

 

A third party evaluation of the GPA program was conducted in a 108-bed inpatient program providing tertiary treatment for older adults with cognitive impairment, late onset psychiatric illness, and chronic psychiatric disorders (Speziale, Black, Coatsworth-Puspoky, Ross, & O'Regan, 2009). Ninety-nine staff participants attended a GPA workshop during a 3-month implementation period. The interdisciplinary sessions included representatives from nutrition services, housekeeping, social work, nursing, therapeutic recreation, administration, and clerical staff. A before-and-after intervention design was used to evaluate staff satisfaction, aggression frequency, and staff and patient injury rates. Incidents of aggressive behavior declined by 50% 3 months after the GPA training. Staff were very satisfied with all aspects of the program.

 

Implementing GPA on an Acute Care Unit

Preparing to Introduce GPA

The nursing leadership team on the 32-bed orthopaedic surgery unit, comprising primarily patients with a fractured hip, had attended local presentations about GPA. In 2008, they met with the GPA Project Steering Committee, which included members of the original GPA curriculum design and evaluation teams, to review the curriculum and determine its fit for acute care. In attendance were two clinical nurse specialist colleagues from a complex continuing care hospital that was in the process of merging with the tertiary care center where the orthopaedic surgery unit was located. This collaboration provided a unique opportunity to learn from a sector where GPA had been embedded for many years.

 

After attending a GPA workshop, the unit leadership team agreed that the curriculum in its current form (i.e., as designed for LTC) had the potential to help staff in acute care environments to gain the knowledge and skills required to become more competent in caring for patients on their unit if some additional content on delirium and restraint use was included. The clinical manager paid the registration fee for the clinical nurse specialists associated with the unit to attend the standardized 2-day GPA Coach Training workshop to become certified GPA coaches. The clinical nurse specialists' program director covered their salaries for the 2 days, and their nursing chief was in full support of their involvement.

 

Conducting the GPA Workshops

In January through March 2009, six 1-day GPA workshops were attended by more than 80% of the 90 staff on the unit, including registered nurses, registered practical nurses, healthcare aides, occupational therapists, physiotherapists, occupational and physiotherapy assistants, pharmacists, registered dieticians, social workers, speech-language pathologists, business clerks, and security personnel. All participated in the four modules described earlier with some additional content on delirium and issues related to the use of restraints. Each received a GPA manual, certificate of attendance, and GPA lapel pin.

 

Staff members were scheduled by the clinical manager to attend the workshop and were paid for their day. The manager also participated in many of the sessions to reinforce her vision of providing evidence-based dementia care and to show support. Following the workshop, the GPA coaches and manager mentored and reinforced new practices on the unit daily. These gestures on the part of the clinical manager are aligned with the supportive behaviors reported in the literature. Schmalenberg and Kramer (2009) identified 10 universal role behaviors of nurse managers that were considered by staff to be essential and supportive including (a) making it possible to attend continuing education to support clinical competence, (b) living the values of the organization with respect to patient care, and (c) fostering sound decision-making by challenging staff to explain how their practice is based in evidence.

 

Measuring Self-Efficacy and Satisfaction

Perceived self-efficacy was evaluated immediately before and after the workshop using a 10-item, 7-point Likert-type survey, the Self-perceived Behavioural Management Self-Efficacy Profile, which was designed to measure participants' self-reported perception of competence in the application of the core competencies of behavioral management embedded in the GPA curriculum (Schindel Martin & Dupuis, 2005). The total sample included 72 participants who attended the workshop. Of this sample, 52 participants completed both the pre- and post-survey. The results for each of 10 competencies reported in Table 2 show a statistically significant enhancement in confidence scores immediately after the workshop as a result of participation in the GPA program.

  
Table 2 - Click to enlarge in new windowTable 2. Mean Scores on Self-perceived Behavior Management Self-Efficacy Profile

Participants indicated a high level of satisfaction with the length of the workshop, the group size, materials provided, instructors, and teaching methods when surveyed immediately following the workshop. Ninety-three per cent of respondents rated the workshop overall at a 6 or 7, with 7 being the highest score (mean = 6.38; SD = 0.60). Of particular significance was how highly the participants rated the item, "practical application in the workplace" with 93% rating that item at a 6 or 7 (mean = 6.52; SD = 0.59). The vast majority of participants said that they would recommend this program to coworkers.

 

While a few written comments reflected concerns about the length of the program and some repetition of content, most were positive and included feedback about (a) the applicability of the program to their setting (e.g., "...very applicable for healthcare workers as sometimes we forget it's the disease not the patient causing these behaviors"; "Very appropriate for our patient population-all things discussed have happened"), (b) the teaching-learning approach (e.g., "It is not just a 'sit-in and listen'-I liked being active in each topic/conversation and all the other staff participating"; "It's great to have everyone on the ward know about it and cooperate together"), (c) the content (e.g., "Very helpful and applicable content"; "Learned a lot of persuasive techniques to keep patients happy and calm"), and (d) what they will do with the new knowledge (e.g., "I will stop and think about my approach and treat the patients accordingly...awesome workshop!"; "I will find out more personal information and involve families").

 

Overcoming Implementation Challenges

Aware that the GPA curriculum was designed for LTC staff, participants challenged some of the content as not being applicable because of the faster pace, higher patient acuity, and more invasive procedures in the acute care environment. In response, the education team developed examples and success stories that illustrated application in the hospital setting. The prevalence of dementia in the acute care population was highlighted to emphasize the need for supporting and responding effectively to persons with behaviors as a basic skill set for all staff. Delirium, which is very prevalent in hospitals, was more fully addressed in the workshop with the application of GPA principles to real cases of patients with delirium. The time that might be required to respond with a person-centered approach was another common concern expressed by the participants. Coaches encouraged participants to consider the time required when behaviors escalate to the point of being self-protective. They discussed what would be involved for staff and how time-consuming it is to call a Code White (violent situation) as it involves additional charting and completing a safety occurrence report.

 

Staff expressed concerns about the impact on falls rates if restraints were not used. To respond to these concerns, the negative effects of restraints were emphasized along with myths related to restraints preventing falls. Using acute care analogies also helped to bridge understanding. For example, participants pointed out that GPA "didn't always work, sometimes patients still escalate." To assist staff to reframe those situations where the use of GPA interventions did not result in a successful outcome, a comparison was made to other types of situations where success rates are low. For example, cardiopulmonary resuscitation is not always successful, yet CPR is an intervention that is consistently attempted when indicated. This comparison resonated with many staff.

 

Listening to Staff Perceptions Following the Workshops

The nursing leadership team checked in with staff in the weeks following the workshops. At their own weekly meetings they shared what they had informally heard and observed. They observed patients with responsive behaviors being admitted to rooms close to the nursing station so they would benefit from being more closely observed and therefore their needs met more easily. They also overheard nurses asking each other about their successes. In a review of qualitative research into successful implementation of psychosocial interventions in dementia care, Lawrence, Fossey, Ballard, Moniz-Cook, and Murray (2012) noted the benefits of staff being able to discuss practical issues associated with the application of interventions in their daily work.

 

The leadership team was told by staff that GPA strategies such as validating feelings, and using distraction and redirection, were effective in preventing and de-escalating the behaviors of patients with delirium, as well as with dementia. Addressing delirium in the workshop seemed to help staff become more sensitive to symptoms of delirium in their patients. Landreville et al. (2013) suggested that because delirium is highly associated with behavioral symptoms of dementia, clinicians should consider the presence of those symptoms as a possible delirium superimposed on dementia.

 

There was a perception among staff that Code Whites were being called less frequently. When the manager investigated this, there had been one call in the year following the introduction of GPA as compared with 11 calls the previous year. Staff also reported that they relied less frequently on Pinel Restraints, a type of restraining system using a combination of waist, limb, or pelvic restraints that are opened with a magnetic key. Unit leaders had been advocating for a restraint-free environment, and being able to offer GPA strategies as alternatives to restraints may have led to this perceived reduction in the use of restraints. Although anecdotal reports of a reduction in Code White alerts and restraint use were encouraging, formal measurements did not take place.

 

Influencing the Spread of GPA Across the Organization

The team members involved in this demonstration project found opportunities to raise awareness among organizational leaders and managers in an effort to gain support for broader implementation of GPA. Following the success on the orthopaedic surgery unit, word about GPA was spread by the unit leadership team. Soon, clinical managers from a medical unit and three rehabilitation units at the same hospital, impressed with the results on the orthopaedic unit, supported some of their staff to become GPA coaches and subsequently to conduct workshops on their own units. These early adopters of GPA in the acute care setting formed an informal network to support one another. Their passion and belief in the principles of GPA contributed to its sustainability on their units and they advocated for the spread of GPA throughout the facility. The findings were also disseminated at the hospital's internal patient safety symposium, as well as through posters at provincial and national healthcare conferences.

 

An opportunity arose for the team to submit a formal application to the hospital's Centre for Healthcare Optimization Research and Delivery (CHORD) that funds evidence-based projects focusing on knowledge translation to improve care. The project findings were presented to senior leaders in an effort to gain their support for the CHORD application. Several members of the senior executive team were required to add their signatures to the proposal for hospital-wide implementation, and thus their commitment to the proposal was established. The one group before-and-after design used in the demonstration project was a limitation, so this proposal included a comparison group and follow-up with participants to determine whether self-efficacy was sustained over time. The application was successful and the GPA in Acute Care initiative was launched in 2010. Finally, a chief of nursing practice who had provided her expertise to the CHORD proposal became a dedicated corporate champion, and embedded the execution of the GPA intervention into her portfolio.

 

Coincident with the introduction of GPA, standardized orthopaedic order sets were revised to limit the use of anticholinergic and benzodiazepine medications in an effort to reduce the incidence of delirium in patients who have had hip surgery. More than ever, staff needed to rely on nonpharmacologic approaches such as GPA interventions to address the behaviors associated with dementia and delirium, and this helped influence senior leaders in the organization. This demonstration project led to revisions to the GPA curriculum itself. The revised curriculum incorporated principles of delirium assessment and care, as well as restraint-reduction strategies. These additional principles were applicable not only in the acute care sector but also in long-term care and complex continuing care settings where GPA was first introduced.

 

Conclusion

This project was the first to introduce GPA into an acute care setting. The curriculum was designed originally for staff working with residents with dementia in long-term care. It was shown to be applicable for staff on an orthopaedic surgery unit caring not only for patients with dementia, but delirium as well. The findings of the demonstration project were very encouraging and indicated that GPA would indeed be an acceptable and feasible educational intervention to implement further throughout the organization. Staff confidence in their ability to support and respond to persons with behaviors associated with dementia increased after attending a GPA workshop, and they reported that they were extremely satisfied with the curriculum, found it to be applicable to their practice, indicated it was also useful for patients with delirium, and would recommend it to others. Further research with strong support from senior leadership is underway to determine the impact of introducing GPA to other types of acute care settings such as Medical and Intensive Care Units, and the Emergency Department.

 

Acknowledgment

The authors thank Jenny Ploeg, RN, PhD, for her thoughtful review of the manuscript.

 

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