Dementia Care Plans in Practice (Interview 1)

This interview was conducted with a Supervising Resident Care Manager and Registered Nurse for people with dementia at a prominent Dementia Care Home.

Please describe your experience working with care plans:
We don’t do specific dementia care plans. Everyone here is demented, including the staff (no, just kidding.) We do a lot of teaching and individual care notes. We do individualized care notes for everyone. I don’t have a set book for persons with dementia only. We work with each person individually, maybe they won’t shower and we have to work with that. We have a whole program here to train people. We have a nurse consultant. We make the care notes up ourselves.

How long have you been doing this type of work?
Since 1980. I worked part-time as a nurse here for many years and since 2001 have been the dementia care nurse manager.

What training/education did you have to prepare you for the work you’re doing?
I went to nursing school and I have a bachelor of science.

What is your favorite part about working with people living with dementia?
Just having fun with everybody and enjoying the day.

What is the most challenging part about working with people living with dementia?
What we find challenging is trying to get people with dementia to do the things that other people want them to do. To gain their cooperation we try to work with the resident’s family caregivers to work with this person. This is the message that we try to teach - To truly enjoy being together. If someone is not happy with what your doing… They can’t think, they have dementia; YOU have to stop and think about what’s a creative way for the day to go smoothly.

Almost like children becoming more independent. They want to do things their way, but you the mother are trying to get them to do the things your way. Those are the types of power struggles and issues a lot of people with dementia have when they are still at home with their families. A lot of people don’t realize the other person isn’t thinking… The caregiver might get frustrated and start yelling so that really is the most challenging thing. Dealing with everybody’s anger and frustration when people just need to relax and figure out that they need to manage daily activities at the level where the patient is at. To realize there is a problem, recognize it and let go of some of the lifestyle habits that worked in the past and try to be where the person is now. To be with them where they are in a friendly and fun way. A lot of people don’t realize that somebody has it and they will just be screaming about why they are the way that they are. They need to acknowledge that the person now has an illness.

So how do you deal with helping the family to accept the person’s limitations?
Now when we get to meet the family, they already have the diagnosis. So now, anything that we want people to do, sometimes I have to say to a family member, we’re not going to give your husband a shower, he doesn’t want one. I have one family member who’s a nurse and she takes her husband home and showers him at home.

Other people we just say to the family, we’ll your relative doesn’t want to shower and we’re just going to wash her in the bed. Is that ok with you? We’re going to give them a “bed bath”. There are ways to take care of people who are really not getting that dirty. They’re not playing in the mud. When they get soiled, there are shampoos that we can apply and then not worry about rinsing them off. Creative ways to give good care to people without screaming and anger ruining everybody’s blood pressure.

Please describe how care plans are developed. Who has input into the process? Who can suggest changes?
Everybody in this building has individualized care notes.
We try to make the care plan in the voice of the person. For example I will write “I like my medicine with my lunch” “Please bring my pills at noon” “I like to take a walk everyday, please take me out”. Writing them in the voice of the person. “Please be gentle when you move my leg, I’ve had back pain for many years”. This is how we write them. We take a narrative approach using what you know about the person to create a plan of care that makes sense. “I need two people to help me transfer out of my wheelchair, I don’t walk anymore”. It’s the same thing with behavior.

So how do you develop the care notes?
Everybody who comes into the building, for every admission, the care manager writes the care notes and then after you gather a lot of information over the next two weeks we do paperwork and then make the care notes as individual as possible.

Who is responsible for communicating the care notes?
I do it. The culinary people do it. The activities department does it. But the initial care notes are always created by the nurse and then as time goes by the whole interdisciplinary team works on it; reviewing it at least every three months.

Today, we’ve gone electronic. We have touch screens so the aids who work with the residents. When they turn on the touchscreen to the person’s name, the care notes pop up. So they communicate verbally and through written material changes and things to do for people.

What do the words “person-centered care” mean to you?
Person Centered Care in Dementia Care is actually known as “The best friends approach”. i.e. If your resident is alert and oriented, you might say, “Hi Mrs. Jones, I’m here to give you a shower… Is that ok with you? Do you like your showers in the morning or at night? That’s when you can get information from people who can communicate and speak. But if your client cannot do that because their dementia is progressing, you might sit down and talk with them a little bit.

This is what we recommend: “Hi I’m _______, I’ll be your nurse tonight… I’d like to help you wash-up before I get you comfortable to go to bed. What would be a good time? 7 or 8 O’clock?” This depends upon the person’s ability. So that’s what we call the best friends approach. We talk to them more than the average person who can think and speak in a gentle way so that they will want to accept the care that we are offering. To get their permission.

If a patient starts yelling, our staff is instructed to stop immediately. Trying to keep the anger and frustration low. That’s the hard part. People cannot think, they cannot speak, and that is a huge communication problem. To work with their permission at their level of comfort. Make it fun; enjoy the day, that’s what we teach. That’s our message.

How do you ensure that the care plan is followed on a daily basis?
I can’t really ensure it. If something happens like somebody falls, I have to review it to make sure everybody knows. We are honest recorders, so when there is a problem, or if I see it, I call it to their attention whether it’s right or wrong. I also talk to staff about what things happened. Basically we have nurses, medics, all kinds of people walking around here, we are not in some individual’s home. There are a lot of people working to make sure the care notes are being followed. We offer families a copy of the care notes if they want it. The plan of care is unique to each person. In the old days, we used to use little index cards to write down details about a person. But so many of us are here for so long together, and the care is so consistent, that we just tell one another about changes.

Like the other day I found out someone liked tea with milk in it. So I added that to their care notes. Again, I’m not sure that everyone is checking the touch screen to review these details, but I advise them to do it. Especially then if something happens.

Can you tell me about some of the fun activities that go on there?
Well, we have so many people at various levels of functional and intellectual ability. If a person is just in their room, they will have one-on-one visitors and TV. Most people at in the assisted living home go out. They have outdoor activities for everybody there. In the memory care community they have extra activities three times a day. So we make sure that everybody is enjoying their day with music and movement, garden club, an accordion player who comes. We have a structured program.

Are care plans at work in your facility? Do you find them effective? If not, what alternatives do you prefer? Please share.