Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Dementia-Friendly Care Homes
Best practices in dementia care
March 2020
Report prepared by
Kishore Seetharaman and Habib Chaudhury
Department of Gerontology, Simon Fraser University
Developed in consultation with:
Michael Kary, B.C. Care Providers Association
Barbara Lindsay, Alzheimer Society of B.C.
Jennifer Stewart, Alzheimer Society of B.C.
Mariana Hudson, Alzheimer Society of B.C.
HTML code: #00A6DA
RGB code: R:0 G:166 B:218
HSV: 194.31° 100% 85.49%
Contents
Executive Summary............................................................................................... 3
Introduction........................................................................................................... 6
Methods................................................................................................................. 9
Findings on Staffing, Education and Training................................................... 11
1.1. Education & Training........................................................................................ 11
1.2. Staffing & Care Practices.................................................................................. 17
Findings on Physical Environment..................................................................... 22
2.1. Domestic scale................................................................................................... 22
2.2. Orientation and wayfinding............................................................................ 23
2.3. Privacy and visual accessibility......................................................................... 25
2.4. Physical accessibility, safety, and comfort........................................................ 27
2.5. Appropriate sensory stimulation and minimizing perceptual distortion...... 28
2.6. Familiarity and homelikeness........................................................................... 30
Community Consultation................................................................................... 31
3.1. Staffing, Education, and Training.................................................................... 32
3.2. Physical Environment........................................................................................ 37
Conclusion........................................................................................................... 41
References........................................................................................................... 43
Appendix A: Infographic Handout.................................................................... 50
Appendix B: Agenda of Community Forum...................................................... 54
Executive Summary An estimated 64% of residents in and (ii) education, training, staffing, and British Columbia’s (B.C.) long-term care practices. The project was conducted care (LTC) homes live with dementia in partnership with the Department of (Seniors Advocate of British Columbia, Gerontology at Simon Fraser University 2018), which indicates the importance and the Alzheimer Society of BC of responsive staff care practices for (Alzheimer Society) and in collaboration optimizing the quality of life (QOL) of with other stakeholders. The synthesized residents living with dementia, as part set of guidelines sets the stage to explore, of any policy and program to improve among various possibilities, the benefits care in LTC. To address this issue, BC Care and pitfalls of developing a designation Providers’ Association (BCCPA) initiated a program for Dementia Friendly Care project with the aim to identify the best Homes in British Columbia. The guidelines practices for people living with dementia identified in this project would be of living in care homes in two key areas: benefit to BCCPA members and other (i) physical environment of the setting, care providers in inspiring and informing Dementia-Friendly Care Homes 3
initiatives to create a more dementia (iv) PCC training should be customized to
friendly care home in terms of the quality different staff roles and tailored to
of care interactions and the physical the issues and challenges they face.
environment. (v) training should incorporate issues
Forty grey literature sources (e.g., reports of family involvement and cultural
based on guidelines from health ministries, competence.
regional health authorities, regulatory (vi) sufficient time and resources must
agencies, care provider organizations, be provided to staff to translate
advocacy organizations, and research training into practice, e.g., PCC
groups) were reviewed to examine facilitator to provide ongoing and
relevant policies and programs in Canada, follow-up training.
USA, UK, and Australia. The review of
(vii) monitoring and performance
the grey literature was followed by
evaluations should be conducted to
community consultation at a forum with
ensure the practice of PCC values.
stakeholders from care homes, regional
health authorities (RHAs) across British • In the area of Staffing and Care Practices,
Columbia, and the B.C. Ministry of Health, the literature suggests that:
and people living with dementia and (i) higher staff-to-resident ratios
caregivers. Findings from the literature should be in place.
synthesis were presented to the attendees
(ii) multiskilled workers should
of the forum, which informed discussions
be hired.
to identify initiatives for implementation
(iii) care aides are part of the team
in the short term, areas that need to be
and should be included in
prioritized for support from RHAs or the
decision-making.
Ministry of Health, and resources in B.C. that
are necessary for the proposed initiatives. (iv) care aide assignments should
reflect the importance of building
Findings and Recommendations strong relationships with residents.
• In the area of Education and Training, (v) open communication should be
the literature suggests that: employed to facilitate information
sharing between staff.
(i) all staff groups should have a
comprehensive understanding of For the Physical Environment in care
the meaning of person-centred homes, the literature suggests the
care (PCC). following criteria:
(ii) family members should receive • familiarity and homelikeness:
PCC education. (i) care homes should have small
(iii) PCC training programs should be households with separate dining
evidence-based. and activity spaces.
4 Dementia-Friendly Care Homes
(ii) décor and furnishings must reflect (iv) signs with clear visual and
a familiar and homelike character. textual information provided at
(iii) private rooms should be in neutral appropriate locations.
colours to encourage residents to (v) outdoor areas should have single
personalize their spaces. exit/entrance.
(iv) the exterior of the care home (vi) outdoor paths should have a raised
should be less institutional and coloured edge.
more homelike. • privacy and visual accessibility:
• physical accessibility, safety, (i) bedrooms should be single-
and comfort: occupancy with private bathrooms.
(i) bathrooms should be equipped (ii) common activity spaces and
with unobtrusive grab bars and bathrooms should be visible from
spacious enough to accommodate the hallway.
care aides.
(iii) all spaces should have clear views
(ii) brightly-coloured handrails should of the outdoors.
be provided in hallways to be
(iv) storage cabinets should provide
supportive of mobility limitations.
clear access of personal belongings
(iii) door frames should be in and safe items.
contrasting colour to be easily
(v) staff workstations should be
perceptible.
located near hallways.
(iv) outdoor spaces should be
(vi) exit doors should be concealed
surrounded by a high fence
behind artwork.
camouflaged with landscaping.
• appropriate sensory stimulation:
(v) seating should be provided at
appropriate intervals along indoor/ (i) spaces should be provided with
outdoor paths. appropriate acoustic and visual
stimulation.
• orientation and wayfinding:
(ii) high-noise spaces should be located
(i) interior layouts should be legible
away from quiet spaces.
with continuous pathways that
don’t end in dead-ends. (iii) wall-art should not contain real-life
objects.
(ii) landmarks should be provided at
major decision points. (iv) floor finishes should be non-
reflective without sharp colour or
(iii) memory boxes should be provided
material differences.
outside residents’ rooms and
activity spaces. (v) lighting should be regulated to
avoid hard shadows.
Dementia-Friendly Care Homes 5
Introduction According to the Alzheimer Society of Advocate revealed that 64% of residents Canada (2019), there are currently over at B.C.’s care homes live with dementia 564,000 Canadians living with dementia, (Seniors Advocate of British Columbia, which is approximately 7.1% of all 2018). It is important therefore to consider Canadian older adults (Public Health the QOL issues of residents living with Agency of Canada, 2017), and this dementia in care homes. New care models number is expected to rise to 937,000 (e.g., Dementia Village, the Butterfly Care in the next fifteen years. Providing Model, and the Eden Alternative) serve services for older adults living with as prime examples of culture change dementia has been earmarked as one in LTC through physical environmental of the B.C. Government’s strategic interventions, renewed staffing priorities in healthcare. Dementia has models, and PCC practices in order to become an important area of focus in improve resident and staff outcomes LTC (British Columbia Ministry of Health, (BC Care Providers Association, 2017; 2017). A 2018 report by the B.C. Seniors SafeCare BC, 2015). 6 Dementia-Friendly Care Homes
Research suggests that the physical (i) environmental design and physical environment of LTC can facilitate the infrastructure and (ii) education, training, achievement of a number of therapeutic staffing, and care practices. A review goals (i.e., the desired relationship and synthesis of grey literature were between the environment and residents conducted on these two topics to cover living with dementia in LTC) which relevant policies and programs from include (i) maximizing safety and security; various jurisdictions in Canada, including (ii) maximizing awareness and orientation; British Columbia, where the findings of (iii) supporting functional abilities; (iv) this review are expected to be applied facilitating social contact; (v) providing in, along with Alberta and Ontario, privacy; (vi) providing opportunities for where several care organizations have personal control; and (vii) regulating adopted PCC in the past decade. Grey sensory stimulation (Chaudhury, Cooke, literature sources from USA, UK, and Cowie, & Razaghi, 2017). Besides the Australia are also reviewed as they have design of the physical environment, several national and regional policies and training, education, staffing, and care programs based on PCC. practices can also positively influence the quality of care (QOC) and residents’ QOL. There are several provincial education and training programs that are offered to care-providers who work with residents living with dementia to better prepare them to deliver PCC for LTC residents, to improve the QOC and increase staff outcomes and safety (BC Care Providers Association, 2016; Canadian Institute for Health Information, 2018). The “Dementia-Friendly Care Home” research project is a part of a British Columbia Care Providers Association (BCCPA) Strategic Plan Project and has been conducted in collaboration with the Department of Gerontology at Simon Fraser University and the This project will provide rationale for the Alzheimer Society of B.C. The aim of project partners to work with the Ministry this research is to identify the best of Health, BCCPA members and health national and international practices authorities to entrench dementia-friendly implemented in care homes for people principles into B.C.’s care homes. As part living with dementia in two key areas: of this endeavour, a ‘dementia-friendly Dementia-Friendly Care Homes 7
care home’ designation would be with the national objective to improve provided to care homes that have the QOL of people living with dementia followed guidelines including, but not and caregivers (Public Health Agency of limited to, those referenced in this report, Canada, 2019). This involves (i) providing both in terms of environmental design holistic and culturally-appropriate care and training, education, staffing, and care to individuals living with dementia; practices. Besides assembling a set of best (ii) building the capacity of care providers practices, criteria, and design principles, to provide high-quality care by evaluating this report also explores the challenges dementia care guidelines, best practices, and benefits of establishing a dementia- and evidence; and (iii) enabling care friendly care home designation program providers to access requisite resources and in B.C. The findings from this project training for delivering high-quality care are also expected to support BCCPA’s (Public Health Agency of Canada, 2019). advocacy efforts through the Canadian The findings from this report will address Association of Long-Term Care (CALTC) to these goals and objectives by proposing inform the priorities outlined in Canada’s recommendations and solutions to have first National Strategy on Dementia. The real-world impact and improve the QOL of objectives of this research align closely residents living with dementia in LTC. 8 Dementia-Friendly Care Homes
Methods To identify grey literature sources “British Columbia.” Selected professionals pertinent to the two key domains of this and administrators at the Regional Health synthesis (i.e., (i) staffing, education, and Authorities in Ontario, Alberta, and training, and (ii) physical environment British Columbia were also contacted to of LTC homes), an initial search was gain access to internal documents that conducted on platforms including were not available publicly. This process Google Search and the Canadian identified one-hundred-and-fifty-six Electronic Library using combinations (156) items. An initial scan of all the of keywords that include: “dementia,” documents was conducted to select items “staffing,” “environment,” “care home,” with sufficient emphasis on dementia- “design,” and “best practices.” Location- specific programs or policies relating to specific searches were also conducted staffing, education, and training, and/or using the aforementioned keywords, physical environment for resident care. followed by “USA,” “UK,” “Australia,” Through this process, one-hundred-and- “Canada,” “Ontario,” “Alberta,” and thirteen (113) items were eliminated and Dementia-Friendly Care Homes 9
forty-three (43) grey literature sources
were included for the final review. The
final list of items includes national and
provincial government policy documents,
as well as organization-level reports on
best practice guidelines. Twenty-eight (28)
of these items focussed on staffing,
education, and training, while fifteen (15)
emphasised the physical environment
for dementia care. Fifteen (15) out of
the forty-three (43) items were national,
provincial, and organization-level reports
from Canada. The table below indicates
the frequency of items by type under both
domains. The sources reviewed here were
not assessed for quality as this was not a
systematic review.
Staffing, Education, Physical
Type
& Training Environment
Provincial - Canada 2 -
Government - US, UK, Australia, etc. 2 -
Regional Health Authority - Canada 5
Health Authority - UK, Australia, etc. - 2
Organizations - Research synthesis 2 -
Organizations - Evaluation 4 3
Organizations - Guidelines 10 9
Organizations - Summary 1 -
Articles in news media 2 1
Total 28 15
10 Dementia-Friendly Care HomesFindings on Staffing, Education
and Training
1.1. Education & Training out their daily routines (Alzheimer’s
Association, 2006). PCC training equips
Knowing how to engage with people LTC staff with the requisite skills to
living with dementia is essential to explore the meaning of certain behaviour
provide individualized, PCC. Looking from the person’s standpoint, thereby
beneath the surface of responsive facilitating better prevention, early
behaviours and cultivating a nuanced intervention, and effective management
understanding of the range of factors of responsive behaviours (Alberta
that might be contributing to this Health Services, 2014). By promoting a
requires LTC staff to be adequately personalized care approach, PCC training
trained in person-centred dementia care, could improve the overall QOC for
with special emphasis on issues such as residents living with dementia in LTC.
social engagement, pain management,
There are some examples of training
therapeutic fibbing, and involving
programs focused on PCC that have been
residents in planning and carrying
adopted by multiple provinces in Canada,
Dementia-Friendly Care Homes 11including Ontario, British Columbia The DementiAbility program being
and Alberta. These include: adopted in Ontario, for example,
(i)
Gentle Persuasive Approach trains staff to engage residents
(GPA), which enables care staff to living with dementia in activities
successfully apply communication that maximize their abilities and
strategies to diffuse responsive interests (Ontario Long Term Care
behaviours and ensure positive Association, 2018).
outcomes for people living with (iv) T
raining for Dementia Care
dementia and family members Mapping, which is a tool that
(Chappell, Bornstein, applies the PCC approach to assess
& Kean, 2014). the QOC in LTC, is provided in
(ii)
P.I.E.C.E.S. (Physical, Intellectual different countries by trainers and
and Emotional health, maximizing organizations affiliated with the
the Capabilities of the individual, University of Bradford (University
Environment and Social needs), of Bradford, 2019).
which offers a systematic, The following sections describe: (i) needs
individualized framework for and challenges; (ii) outcomes; and
detection, assessment, care (iii) recommendations for the training and
planning, and identifying education of LTC staff in dementia care.
appropriate care strategies for
older adults living with dementia 1.1.1. Needs and challenges
(Alberta Health Services, 2014; associated with staff education
British Columbia Ministry of and training
Health, 2016).
a) Understanding Person-centred Care
(iii) Other examples of PCC training
The first and foremost step in providing
programs include Supportive
PCC is facilitating adequate training
Pathways in Alberta, which
to enable LTC staff to develop a
is focussed on issues such as
comprehensive understanding of the
collaborating with families,
meaning of PCC. An objective of PCC
creating normal living
training is to encourage care staff to
environments, providing
reflect upon their motivations to work
meaningful activities, supporting
with residents living with dementia
responsive behaviours, sexuality
(Bamford et al., 2009). Providing PCC
and intimacy as a part of a
training to all LTC staff members,
normalized life experience, and
including those who are not in direct
ensuring safety and security for the
caregiving roles (e.g., housekeepers,
person, other residents and staff
cooks, drivers), would ensure that there
(Alberta Health Services, 2014).
is consistent understanding of the
12 Dementia-Friendly Care Homesmeaning of PCC across the LTC workforce, what staff members perceive as challenges enabling any staff member to extend is imperative to deliver training and support to residents whenever needed education that is relevant to everyday (Alzheimer Society of Canada, 2011; care practice (Alzheimer’s Society, 2007). Armstrong et al., 2019; Bamford et al., An example of this is training LTC staff 2009; Vancouver Coastal Health, 2017). to involve family members in the care Without this training, it is evident that routines of their loved ones (Alzheimer’s there will be varied and contradictory Society, 2007). Such awareness training understandings of PCC among care staff. will enable staff to understand family Inconsistent understandings deter care members’ perspectives and better assess staff from realizing the full potential for residents’ care needs (Carers Trust, 2016). implementing person-centred values in The planning and delivery of this training dementia care (Bamford et al., 2009). program need to be done in consultation Framing the delivery of PCC as mandatory with family members (Carers Trust, 2016). through stringent regulations that do not account for the delivery of appropriate and adequate training forces care homes to adopt PCC as a label, without care staff having clear and uniform understanding of what it means (Bamford et al., 2009). Therefore, it is necessary to institute PCC training at the provincial level with adequate dedicated funding from the government (Chappell et al., 2014; Dementia Initiative, 2013; Ministry of Health and Long-Term Care, 2016). b) Contextualization of training It has been found that the best practices learned through training and education differ significantly from care practices actually followed in LTC (Alzheimer Society of Canada, 2011). There is a need to bridge this gap and ensure that the Contextualizing PCC training includes content of training programs critically responding to the need for cultural examines and corresponds to existing competency among LTC staff (Bamford care practices, so that the training is et al., 2009; British Columbia Ministry responsive to the specific issues faced of Health, 2016), including the needs of by LTC staff (Alzheimer’s Society, 2007; residents who are part of the LGBTQ2S+ Bamford et al., 2009). Understanding community (Alzheimer’s Society, 2007). Dementia-Friendly Care Homes 13
c) Applying training to practice outcomes to be duly evaluated so as to
The success of staff training and education improve the impact of training on care
and positive outcomes are facilitated by a practice. At present, there is a lack of
concurrent change in organizational ethos routine monitoring to assess the impact
and care practices. A shared ethos that of dementia care training on the QOC
supports and reflects the PCC approach is for residents living with dementia (Care
necessary for the successful translation of Quality Commission, 2014). Ramping up
PCC training into practice (Bamford et al., post-training evaluation can inform the
2009). However, there are several factors provision of tailored and individualized
that may challenge this process. For care routine and thus improve resident
instance, it is generally agreed upon that outcomes. Supportive and effective
dedicating sufficient time is integral to leadership is also necessary to facilitate
successfully apply lessons learned through the successful implementation of
training into everyday practice in LTC. training and its translation into practice
However, giving the staff the necessary (Alzheimer’s Society, 2007).
time to put what they have learned into
1.1.2. Outcomes of implementing
practice is at odds with the notion of
staff education & training
maximizing the time spent on caring
for residents, which results in training a) Improved quality of care and resident
being delivered in shorter periods of time outcomes
(Chappell et al., 2014).
P.I.E.C.E.S. training helps direct care
In a recent evaluation of dementia care workers understand the value in taking
training, care staff reported that an the time to know residents better and
overload of information was covered in provides a systematic approach to identify
a shorter time frame (e.g., two days), risks, causes, and strategies related to
instead of a more ideal, extended time residents’ responsive behaviour (McAiney,
frame (e.g., five days). Training offered 2005; Vancouver Coastal Health, 2017).
as part of the induction program at Effective training ensures care staff
care homes has been found to be members know how to communicate
incomprehensive and not supplemented with residents, which involves reading
with follow-up, in-depth training (Care non-verbal signs and cues that may
Quality Commission, 2014). One-off indicate residents’ lack of understanding,
training sessions usually result in staff embarrassment, discomfort, or pain,
returning to their usual practices soon can help considerably improve resident
after they have received training, outcomes, e.g., pain management
which increases the need for multiple (Alzheimer Society of Canada, 2011;
follow-up sessions (Alzheimer’s Society, Carers Trust, 2016; Department of Health,
2007). There is also a need for training Social Services and Public Safety, 2015).
14 Dementia-Friendly Care HomesTraining facilitates care staff’s intellectual capacity, emotional and
understanding of residents’ responsive spiritual health, functional capabilities,
behaviour, which in turn eliminates and environmental, social, and cultural
the administration of antipsychotic factors (McAiney, 2005).
medication to manage agitation and GPA and P.I.E.C.E.S. training foster group
aggression (Chappell et al., 2014; participation, open communication, and
Cognitive Decline Partnership Centre, team building (Alberta Health Services,
2016). Evaluation of GPA and P.I.E.C.E.S. 2014). P.I.E.C.E.S. training has been shown
training administered in six care homes to promote team-work across different
in Vancouver (Dementia CARE Initiative) disciplines and hierarchies within and
revealed positive behavioural outcomes beyond the care home setting (McAiney,
for residents, decrease in the use of 2005). Dementia care training has been
antipsychotic medications and physical suggested as offering the opportunity
restraints and increase in management of for LTC staff members from different
responsive behaviour (Vancouver Coastal care homes to learn from each other’s
Health, 2017). experiences and share lessons learned
Evaluation of P.I.E.C.E.S. training has also (Bamford et al., 2009).
found an associated improvement of
residents’ QOL and dignity (Vancouver
Coastal Health, 2017). PCC training also
helps care staff build trust and develop
meaningful relationships with residents
(Alzheimer’s Association, 2006). P.I.E.C.E.S.
training has also been found to enable
direct care workers in recognizing the
autonomy and choice of residents living
with dementia (Vancouver Coastal
Health, 2017).
b) Improved staff outcomes
1.1.3. Recommendations for staff
Dementia care training also improves staff education and training
outcomes (e.g., satisfaction, calm, feeling
empowered) (Vancouver Coastal Health, a) Evidence-based training and education
2017), which has been linked to reduced Interdisciplinary dementia education and
staff turnover (Alzheimer’s Society, 2007). resources for health-care professionals
Evaluation of P.I.E.C.E.S. training in care (e.g., PCC training) should be evidence-based
homes in Ontario showed that training and supported by expert knowledge or data
increased staff members’ confidence in on resident outcomes (British Columbia
their ability to assess physical health, Ministry of Health, 2016).
Dementia-Friendly Care Homes 15b) Tailoring training to job roles Training staff members in multiple skills, Dementia care training may be more e.g., to be care aides as well as activity effective when it is customized to the job aides (Canada Mortgage and Housing role of the care staff (Care Inspectorate, Corporation, 2015) may help reduce the 2017). Covering general content on PCC number of staff workers in the care home with an approach targeted towards key and help achieve consistency in giving staff groups may increase the likelihood care (Alberta Health Services, 2014). of implementing PCC within the scope c) Educating family members of one’s job role (Bamford et al., 2009). Providing PCC education for family This includes (i) offering accessible members shortly after LTC staff have education to direct care workers and received training has been recommended (ii) enhanced dementia curriculum for for family members to better understand health-care providers, managers, and changes in care philosophy in the care emerging professionals preparing to start home (Vancouver Coastal Health, 2017). practice (Ministry of Health and Long- PCC education for family members should Term Care, 2016). Additionally, providing also involve supporting them in dealing dementia education in institutions of with feelings of grief and loss, navigating higher learning is expected to increase services, and accessing information on dementia care competency among future caregiving (Alberta Health Services, 2014). health-care professionals (British Columbia Ministry of Health, 2016). 16 Dementia-Friendly Care Homes
d) Translating training into practice practices” (Dementia Initiative, 2013,
Providing staff training as an ongoing p. 30; Ministry of Health and Long-Term
process through periodical refresher/ Care, 2016).
follow-up sessions is recommended
for successful application of training in
1.2. Staffing & Care Practices
practice (Alzheimer Society of Canada,
1.2.1. Needs and challenges
2011; Alzheimer’s Society, 2007;
associated with staffing and care
Armstrong et al., 2019; Chappell et al.,
practices
2014; McAiney, 2005). Identifying a
care worker as the site GPA and/or a) Culture change
P.I.E.C.E.S. facilitator to provide training Culture change initiatives that prioritize
support on a day-to-day, as-needed basis outcome-focussed rather than task-
could potentially ensure that training focussed care, as well as foster a ‘can
is ongoing and a part of the daily care do’ approach, involved leadership, open
routine (Vancouver Coastal Health, 2017). communication between staff members,
Other practice innovations that are and empowerment of direct care staff
recommended include training-in-practice, are essential to deliver high-quality PCC
supervised practical work, and group with improved resident outcomes
debriefing, thereby integrating training (Age UK Gloucestershire, 2015; Alberta
into the therapeutic milieu and bridging Health Services, 2014; Armstrong et
the gap between training and practice al., 2019; Beynon & Wood, 2017; Care
(Bamford et al., 2009). Inspectorate, 2017). Facilitating culture
Regular monitoring and performance change also involves reconsidering
evaluations are recommended as traditional approaches to care and
a way of tracking the care staff’s challenging conventional notions
application of PCC training (Alzheimer’s of caregiving (e.g., reconsidering
Society, 2007; Chappell et al., 2014). organizational perceptions and attitudes
Evaluation results should then be used related to risk and augmenting resident
to make improvements to the QOC. autonomy to boost participation in
It is recommended that care homes’ household activities, feel free to engage
leadership groups offer their support in the outdoors, and have enhanced QOL)
and commitment to improving QOC by (Armstrong et al., 2019).
integrating training and evaluation Examples of culture change models in
into care practice (Care Quality LTC include: (i) the Butterfly Household
Commission, 2014). People in leadership Model of Care, which originated in the
positions at care homes should foster UK and is now informing organizational
a training and learning environment culture change in care homes across
that offers opportunities for “informal Alberta and Ontario (CTV News, 2018);
coaching and modelling of effective (ii) Eden Alternative, which is a PCC model
Dementia-Friendly Care Homes 17of culture change in LTC that originated the shortage of care workers are major in the US and is being adopted in Canada, barriers as they tend to disrupt the involves empowering care staff, residents, continuity of care and relationships and families to build care partnerships built by staff with residents (Age UK that afford residents and their families Gloucestershire, 2015; Alzheimer’s dignity, choice, and independence, while Society, 2007). Efforts should be taken by increasing job satisfaction among staff the leadership in care homes to ensure members (Eden Alternative, 2012); and that staff members feel supported, (iii) the Green House project, which encouraged, and fulfilled to stay in their is another PCC-based culture change jobs while having sufficient opportunity model in LTC in the US; and achieves for professional growth and skill personalized PCC through features such development (Alzheimer’s Society, 2007). as a small-scale, homelike environment, advanced staff training, and high staff- to-client ratio (The Green House Project, 2019). However, the lack of resources and organizational support have been cited as barriers to the implementation of best practices in dementia care and culture change within care homes (Bamford et al., 2009; Care Quality Commission, 2014). Furthermore, there is a paucity of evidence on (i) the impacts of these culture change initiatives on resident’s QOL and health-related outcomes and (ii) which specific interventions have the biggest impact on resident and staff outcomes, thus challenging the ability to draw clear conclusions from different Consistent assignment of direct care staff culture change approaches (Armstrong to residents is also integral to the success et al., 2019). of PCC and continuity of care. Maintaining b) Staffing level and consistency continuity with residents allows LTC staff Adopting the PCC paradigm is contingent to understand residents’ preferences and on having adequate staff. Inadequate needs and build trust and relationships staffing levels tend to limit the scope (Bamford et al., 2009). This is linked to of care delivery to risk management, the need to have a good understanding thus posing a barrier to the delivery of of individual needs, capacities, and PCC (Alzheimer’s Society, 2007; Bamford emotions, as part of the PCC approach et al., 2009). High staff turnover and (Armstrong et al., 2019). It is imperative 18 Dementia-Friendly Care Homes
for staff working on different shifts to autonomy (Alberta Health Services, 2014;
engage in clear and open communication Dr. Robert Bree Collaborative, 2017; Eden
at the time of hand-over for an enhanced Alternative, 2012, p. 6).
understanding of residents’ responses,
which can be particularly important for 1.2.3. Recommendations for
staff members who are not familiar with staffing and care practices
a resident (Alberta Health Services, 2014).
a) Increased resources and staffing levels
Frequent changes in staff’s assignment to
Previous research indicates the need to
residents can result in confusion, which
raise current staffing levels in order to
is detrimental to the staff’s ability to
maintain QOC and further raise levels
deliver high-quality care (Care Quality
to improve the QOC (Armstrong et al.,
Commission, 2014). Maintaining the
2019). Staff stability and continuity are
stability of staff-resident relationships,
recommended for the viability of PCC,
which is key to delivering PCC, is also
thereby necessitating the elimination
challenged by frequent absenteeism,
of factors that contribute to high staff
turnover, and recruitment of untrained
turnover and redressal of operational
care staff (Chappell et al., 2014).
and management issues (Alberta Health
c) Staff and resident autonomy
Services, 2014; Armstrong et al., 2019).
Providing individualized care is also It is recommended that direct care staff
determined by the direct care staff’s be provided with adequate time for
capacity to make decisions and whether caregiving and commensurate equitable
they feel empowered in doing so. The wages in order to maximize the impact
involvement of direct care staff in care of PCC on the QOL of residents living
planning and decision-making helps with dementia (Alzheimer’s Society, 2007;
improve resident outcomes (Alzheimer’s Armstrong et al., 2019; Beynon & Wood,
Society, 2007). Good leadership is 2017).
necessary to enable direct care staff
LTC staff should have access to specialized
to feel empowered to make the best
dementia care staff (e.g., dementia
decisions for residents (College of Licensed
champions, dementia care specialist,
Practical Nurses of Alberta, 2015). A
mental health behavioural support
strictly top-down hierarchical structure is
consultant, and case managers) who can
detrimental to the decision-making capacity
provide expertise and skills training as
of LTC staff (Eden Alternative, 2012).
needed on a day-to-day basis (Alberta
It is also important to empower residents Health Services, 2014; Care Quality
and family members to actively be Commission, 2014; Healthwatch Norfolk,
involved in making decisions related 2018; Vancouver Coastal Health, 2017).
to the care routine of persons living This staff member will be tasked with
with dementia, thereby respecting their coordinating ongoing in-practice training,
Dementia-Friendly Care Homes 19prioritizing topics for training (or to help reduce behavioural symptoms refreshers) in the future, and recommend and improve QOL of residents living social and environmental strategies to with dementia in care homes (Ontario manage responsive behaviours (Alberta Long Term Care Association, 2018). Health Services, 2014; Healthwatch BSO teams support frontline staff Norfolk, 2018; Vancouver Coastal at their designated care homes by Health, 2017). In addition to providing offering dementia education, training, on-site support, telehealth support is and problem-solving to manage recommended for care homes in rural or challenging behaviours (Ontario Long remote locations (Alberta Health Services, Term Care Association, 2018). This 2014; Vancouver Coastal Health, 2017). training is known to help LTC staff Examples include: feel “significantly more supported • The Regional Knowledge Coordinator and capable of developing solutions” for Complex Behaviours (RKC-CB) (Ontario Long Term Care Association, at Interior Health, British Columbia, 2018, p. 7). collaborates with care staff at different • Challenging Behaviour Resource care homes on a referral basis to Consultants, as part of the Challenging educate them on PCC and help them Behaviour Program in the province of develop behavioural care plans for Nova Scotia, provide consultation to residents with responsive behaviours. LTC staff on “identifying biological, A recent evaluation (Ward & Bader, psychological, and social indicators 2018) of this program found that 88% of responsive behaviours and find of residents who received care based solutions” for individual residents on the input of the RKC-CB had lower (Nova Scotia Department of Health and incidence of responsive behaviours. Wellness, 2013, p. 11). The majority of care managers (84%) Staffing levels should be increased with reported their satisfaction with the a higher staff-to-resident ratio so as to services of the RKC-CB (Ward & Bader, achieve the best outcomes of PCC (Alberta 2018). The introduction of the RKC-CB Health Services, 2014; Alzheimer’s Society, (i) encouraged care staff to adopt a 2007). Adopting innovative staffing proactive approach and seek help models to improve staff autonomy is earlierrather than delaying the process; linked to the successful adoption of (ii) made staff realize the need and PCC and enhanced resident outcomes. value of care planning; and (iii) avoided The Green House project (The Green visits to the emergency departments or House Project, 2019) is an example of hospital admissions of residents. how decentralizing and reducing staff • Behavioural Supports Ontario (BSO), hierarchy without increasing overall a provincial program in Ontario that staffing can facilitate the formation of hires and trains specialized staff teams separate self-managed teams of direct 20 Dementia-Friendly Care Homes
care workers. Care aides and nursing staff (Bamford et al., 2009). With adequate
members can consult with each other on monitoring, leadership must ensure that
an as-needed basis, thereby significantly the staff are aware and equipped with the
improving the autonomy of care aides. skills required to facilitate occupation and
Relationship-building between LTC stimulation among residents (Alzheimer’s
staff and the resident can be promoted Society, 2007).
by hiring multi-skilled workers who e) Staff collaboration
can combine personal care with other
Interdisciplinary care team meetings,
activities (e.g., meal planning, recreation,
staff case conferences, and unit huddles
and housekeeping) in order to spend
that involve leadership, as well as
more “unscheduled” time with residents
front-line staff (e.g., direct care staff,
(Alberta Health Services, 2014).
LPNs, RNs) are recommended to enable
b) Consistent staffing mutual learning, information-sharing,
It is recommended that care staff be collaborative problem-solving, and
assigned to the same residents in order to brainstorm solutions that are tailored to
maintain consistent care practices that are residents’ needs (Alberta Health Services,
tailored to suit the needs and preferences 2014; Bamford et al., 2009; Chappell et al.,
of individual residents (Chappell et al., 2014; Vancouver Coastal Health, 2017).
2014). No more than eight personal care This recommendation stems from the
assistants should be assigned to a given need to promote flexibility, teamwork,
resident within a one-month period and greater autonomy for front-line staff
(Chappell et al., 2014). Identifying certain in decisions on caregiving (Armstrong
staff members as the primary caregivers et al., 2019). Interdisciplinary meetings
for a household/unit can further improve are best supported by optimal staffing
staffing consistency (Alberta Health levels, good mix of skills among team
Services, 2014). members, and the practice of inclusive
c) Streamlined caregiving communication (Alberta Health Services,
2014; Ministry of Health and Long-
When appropriate, the use of slow-
Term Care, 2016). Collaboration and
release medications is recommended
information-sharing between care homes
to reduce the frequency of medication
have also been recommended in order
administration and increase opportunities
to learn and exchange effective practices
for LTC staff to spend uninterrupted time
and approaches from similar and different
with residents (Alberta Health Services,
care settings (Armstrong et al., 2019).
2014).
d) Monitoring staff performance
Both informal and formal supervision can
contribute to a conducive management
style for the sustenance of PCC practices
Dementia-Friendly Care Homes 21Photo courtesy of The Village in Langley
Findings on Physical Environment
This section consists of design accessibility; (iv) Physical accessibility,
recommendations for the physical safety, and comfort; (v) Appropriate
environment of care homes. These sensory stimulation and minimizing
recommendations are arranged according perceptual distortion; and (vi) Familiarity
to the various spatial levels of the and homelikeness.
LTC environment and correspond to
different therapeutic goals (Cohen & 2.1. Domestic scale
Weisman, 1991). These goals highlight the
Care homes should have a small scale
relationship between the residents with
(number of spaces) in order to convey
dementia and the LTC environment and
a familiar/domestic character, which in
serve as guiding principles for the design
turn facilitates participation for residents,
of a therapeutic physical environment.
whereas larger scales are associated with
The therapeutic goals discussed here
high levels of agitation and confusion
include: (i) Domestic scale; (ii) Orientation
(Fleming & Bennett, 2017; Government of
and wayfinding; (iii) Privacy and visual
Alberta, 2014). Clusters of resident units
22 Dementia-Friendly Care Homesor households should be small in size floor plans should be avoided as they are
to maximum residents’ sense of control likely to confuse and mislead residents
(Alzheimer’s Australia, 2004; Ministry of (Chmielewski, 2014). Circular, clutter-
Health, 2016). While households with free hallways are more conducive for
eight to 12 residents are expected to wayfinding than long, narrow corridors
preserve a domestic feel, household (Centre for Excellence in Universal Design,
size should not exceed 15 residents 2015; Chappell et al., 2014).
(Alzheimer’s Australia, 2004; Fleming & Additionally, corridor lengths should be
Bennett, 2017; Housing21, n.d.). minimal so that residents do not have to
Households grouped and planned to travel long distances to access common
resemble a village setting help create a spaces in the care home (Fraser Health,
familiar community-like environment with 2018). These paths must (i) be without
self-contained and/or shared common dead ends; (ii) end in destinations,
living spaces (Chmielewski, 2014). (iii) away from residents’ rooms; and
Examples of this include: (i) Dementia (iv) pass alongside activity/social spaces,
Village in Weesp, Netherlands, which thus enabling residents to preview and/
consists of 23 small-scale group houses or join the activity (Canada Mortgage and
designed to resemble houses in the Housing Corporation, 2015; Chmielewski,
community, with streets, squares, gardens, 2014; Fraser Health, 2018; Housing21, n.d.;
parks, salons, music hall, supermarket, Ideas Institute, 2010).
and restaurant; and (ii) Central Haven Circular or looped paths should be
Special Care Home, a care home with supplemented with stop-off points to
about 60 residents, in Saskatoon, sit and rest, opportunities for social
Canada, which resembles a small town interaction, and stimulating features
with a chapel, café, childcare centre, art that promote activity and engagement
studio, educational spaces, green house, (Fleming & Bennett, 2017; Housing21, n.d.;
community garden, auditorium, gift shop, Ideas Institute, 2010). These paths should
and community event spaces (Canada also offer uninterrupted visual access to
Mortgage and Housing Corporation, 2015). important areas and entrances in the care
home to promote wayfinding between
2.2. Orientation and spaces (Centre for Excellence in Universal
wayfinding Design, 2015; Chmielewski, 2014).
The floor plan should be based on a Cues that support orientation and
simple layout that is intuitive, can be wayfinding include: (i) familiar and
easily remembered by the residents, and meaningful landmarks at decision
involves a minimal number of wayfinding points (e.g., change in direction or level)
choices (Alzheimer’s Australia, 2004; (e.g., artwork that triggers memories,
Chmielewski, 2014; Fraser Health, 2018; tapestries, sculptures; seating); and
Housing21, n.d.). Identical or mirrored
Dementia-Friendly Care Homes 23(ii) changes in the colour/texture of Fleming & Bennett, 2017; Fraser Health, surfaces (Alberta Health Services, 2014; 2018; Government of Alberta, 2014; Study, Chmielewski, 2014; Department of Health, n.d.). In addition to providing memory 2015; Fraser Health, 2018; Housing21, boxes outside private spaces, function- n.d.; Nova Scotia Department of Health, specific memory stations (e.g., gardening 2007; Study, n.d.). Consistent colouring or sports memorabilia and antique of doors, signs, walls across spaces with elements) at the entrance to common similar functions in all units of the care areas or group activity spaces could evoke home will help create the distinction familiarity and prompt recognition between different spaces and promote (Study, n.d.). identification (Housing21, n.d.; Study, n.d.). The position of cues can be manipulated to guide residents, such as placing off- centre photos at the end of a hallway that are partially revealed may prompt a resident to turn in order to see the full photo (Study, n.d.). Different types of cues that highlight the meaning or function of a space should be provided to help residents with different cognitive abilities recognize an area. For example, to help residents recognize their bedroom, cues should be incorporated through Signs should be placed at an appropriate furniture, wall colour, signs, etc. (Centre height from the floor and closer to the for Excellence in Universal Design, 2015; floor to support residents whose line of Department of Health, 2015; Fleming & vision is at a low-level (Department of Bennett, 2017, p. 21; Housing21, n.d.). Health, 2015; Fleming & Bennett, 2017; The number of cues should be minimized Hodges, Bridge, & Chaudhary, 2007). so as to avoid visual clutter (Fleming & Signage should use a combination of Bennett, 2017). words and images of an appropriate size Memory boxes at the bedroom door that are linked to the function/activity containing meaningful objects in the space (Alzheimer’s Australia, (e.g., personal souvenirs, photos of loved 2004; Chmielewski, 2014; Department of ones, cherished mementos) could serve Health, 2015; Fraser Health, 2018, 2018; as wayfinding cues and help residents Nova Scotia Department of Health, 2007). identify their respective rooms (Canada Signs should not have non-reflective Mortgage and Housing Corporation, surfaces with high contrast against the 2015; Centre for Excellence in Universal background at different lighting levels Design, 2015; Chmielewski, 2014; (Centre for Excellence in Universal Design, 24 Dementia-Friendly Care Homes
2015; Department of Health, 2015). The Fraser Health, 2018; McAdam & Williams,
amount of information in the sign should 2017). Similar to indoor hallways, outdoor
be minimal to avoid cognitive overload paths should also be continuous loops
(Department of Health, 2015). lined with destination points and no
Lighting can be employed to provide dead ends, so as to avoid confusion and
directional cues to attract residents frustration (Chmielewski, 2014; Housing
towards common spaces and activity Learning & Improvement Network, 2013;
spaces (Canada Mortgage and Housing McAdam & Williams, 2017). Multiple
Corporation, 2015; Greasley-Adams, intersecting paths with varying lengths, as
Bowes, Dawson, & McCabe, n.d.). Motion opposed to a single common path, should
or sound-activated lights or pressure be incorporated into the outdoor space
mats equipped with light sensors that to promote variety and choice for people
automatically turn on lights have been with different cognitive capacities and
recommended to lead the way for mobility challenges (Chmielewski, 2014;
residents living with dementia wanting McAdam & Williams, 2017).
to go to the bathroom at night (Centre
for Excellence in Universal Design, 2015;
2.3. Privacy and visual
Greasley-Adams et al., n.d.).
accessibility
Outdoor spaces and gardens should The LTC environment should offer
also be designed with orientation and residents varying degrees of privacy
wayfinding cues to afford residents a to support different functions, ranging
higher sense of control and confidence from public (e.g., living room, dining
(Alzheimer’s Australia, 2010; Canada room, kitchen) to private (e.g., bedroom)
Mortgage and Housing Corporation, (Chmielewski, 2014; Fleming & Bennett,
2015; Housing Learning & Improvement 2017; Housing21, n.d.).
Network, 2013, 2013; McAdam & Williams, To provide adequate privacy, bedrooms
2017). Providing a single point of entry should be single-occupancy with private
to the outdoor area that is recognizable en-suite bathrooms and equipped to
serves as a landmark for residents to use accommodate a spouse or a visiting family
in finding their way back inside (Fleming member, if need be (Alzheimer’s Australia,
& Bennett, 2017; Ministry of Health, 2016). 2004; Chmielewski, 2014; Department of
The paving of outdoor paths should Health, 2015; Fleming & Bennett, 2017;
be even and have consistent colour Ministry of Health, 2016). Providing
without patterns and dark lines and a private kitchen and dining space
raised edge rendered in a contrasting (in addition to a common kitchen and
colour to help residents differentiate dining area) within residents’ rooms could
paving from green space and support afford more flexibility for the timing and
wayfinding (Alzheimer’s Australia, 2010; choice of meals (Canada Mortgage and
Housing Corporation, 2015).
Dementia-Friendly Care Homes 25To promote acoustic privacy, rest, and belongings (Housing21, n.d.). Having relaxation, the bedrooms should be storage in shared spaces with clear sound-insulated, so as to prevent sound visual access to safe objects can support from travelling into neighbouring rooms residents’ engagement in household (Alzheimer’s Association, 2006; Canada activities, such as open shelving or Mortgage and Housing Corporation, cabinets with glass doors in the kitchen 2015; Fraser Health, 2018). While reducing that offer visual access to safe cooking ceiling heights helps improve the acoustic equipment and ingredients and facilitate quality of spaces, noise transference participation in meal preparation or between spaces may be reduced by serving (Alzheimer’s Australia, 2004; using vinyl flooring, acoustic linoleum, or Centre for Excellence in Universal carpets for floor surfaces (Department of Design, 2015; Greasley-Adams et al., n.d.; Health, 2015). Housing21, n.d.). Common spaces (e.g., kitchen, dining, and Private and common spaces should afford activity areas) must be in close proximity views of the outdoors so as to enable and clearly visible from hallways to residents to orient themselves to the time increase opportunities for accessibility, of day or season and encourage them to social interaction, and participation access the outdoors (Alzheimer’s Australia, (Chmielewski, 2014; Department of 2010; Centre for Excellence in Universal Health, 2015; Fleming & Bennett, 2017). Design, 2015; Chmielewski, 2014; Fleming Bathrooms should be proximate and & Bennett, 2017; Housing Learning & visually accessible from common spaces Improvement Network, 2013; Housing21, so that residents may be prompted to use n.d.; Ministry of Health, 2016). During it, when in need (Centre for Excellence poor weather conditions, windows should in Universal Design, 2015; Fraser Health, be screened to hide views of outdoor 2018). Innovative design solutions should paths from plain sight (Chmielewski, be employed to modulate the accessibility 2014). of certain areas, such as using double Design features, such as windows or doors to enhance visual access to kitchens, wall openings that offer visual access while limiting physical access due to between spaces may be used to support sanitary regulations (Chmielewski, 2014). unobtrusive monitoring of residents Providing sufficient unobtrusive storage by staff members (Chmielewski, 2014). space in rooms can help minimize clutter Staff’s visual access may also be enhanced by enabling residents to store their by locating staff workstations near belongings in an organized manner and circulation paths, thus enabling them effectively manage their personal space to not only monitor residents but (Alzheimer’s Australia, 2004). Personal also engage in informal interaction wardrobes should have glazed doors to and participate in everyday activities offer residents clear visual access to their (Chmielewski, 2014; Fraser Health, 2018). 26 Dementia-Friendly Care Homes
Other environmental/technological spacious enough to accommodate care
strategies to facilitate unobtrusive staff for bathing or toileting (Alzheimer’s
monitoring include installing door Australia, 2004; Fraser Health, 2018). The
sensors, bed occupancy sensors, or bathing space should be designed to
floor sensors, which can be useful to provide a sense of calm and peace and
alert staff to an emergency or residents eliminate anxiety (Fraser Health, 2018).
needing assistance (Canada Mortgage Common toilets should be provided in
and Housing Corporation, 2015; Centre close proximity to activity spaces and
for Excellence in Universal Design, 2015; circulation paths with unobtrusive entry
Housing21, n.d.). and maximum privacy (Alzheimer’s
Environmental strategies to curtail Australia, 2004). Bathroom fixtures should
residents’ exit-seeking behaviour include be safe to use, conveniently located, and
concealing exit doors behind artwork easily controlled by residents (Alzheimer’s
or colour-matching protection panels Australia, 2004). Vanity mirrors should
that match the finish of the surrounding have shutter doors that can be closed, as
walls and camouflaging door handles need be, to avoid confusion or distress
(Alzheimer’s Australia, 2004; Centre for when residents do not recognize or are
Excellence in Universal Design, 2015; not comfortable with their reflection
Chmielewski, 2014; Department of Health, (Centre for Excellence in Universal Design,
2015; Fleming & Bennett, 2017; 2015; Chmielewski, 2014; Government
Fraser Health, 2018; Hodges et al., 2007). of Alberta, 2014). Using heated mirrors
Exit doors should open into administrative is recommended to avoid blurring of
areas where concerned staff members can reflection (Centre for Excellence in
guide residents who have exited the living Universal Design, 2015).
environment back inside (Chmielewski, Residents living with dementia facing
2014). mobility challenges should be provided
with corridor handrails rendered in bright
2.4. Physical accessibility, colours; preferably red or yellow hues
safety, and comfort and not blue or green hues for maximum
perception (Centre for Excellence in
Bedrooms should have ceiling lifts and
Universal Design, 2015; Department of
beds set low to the floor with headboards
Health, 2015; Fraser Health, 2018).
facing the bathroom to provide residents
easy access to the bathroom, which can It is recommended to avoid doors that
be helpful especially at night (Canada are not self-closing as they may pose
Mortgage and Housing Corporation, 2015; as a hazard when left fully or partially
Fraser Health, 2018). Bathrooms should open (Centre for Excellence in Universal
also allow for the operation of ceiling Design, 2015). Threshold strips and
lifts and be provided with unobtrusive border details at the doorway should be
supports, such as grab bars, and be avoided as they pose barriers to residents’
Dementia-Friendly Care Homes 27You can also read
