Staff in newer facilities and those who feel they are well trained have a more person-centred attitude to care than staff in older facilities where the medical model rules (Zimmerman et al., 2005). Once, long-term care was based in institutional procedures, creating staff anxiety around accountability. Today, there is a move towards facilities as a ‘place for living, with good medical and nursing care supporting rather than dominating daily life’ (Brawley, 2006).
Changes you can make now
- Have regular staff meetings where staff at all levels can talk about issues, swap information and ideas, and support each other in specific problem-solving.
- Start an induction program on dementia-friendly care for new staff. Include ongoing mentoring for staff in facilities going through culture change.
- Put flowers in staff areas to brighten up the facility and create positive feelings among staff.
- Talk with staff about what changes might be made to improve their work conditions and experiences. Ask them what type of environment and resources they think they need to deliver appropriate care.
- Change a space in a facility to create a staff retreat or time-out area where staff can relax, read books or reports over a cup of tea or use a computer.
- Organise a regular in-service training program to update staff skills and knowledge. Include training and information about communication with family members and friends, cultural issues affecting food preparation or personal care practice, the importance of understanding people’s rich life stories, and the role of attitudinal and organisational change in creating person-centred care.
- Arrange the same staffing to keep relationships of trust and familiarity between staff, people with dementia and families.
- Have incentives for all staff to improve the quality of their work. Hold an afternoon tea to acknowledge new work practices supporting dementia-friendly principles. Run special training for innovative staff and celebrate with people with dementia and family members to recognise staff service and understanding of people’s needs.
- Start an equipment replacement plan with input from all staff, including kitchen, cleaning, gardening, care and nursing staff.
- Change a facility to increase staff efficiency. Redesign for easier access to regularly used equipment, to support people’s independence, and to help observation.
Staff and person-centred care
Person-centred care has many benefits for staff when suitable structures and attitudes are in place. Staff can build more rewarding relationships with people with dementia and share a less stressful and more home-like environment. They have greater task variety, are more creative and feel more capable.
Person-centred care is quality care for older people. Its key features are:
- a shift away from care for and protecting the body to helping people gain personal satisfaction in their lives
- creating individualised living spaces
- allowing staff to be advocates
- each person’s personal growth and sense of contribution
- ongoing links with the wider community.
Home-like environment checklist
To create a dementia-friendly environment, staff need to be treated in a person-centred fashion, and supported to think creatively in resolving issues. For care to meet individual needs and wishes, staff should help plan and design dementia-friendly environments. Staff must be taken seriously as full participants in the workplace and their insights valued. Staff are the key to dementia-friendly care.
All staff need:
- supervision to support their work
- emotional support to deal with work stresses, such as the decline and death of people they have become close to
- basic training in dementia care
- staff development
- chances to join in decision making
- chances to make policies on the basis of their knowledge.
Practical issues arise for staff when trying to balance the need for care and safety (staff members’ duty of care) with care centred on the person rather than institutional procedures. Training, supervision and insights of staff can help with balanced care.
Duty of care vs person-centred care action tool
Culture change needs care in a home-like environment, rather than an institution based on procedures and routines. Old style top-down structures are not flexible approaches to care and decision making, and often undervalue staff members’ knowledge and skills. Creating a flatter organisational structure of authority and responsibility lets direct care staff better meet people’s needs. A more creative organisational structure promotes interesting and meaningful work.
Culture change in facilities means ‘moving from an old style nursing home model, characterised as a system that is unintentionally designed to foster dependence … to a regenerative model’ (Brawley, 2006). Dementia-friendly care needs change of organisational and individual attitudes.
Organisational change is complicated. It takes time and awareness by management and staff to set up new practices and change people’s outlooks.
First change attitudes about the medical model of care and encourage a social model, with support from all levels of the organisation along the way. Change policies, procedures and investment in staff development. Create an environment where staff members are willing to raise issues and receive guidance and supervision. Involving staff in forming new policies helps change the social environment.
Key points for organisational change
- The organisation must be committed to the long-term and make changes gradually.
- Simple changes having positive results for people with dementia are easier to make than complicated changes with less visible results.
- Staff training may reduce job strain, increase job satisfaction and reduce staff turnover.
- Redistribute authority and responsibility to empower staff and inspire creativity. Staff must have the confidence through skills and knowledge to make decisions promoting care.
- Staff can find it hard to start a new approach without a coach or supervisor to help them. They may need coaching or supervision and managerial support to put new ideas into practice.
- Staff find it hard to start a new approach when managers do not accept change or do not encourage it, so change has to move on different fronts at the same time.
- Frontline supervisors trained in coaching and mentoring are most effective when they guide staff in reflective dialogue.
Staff development reviews, keeps up and builds new workforce skills. It includes formal and informal learning in an organisation, ongoing in-house education and external study.
Skills and knowledge gained through education and training need to be used in the workplace. In-service sessions can increase knowledge but may not promote change. Ability to sustain change over time rests largely on mentoring and supervision. Knowledge and skills obtained through education and training must be supported by the organisation through supervision.
Staff development programs can have major effects on quality of care. One program offered practical learning at in-service sessions and started on-the-job coaching, set homework and offered tools and skills for mentors, who supported staff on the job (Boettcher et al., 2004).
Staff development needs to look at philosophy of care, creative problem-solving, actual behaviours, problems related to job satisfaction, issues for families and friends, organisational structures and schedules, and staff willingness to speak up and join in.
Good staff development is:
- available as needed
- available to all staff
- preferably in-house
- includes on-the-job induction and ongoing supervision.
Staff development checklist
Physical environment for staff wellbeing
The physical environment affects staff attitudes and approach to care. Making a facility a home-like environment is good for people with dementia, and gives staff a better workplace. Personalise people’s bedrooms, create comfortable lounge rooms in pleasant colours and appealing materials, and replace hospital-like corridors with a home-like space, and older institutional attitudes are harder to hold on to.
Thoughtful physical design benefits staff in work practices, workloads and safety. Good bathroom design can ease staff stress, including placement of doors, choice of showers and taps, and assistive technology. Garden design can give staff options, for example, quiet barrier-free spaces are stress-free for people with dementia and need little supervision. Wayfinding cues and refreshing gardens offer pleasant work conditions and options for activities. Physical design for safe independent activity and home-like comfort for people with dementia supports staff.
Bathrooms and bathing
Gardens and outdoor spaces
Changes to the physical environment focusing on staff relaxation and educational options are needed. Staff need a quiet time-out area. They need a place to sit, look at documents and computers, chat casually with other staff members, and for personal storage space.
New residential facilities
Staff support through physical design
New technologies for quality care and staff support
New technologies are accepted in most organisations as vital to everyday work. Care facilities have been slower to use technology, often seeing it as expensive or needing additional staff training. Some fear new ways of doing things.
Much technology can be cost effective, enabling staff to work more efficiently. New technologies include IT solutions on staffing and scheduling of shifts, wireless laptops, nurse call systems, infra-red security systems and safety devices in kitchens.
To find cost-effective ways for supporting staff and giving more flexible care, ask:
- What technologies do we currently use?
- Where might care be aided by new technologies?
- What technologies would be useful to have now?
- What physical redesign would they need?
- What changes in organisational structures or culture would they need?
- What technologies might be used in a new facility?
No-lift policies in workplaces may have lowered injury rates but facilities can be dangerous workplaces.
- Workplace injuries, like musculoskeletal back injuries, are a risk in facilities.
- Over two per cent of nurses have chronic back pain and 12 per cent leave the workforce every year due to injury.
- Nursing and care staff often lack training that could reduce work-related ‘resistance to care’ hazards and injuries and improve quality of care.
WorkSafe Victoria has a guide for designing safe workplaces in health, aged care, rehabilitation and disability facilities.
A staff member’s story
I read about a program in a journal I found in the staff room. It was about life enrichment for people who were, well, not functioning at all. It was so simple I thought, why not? I’ll give it a go.
We had three or four people with dementia I thought about when I was reading it. I couldn’t remember the last time I saw them up and about, or anyone spending time with them other than during personal care. I talked to the DON and told her all about it. She said I could try it as long as I documented what I was doing and what, if any, outcomes there were for people. I thought that was pretty good. Most of the people I work with thought I was crazy - ‘just wasting my time’, they said.
The thing was we had lots of information about these people - what their jobs used to be, hobbies, interests, family members, all sorts of things. So I started going in every morning for just a few minutes and talking to them … just talking, about the things in their life story. For three or four weeks - I can’t remember how long exactly - I went into their rooms when I had a spare few minutes. Like I said, I got hassled by other staff. You know - ‘like we don’t have enough to do without you wasting time’, ‘chatting away like an idiot to people who couldn’t possibly talk to you or even understand you’. But I wanted to try.
I talked to Mrs C about her kids and grandkids, and her collection of teapots with flowers; oh how she liked flowers! With Mrs D. it was about her crafts, she had a couple of beautiful quilts in her room that her daughter told me she had made years ago. After about my third visit, Mrs D. started to tell me about each square in the quilt on the bed. Each one had a special meaning and memory for her. Of course, she was telling me the same thing about the different squares sometimes, but every once in a while she would tell me a new story for a different square.
Mr B loved boxing. I hate it, but I noticed a fight on the TV one night at home and I listened to what the announcers were saying. The next day I went in and told Mr B. all about it. Even other staff who heard me thought I was a boxing fan! Mr B. turned his head and looked at me and I touched his hand and he smiled that day. Wow, I couldn’t believe it!
Not much else happened, but I kept it up. I got to be quite knowledgeable about boxing. I got a book out of the library about the greats of boxing and started reading to Mr B. a couple of times a week. As I said, nothing much else happened as far as outcomes, except, well, it was funny really. I started to notice other staff were talking to people too. I noticed Mr B. was dressed and in a wheelchair at the window instead of in bed most days. And staff would make sure Mrs C was in the atrium or the garden with her family when they came to visit. She was even having tea, made in one of her favourite teapots. And then Mr B’s family brought in a beautiful coffee table book about boxing and started reading to him. I noticed other staff would take a few minutes once in a while and read from the book to Mr B. too.
We all got to know each other a little better over time - people with dementia, their families and staff - and we all seemed happier too, if that makes sense. We didn’t have any more time in the day, we just used it differently, I guess. I didn’t give it much thought until a few months later when I was so surprised to get a ‘Quality Improvement Award for Innovative Practice’ - me! They had a morning tea for me and the staff. Residents and families were there too, to see me get my award. It was amazing. They said such nice things: that I had been, let me get this right, ‘active in helping change practice and having a major impact on people’s quality of life’. Me! You know what the best thing was - my tea that day came out of one of Mrs C’s teapots!
Case study - Lyndoch Nursing Home
At Lyndoch Nursing Home, Warrnambool, staff receive specific education about dementia. They attend workshops on the sexuality of people with dementia, supported by procedures, posters for staff areas and brochures for families on sexuality.
Trained in dementia care, staff map how satisfied people are with their lives. Mapping finds causes of negative or positive responses in people. Care plans are changed to get rid of negative triggers or experiences and include activities for positive experiences.
Issues to consider
- Low staff satisfaction
- Staff excluded from decision making
- Lack of organisational, professional and emotional support
- Little acceptance of the importance of staff relationships with people with dementia
- Supporting all staff in dementia friendly care
- Caring for people with unmet need
- Delivering person-centred care in task-oriented organisations
- Workplace injury
Research says ...
- How all staff feel their work is valued impacts on quality of care.
- Staff satisfaction is affected by personal job satisfaction, workload, team spirit, relationships with co-workers, training and professional support.
- Physical assaults on staff are linked to high workloads, being left out of decision making, poor access to educational programs and inadequate training.
- Job applicants’ values, attitudes and warmth of feeling are often better signs of likely work performance than experience or qualifications.
- Basic training in dementia care and further staff development produce positive staff experiences.
- Person-centered care is more likely where staff communication and connection with people with dementia are treated as core work.
- Staff satisfaction is greater when all staff have a sense of ownership of the workplace.
- Professional supervision is important for staff support.