Implementing PAC in a Dementia Specific Area of a Residential Care Facility in Australia
by Rejane Le Grange, Occupational Therapist,
Sandy Crowe, Registered Nurse,
Theresa Smith, Registered Nurse, and
Emily Bennison, Occupational Therapist
I work for a not-for-profit organization in Western Australia that runs aged care residential facilities and home care services. We pride ourselves in providing support, care, and accommodation for a full life. I head up the organization’s Dementia Services Team, DST. This small group of professionals is dedicated to ensuring that people living with dementia are provided with the best possible care by their care services.
In 2019, the DST conducted a research study to see if training staff to apply Teepa Snow’s Positive Approach® to Care in their everyday care made any difference to the well-being of the people living with dementia and/or to the care partners.
Often, knowledge about dementia and care plan guidelines are not enough to commit staff to the best approach when providing care. The assessments conducted prior to our training program showed that staff scored an average of 82% on their knowledge about dementia. In spite of good dementia literacy and DST guidance, incidents of resident resistance continued to occur.
The staff was not able to identify the difference between the suggestions made by the DST in the care plans and how they were noted to actually implement care. Years of caring experience in aged care coupled with confidence in executing tasks such as showering appears to impede on one’s ability to recognize the need for change. Care partners resort to their automatic care habits and do not have insight into how their approach impacts on the person for whom they are meant to be a care partner.
Our goal was to empower staff to better identify why their approach might create resident agitation (or fear) and help them to implement appropriate approaches until these became automatic.
Positive Approach® to Care (PAC) addresses staff development in a positive manner by not only providing training and coaching, but also practicing behavior techniques aimed at instilling automatic positive caregiving responses. PAC’s tailor-made strategies were used to guide the staff of 12 coaching in two dementia-specific care houses consisting of 25 residents. An education program was implemented over a period of two months from October to December 2019. Currently when staff support is needed, coaching is still ongoing.
The project included pre and post assessments and evaluations that considered resident and staff well-being; the prevalence of complex behaviors; residents’ level of care dependency; staff knowledge of dementia and dementia care strategies; and the reporting of incidences where residents express agitation towards care partners.
Pre and post assessment outcomes were then compared to identify if PAC training made a difference in the measurement of the above-mentioned tools and therefore to the residents’ quality of care and well-being.
Summary of Results
- Staff’s average knowledge of dementia was already high at 82% before the training. Their dementia knowledge post training was 90%.
- 71% of staff identified the training package as very helpful (score 8-10 out of a maximum score of 10). Staff indicated appreciation and anecdotally reported improved skills level and on the job support. Upon completion of the course, one care partner said: “I used to feel I was a care partner who looked after people with dementia but now I feel I’m a skilled dementia care partner.”
- Since the training, there has been a 37% decline in incidents from an average of 3.3 (Feb 19 – Oct 19) to an average of 1.5 (Nov 19 – 24 April 20). Incident reporting about resident agitation towards staff dropped to zero directly after the training and then increased sharply during the last month of the training/coaching.
- The training clarified where actions were provocative and staff needed support. Post training incidents were mainly triggered by episodes of incontinence. Reported incidents at the meal table were reduced to zero. The incidences that occurred post training clearly identified the staff who needed more support and what support was required.
- The Cohen Mansfield Agitation Scale Assessment (CMASA) is a commonly used standardized assessment of unmet needs. The pre and post assessments were done by a specific DST member and the Clinical Nurse. The same assessors were used to ensure the validity of the assessment. Two months passed between the assessments. The range of questions and the assessment of the 25 residents without review of the pre assessments further validate the reliability of the assessment as a measure of change. The overall results of the CMASA (short version) shows a 5% overall average reduction in agitated behavior from the level of behavior pre training. Positive changes were noted in less verbal aggression, grabbing and destroying, constant requests for attention, repetitive vocalization, complaints, negativity and screaming. An average increase of an 8% change was noted in restlessness and a 18% change in inappropriate dressing. The table below shows the % difference in individual resident’s total agitation scores.
- Dementia care mapping (DCM) observation tool identified that contrary to before training no personhood deterrent (a term to explain social situations with the potential to trigger agitation) were observed post training.
- The care dependency scale (CDS) indicated that the same residents were more dependent on care. Exceptions were noted in terms of social engagement, involvement in daily activities and recreation where they were perceived to be more independent.
- It is difficult to estimate the cost of intervention against the potential cost of no intervention. The pre/post results indicate that there is a measurable change in staff care practice.
- The cost of training 12 staff over 8 weeks was approximately AU$3,300.00 – Staff hourly rates for attending training and the coaching sessions.
- Two current open workers compensation claims for staff injury inflicted by residents are expected to total approximately AU$195,000. The calculation of the cost in human trauma and overtime for the HR department staff is not available. The cost of preventative training across the whole organization is only 26% of the cost of the current pending workers compensation. This does not take into consideration the financial advantage to the organization’s brand and delivering services that moves us closer to our vision, purpose, and values.
Focus on coaching staff how to use Positive Physical Approach (PPA) to connect with people living with dementia (PLwD).
It is recommended that financial and other KPI’s be established to support the strategic rollout of this program across all our organization’s residential aged care facilities. One such KPI will be the outcomes of accreditation visits.
Use pre and post assessments and other KPIs to evaluate outcomes and keep the program on track and accountable.
Develop Policies and Procedures based on PAC methods that support the prevention of resident agitation.
Our organization supports the training of more PAC Trainers and Coaches to promote the PAC approach in Australia and empower staff to resolve issues using local expertise.
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Rejane Le Grange is an Occupational Therapist who has worked in aged care in Australia for approximately 22 years. She currently manages a small multi-disciplinary team of dementia consultants. They provide support to residential, mental health, and community services in our organization. Earlier in her career she managed residential aged care services.
Co-authors: Sandy Crowe is a General Registered Nurse with many years of experience in dementia and management, Theresa Smith is a General Registered Nurse, Nurse Specialist, and Consultant in mental health, and Emily Bennison is an Occupational Therapist with PAC experience from when she worked in the United Kingdom before returning to Australia.