Communication in patients with dementia is often impaired. Today, six million Americans live with some form of dementia (US Department of Health and Human Services, 2016), and the older adult population is expected to expand, from 43.1 million in 2012 to 83.7 million by 2050 (Ortman, Velkoff, & Hogan, 2014). Thus, there is a need for nurses to improve communication skills with patients who are cognitively impaired. This article reports on an educational innovation designed to provide nursing students with an intergenerational educational experience to develop communication skills with a diverse population of older adults with cognitive issues.
BACKGROUND
Increased diversity in the older adult population supports the need for person-centered, culturally based care (Savundranayagam, Sibaliia, & Scotchmer, 2016; Testad et al., 2016). Nursing students can be instrumental in providing person-centered care to older adults but may face difficulties in understanding patients with cognitive issues. Impairments in word finding, language skills, and memory in patients with dementia create obstacles for effective communication and understanding patient needs. Learning experiences that support the development of person-centered communication skills in dementia care are warranted.
Music programs have been shown to improve outcomes in patients with dementia with decreases in agitation and reductions in the use of antipsychotics in the long-term care setting. Evidence points to the positive effects of personalized music in patients with dementia. Studies show that, in persons with mild to moderate dementia, music can evoke memories and may enhance social communication and behavior and decrease untoward behaviors such as agitation (Cuddy, Sikka, & Vanstone, 2015; Long, 2016; Ridder, Stige, Qvale, & Gold, 2013; Thomas et al., 2017).
According to the Music and MemorySM organization (https://musicandmemory.org), personalized music playlists should be a standard of care in long-term care facilities. The Music and Memory organization helps establish and support programs in long-term care facilities and offers certification for participating institutions.
This original educational innovation was developed by the authors and involved 110 baccalaureate nursing students, over a one-year period, who created personalized music playlists for assigned patients with dementia residing in certified long-term care facilities. The facilities were certified in Music and Memory as part of an initiative from the Texas Department of Aging and Disability Services to reduce antipsychotic use in patients with dementia.
The primary aim of the innovation was to provide learning opportunities with cognitively impaired patients who required modified communication skills to effectively interpret their preferences. An additional aim was to demonstrate the use of alternative nursing interventions in a vulnerable, diverse, older adult population that students can use in the practice setting after licensure. This project obtained institutional review board approval, and students submitted weekly journals on a voluntary basis.
PROCEDURE
Each student was assigned an individual patient and received community-based service-learning hours for participation. (The protocol developed by the authors and utilized in implementing the programs is available as Supplemental Digital Content 1 at http://links.lww.com/NEP/A79.) Students were asked to submit a reflective journal each week. Journaling allows students to identify and explore feelings and behaviors and connect theoretical knowledge about interventions learned in the classroom with lived experiences and observations in the clinical setting. Reflective journaling has been used throughout nursing education to evaluate students' critical thinking and clinical reasoning (Van Horn & Freed, 2008). The prompts for journaling in this project were as follows: "How did your patient respond to the music?" "How did you select the music?" and "What are your feelings about today's encounter?" Students were also encouraged to share other reflections not related to the prompts.
Patient ages ranged from 65 to 92 years. Ethnicities represented were Asian, Black or African American, Hispanic, and White. The Brief Inventory of Mental Status of participating patients revealed scores from 3 to 10, indicating moderate to end-stage dementia.
As most patients could not verbally communicate their music choices, students used a variety of approaches to assess their musical tastes and develop individualized playlists that were meaningful to the patient. Their journals reflected various approaches to determine appropriate personalized music. Students used cell phones, computers, and tablets to pull up music videos and watch for a response. In addition, they used splitters to simultaneously listen to music with the patient and watch for a response to the music. When a positive response was noted, they downloaded the music onto personal iPod shuffles, which were available in the certified facilities. Positive communicative reactions included responses such as head shaking, finger tapping, and decreased agitation. When family and significant others were present, students consulted with them to gather data. Students met with their patients weekly for a minimum of eight weeks. Their reflective journal entries after each visit detailed their feelings about the interaction, experiences, observations, and patient reactions.
JOURNAL SUMMARIES
A review of the journal entries written by the nursing students revealed many positive outcomes for patients and students. Students' use of communication skills while interacting with cognitively impaired patients was evident. The journal entries told of patients having a physical response to the music and improved communication. The students observed physical responses such as smiling, grinning, laughing, hand tapping, toe-tapping, dancing, humming, and singing. Students often reported that, during or after music sessions, the patients would become more talkative and reminisce about past experiences with friends, family members, work, or other activities. Patients who had previously not had meaningful conversations told of the names of family members, childhood activities, their work environments, and important events from the past.
There was an overwhelmingly positive response from students. Although the students reported challenges to interacting with patients and difficulties in developing the personalized music playlist, many reported that they "enjoyed their time together" or that they "felt proud" to participate. One student wrote, "This has been an exceptional experience and I'm very fortunate to have taken part in this opportunity. Thank you for letting me be a part of it."
CONCLUSION
It is anticipated that the knowledge gained from this unique experience will transfer with students into practice settings after licensure. As older adults are a part of almost all nursing practice settings, the knowledge gained from this analysis can be generalized into any type of nursing practice.
Participation in the music and program gave students an enriching learning experience with a vulnerable population. The program provided students the opportunity to help individuals suffering from dementia recollect memories and engage in social interaction. Themes extracted from the data can guide both educational and direct practice approaches used with older adult patients in long-term care and other health care settings.
REFERENCES