At a glance…
Through dedicated staff training, assembling these “pieces of the puzzle” yielded many facility-wide benefits.
Village Nursing Home has seen dramatic success in its project to enrich the abilities of staff interacting with residents with dementia-a project named “Pieces of the Puzzle.” The project has two objectives: (1) truly empowering certified nursing assistants (CNAs) to support a person-centered care model; and (2) providing these empowered CNAs with the best therapeutic recreation tools, in accordance with the American Therapeutic Recreation Association's (ATRA) Dementia Guidelines.
At the time of project development, Village Nursing Home understood that caregiver decision making and authority composed the foundation of any efforts to improve quality of care and quality of life for its residents. Among the Pioneer Network facilities that have created person-centered care environments, those who have seen positive outcomes in resident satisfaction and other quality-of-life measures-including Chase Memorial (the first Eden Alternative home), Providence Mount Saint Vincent, and the Wellspring facilities-have been those who have “empowered” the frontline caregivers. Almost all facilities that have empowered their CNAs and created person-centered cultures of care have also seen dramatic decreases in staff stress levels, which studies have linked to resident abuse and neglect. Furthermore, Drs. Reinhard and Stone, in their formal evaluation of the Wellspring Model, noted a link between quality-of-care measures and CNA empowerment.1 Clearly, person-centered care through caregiver empowerment is a “best practice” work environment intervention that improves the health and quality of life for residents.
Yet, the Village Nursing Home project was unique because it combined person-centered care efforts with a “toolbox” of evidence-based dementia recreation methods and the ability to personalize activities. Therapeutic recreation provides many health and quality-of-life benefits for nursing home residents, particularly those with dementia. More than simple diversion, purposeful and meaningful activities will improve mental status and functioning. In fact, study after study has shown that nursing home residents with cognitive impairments who receive recreation therapy demonstrate significantly improved depression levels, increased activity and alertness levels, and lowered fall rates. Yet, in most nursing homes, many residents access activity programs only occasionally, and those programs are not always suited to an individual's preferences or even functional level.
The Pieces of the Puzzle project made on-unit, individualized activities the responsibility of every CNA. Drawing on best practices and the Dementia Guidelines, CNAs first learned a bit about each of their residents and then made meaningful activities ubiquitous on the unit. For example, “personal [workstations] activities” that are designed with the resident's past life story/occupation in mind have been very successful; these can include a mock office area, baby care items with lifelike baby dolls, sheets or linens for folding, or simple tools. Residents are able to wander in and out of the activity area during the day, engaging in individual, meaningful activities that allow them to explore and manipulate.
By integrating therapeutic recreation planning and activities into improved caregiving responsibilities and into the caregiver-resident relationship, we anticipated the following benefits:
lower levels of agitation
lower levels of depression
increased engagement and socialization
The Pieces of the Puzzle project sequenced the two interventions, with the first four months of the project concentrating on building a person-centered care environment. This was accomplished by:
selecting staff who expressed a preference to work with residents with dementia;
implementing consistent assignment of CNAs to individual residents (as the consistent assignment of caregivers to residents enables CNAs to gain important insights into each person) and;
training the CNAs in communication and problem solving, through working with the Paraprofessional Healthcare Institute (PHI) and their Pioneer Network training modules.
However, we understood that training the CNAs was not sufficient in itself to support such a dramatic change in their responsibility and authority-changes in their supervisory relationships were also required. Therefore, the dementia unit's nurses, social workers, therapeutic recreation staff, and other supervisors were trained by PHI in “Coaching-Supervision.” This method of supervision focuses on relationship-building and on the role of supervisors in supporting further development of problem-solving skills on the part of line staff.
The final component of building CNA-empowerment was the establishment of a biweekly support group for the unit's CNAs. Dubbed “post-training discussion groups,” the CNAs met to discuss their new roles and to share concerns and ideas, and these were also used as “booster sessions” for the training material.