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.
