Facilitators Guide for Basic Dementia Care Competencies



Facilitator’s Guide:

Developing Basic Dementia Care Competencies

This guide is meant to assist participants who attended to Track 1 of the Conference "Transforming Care for Veterans with Challenging Behaviors” on August 26-28, 2008 to teach these skills and competencies to staff in their local medical centers, community living centers, and networks.

The goal of this guide is to assist participants as they work through the experiential exercises designed to develop the needed knowledge, skills and attitudes to help leaders in each VISN within the Veterans Health Administration master the following core dementia skills:

1. Positive Physical Approach

2. Systematic Cueing

3. Hand-under Hand

4. Responding to Distress

5. Positive Verbal Interactions

Because not all staff will have skill using experiential learning or coaching approaches, we include two additional sessions needed to embed the new skills on a unit:

1. Observing Behavior of Others Objectively

2. Giving Constructive Feedback

Be aware that in order to successfully teach these skills, the trainer will need to practice the skills as well. We recommend asking a colleague to observe your skills, both in simulation and in real time to build competence in each one of the dementia care skills, as well as your skills as a coach.

The facilitators guide contains the following teaching aids for each topic:

1. Session Overview that includes goals for session, learning activities & materials or set up needed.

2. Experiential exercise with discussion questions/prompts for facilitating learning from the exercise

3. A skills checklist

4. Supplemental handouts that help to illustrate the technique further

A recommended training schedule is summarized on the next page.

Special thanks to the trainers who contributed to this facilitator’s guide:

Melanie Bunn, RN, MSN, GNP & Teepa Snow, MS, OTR, Eastern North Carolina Alzheimer’s Association, Jorge Cortina, MD, VISN 6 Geriatrics & Extended Care Service Line Manager, Frances Freeman-Jones, C.N.A., Durham VAMC, Kathryn (Kitty) Hancock, RN, MSN, Nurse Educator, Asheville VAMC & Eleanor S. McConnell, RN, PhD, GCNS, BC, Durham GRECC

Training Schedule

|Time |Activity |Comments |

|8:30 – 9:15 |Skill #1: |Exercises comparing effects of common approaches v. approaches that |

| |Positive Physical Approach |maximize use of preserved abilities. |

| | |Skills checklist & practice |

|9:15-10:00 |Skill #2: Systematic Cueing |Exercises to develop awareness of our use of cues, and how they can be |

| | |used systematically to support function and control for veterans with |

| | |various levels of cognitive function |

| | |Progression of dementia & levels of cognitive function |

| | |Skills checklist & practice |

|10:00-10:15 |Break | |

|10:15-11:00 |Skill #3: Hand-Under Hand |Exercises comparing effects of physical assistance techniques that engage|

| | |the veteran v. physical assistance that removes control from the veteran |

| | |Job Aid for hand-under-hand technique |

| | |Skills checklist & practice |

|11:00-11:30 |Skill #4: Responding to Distress |Exercises on recognition of affective states: Anger, Fear, Sadness, |

| | |Discomfort, Pleasure |

| | |Exercises effects of common approaches to veterans with cognitive |

| | |impairment who are distressed v. those that take into cognitive level |

| | |Skills checklist & practice |

|11:30-12:00 |Skill #5: Positive Verbal Interactions |Exercises to raise awareness of negative affect from unsystematic verbal |

| | |cueing & to build skill in providing simple verbal cues. |

| | |Skills checklist & practice |

|12-1:30 |Lunch | |

|1:30-2:00 |Coaching Skill #1: |Exercise to practice observation of new skills & use of simulated patients|

| |Observing behavior of others objectively |to allow controlled observations |

|2:00-2:30 |Coaching Skill #2: |Exercises to practice giving feedback to others that is specific, |

| |Giving constructive feedback |constructive, and timely |

| | |Additional practice with basic skills checklists |

|2:30-3:00 |Practice Observation and feedback techniques |Time for additional practice with skills, or reflection on challenges to |

| | |implementation |

Session 1: Positive Physical Approach

Learning Goals

• Describe key steps in approaching person with dementia

• Discuss rationale for each step

• Experience negative affect associated with incorrect approach

• Demonstrate positive physical approach (PPA) with simulated patient

Learning Activities

1. Show slide set providing an overview of the experiential learning model &

basics of dementia

(fileref: 1-Transforming Care for Veteran's with Challenging Behaviors-Snow Slideset Part 1 Intro to dementia and ELC.ppt)

2. Experiential exercises focused on approach techniques:

(fileref: 2-Positive_Approach-Teachers guide.pdf)

3. Explore challenges regarding implementation of PPA at unit-level

Handouts

• Positive physical approach skills checklist (below)

• Getting started with dynamic assessment (handout on next 2 pages)

Approach Skills Checklist – Observation of Skill Use

Caregiver: ____________________________________________

|Key Steps of Positive Physical Approach |Y= Yes |Comments |

| |N = Not seen | |

| |NA= not applicable | |

|Pauses at edge of public/personal space | | |

|Approaches within visual range | | |

|Moves one step/second during approach | | |

|Offers social contact before task Initiation | | |

|Uses supportive stance during interaction: | | |

|to the side at eye-level | | |

|Respects personal space during initial contact | | |

|Uses preferred name for attention | | |

|Offers physical contact to establish interaction | | |

|Awaits resident response | | |

|Acknowledges resident responses | | |

Recommendations for Continued Practice

Come from the front - within visual range

|If the resident….. |It may mean…. |So….. |

|Looks up as you come near |They attend to the sounds, sights, & activities |Adjust environmental lighting and sound - with |

| |around them |permission (if the resident has comprehension skills)|

| | |Knock on the door before entering their room |

| | |Call a greeting before approaching |

|Continues to attend to their own actions or objects |They attend only to what is immediately in front & |Don't expect the resident to listen to your voice |

| |close |UNTIL you are right there and they focus on you |

Go SLOW

|If the resident….. |It may mean…. |So….. |

|Responds swiftly with a greeting or eye contact |They can process visual information fairly well |Use visual cues to get messages across |

|Is slow to respond or acknowledge you |They process information slowly |SLOW DOWN during tasks |

Get to the Side

|If the resident….. |It may mean…. |So….. |

|Follows you with their eyes or body |They are somewhat oriented to movement in space and |Use visual cues such as gestures, pointing, combine |

| |can track movement some |verbal with visual cues |

|Loses you as you move to the side |They lack peripheral attention and focus only on |Re-establish or always maintain physical contact, if|

| |what is 'right' in front - |you or the task requires movement |

| |They may have trouble tracking demonstrations, |Use guidance and hand-under-hand assistance |

| |visual cues, verbal instructions | |

Get Low

|If the resident….. |It may mean…. |So….. |

|Smiles and begins to interact with you |They are able to attend to you as a person |Use verbal cues that match comprehension ability |

| | |Use gestures, demonstration, objects to help |

| | |Use touch for attention and tactile guidance |

|Continues to regard own actions or objects |They may need help to focus attention on any tasks |Prepare objects and set-ups for use prior to |

|immediately in front | |presenting them |

| | |Make sure the work surface is well lit |

|Continues to be non-engaged - non-alert/aroused |They are still not aware of you and may startle with|Move slowly and keep voice and movements slow and |

| |auditory or tactile contact |steady |

Offer Your Hand

|If the resident….. |It may mean…. |So….. |

|Takes your hand and shakes it, then lets go |They are able to use social greeting behaviors |Provide work surfaces with objects and utensils that|

| |They have grossly intact hand function |are familiar to do tasks |

| | |Provide social contact before engaging in tasks |

|Looks at you, then your hand and back before taking |May have trouble seeing the 'whole' picture or task.|Present objects and tasks one step at a time |

|it |Processes in pieces |Use the visual environment to cue for tasks |

| | |Simplify and minimize verbal cues and information |

|Looks at your hand or takes it and explores it |Processes objects, the environment, tasks, and |Organize the visual environment for safety |

| |helpers as things to be explored and handled or |Provide objects and tasks that are designed to be |

| |mouthed |handled and mouthed |

| | |Expect to provide tactile help thru hand-under-hand |

| | |guidance or assistance and dependent care for more |

| | |complex manipulative activities |

|Does not interact with your hand |Not able to process objects in the environment |Provide hand-under-hand assistance or dependent care|

| | |for tasks |

Call Their Name

|If the resident….. |It may mean…. |So….. |

|Responds verbally in greeting |They can comprehend some verbal information |Use verbal cues to introduce tasks and activities… |

| | |Determine level of comprehension NEXT |

|Looks around then makes eye contact |They recognize their name and can figure out that |Use verbal cues that support visual or tactile cues |

| |someone is trying to get their attention |Use visual cues in the work space to encourage |

| | |activity |

| | |Expect difficulty in shifting attention from the |

| | |task to you, SO limit talking … let them focus on |

| | |the task |

|Does not seem to respond to name |They may not process auditory language |Wait 10 seconds and try again |

| |They may not be alert YET… |Combine name cue with touch for attention prior to |

| | |doing tasks |

| | |Expect to provide dependent care and some |

| | |hand-under-hand assistance |

Learning Goals

• Describe 3 types of cues: visual, verbal, tactile

• Demonstrate how each type of cue can be used in caregiving

• Discuss how brain damage from dementia influences ability to use each type of cue

• Experience negative affect associated with cues that cannot be processed

• Experience negative affect associated with excess dependency

• Demonstrate effective use of visual, verbal and tactile cues in simulations showing various levels of cognitive function.

Learning Activities

1. Show overview developed by Melanie Bunn

(fileref: 3-VASystematic Cuing-train the trainer version-bunn.ppt)

2. Observation of simulated or videotaped care situations & identification of cue types

(see handout on next page)

3. Experiential exercise for types of cueing & practice with skills checklist

(see Bunn slideset notes referenced in #1)

4. Explore challenges in implementation of systematic cueing

Handouts

1. Skills checklist for systematic cueing (below)

2. Matching types of help handout (next page)

3. Types of cues organized by level of cognitive function

(fileref: McConnell-Cues by Level-final.doc)

Skills Checklist for Systematic Cueing

|Categories of Cues |Sequence for cues |Examples: |

|· Visual |Visual then |Visual – point, show props or objects, gesture, demonstrate |

| |Verbal then | |

| |Tactile | |

| |OR | |

| |Show – Tell – Touch) | |

|· Verbal | |Verbal – talking & telling, step-by-step instructions, simplified & |

| | |short sentences, use of name, positive comments |

|· Tactile | |Tactile – shake hand, hold hand (hand-under-hand), squeeze hand (HuH), |

| | |touch body part, use hand-under-hand |

|Criterion |Demonstrates Y/N |Comments |

|Identifies visual, verbal and tactile cues in simulated care situation.| | |

|Demonstrates combined use of 3 categories of cues in simulated care | | |

|situation | | |

|Uses 3 categories of cues in the correct sequence during observed | | |

|social interaction with resident & adapts based on veteran response | | |

|Uses 3 categories of cues in the correct sequence during observed | | |

|resident care & adapts based on resident response | | |

|Matches specific cues in each of three categories to the resident’s | | |

|abilities and level of cognitive function. | | |

Cues: Examples of cues in specific care situations.

Note: cueing strategy must be aligned with cognitive level or veteran is likely to be frustrated resulting in challenging behaviors

|Outcome of Care |Visual |Verbal |Tactile |

|Building caring relationships|1. Smile |1. Hi! |1. Shake hands |

| |2. Wave |2. Good morning! |2. Firm touch on shoulder |

|Engaging veteran in |3. Offer hand |3. Good to see you! |3. Hug |

|meaningful time use |4. Signs for social events |4. Nice shirt you're wearing! | |

| | |“I’m ---(give your name). | |

|Oral care completed |1. Pictures on vanity or drawer showing|1. Would you like to brush your teeth or wash|1. Hand the person the toothbrush |

| |oral care supplies |your face? | |

| |2. Place toothbrush and toothpaste in | |2. Using hand-under-hand support, place|

| |view |2. "Time to brush your teeth" |toothbrush in veteran's hand and move |

| |3. Put paste on toothbrush & point |OR |toothbrush toward teeth |

| |4. Show person toothbrushing motion | | |

| | |3. Step-by-step instructions: | |

| | |"Pick up the toothbrush" | |

| | | "Put the toothbrush in your mouth." | |

| | | "Brush" | |

| | |"Spit" | |

|Eating |1. Show person dining area set for food|1. "Let's go eat." OR |1. Hand the person a sandwich |

| | |2. "It's lunchtime" OR | |

| | |3. Step-by-step instructions: |2. Using hand-under-hand support, place|

| | |“Pick up the cup” |cup in veteran's hand and move cup or |

| | | |other food toward mouth |

| | |“Drink” | |

|Dressing |1. Place clothes out in view of |1."Mr. X -- please put on that shirt" OR |1. Hand shirt to veteran |

| |veteran. |2. Mr. X - its time to get dressed -- put on |2. Using hand-under-hand hold, guide |

| |2. Point to shirt. |the shirt now OR |the veteran’s arms through each sleeve.|

| |3. Demonstrate or mime putting on shirt|3. Step-by-step instructions | |

|Bathing |1. Show person bathing area set up for |1. “Mr. X – time to wash up” |1. Hand washcloth to veteran |

| |a bath (towels, soap, shower). |2. “Step by step instructions |2. Using hand-under-hand help veteran |

| | | |to pick up warm washcloth & wash face |

|Toileting |1. Take person into toilet room |1. “Mr. X – time to use the toilet” |1. Assist with transfer onto toilet |

| | |2. “Step by step instructions: | |

|Taking Medications |1. Show person pill cup & water |1. Do you want your pills one at a time, or |1. Give person pill cup & water |

| | |all at once? | |

| | |2. Time for your pills | |

See separate handout on cueing according to level of cognitive function.

Learning Goals

• Describe 3 reasons why hand-under-hand (HUH) is preferred approach to providing physical assistance with basic care (see list on page 4-2).

• Demonstrate HUH handclasp

• Experience difference in completing tasks with HUH assistance v. routine assistance in oral care and drinking from a cup.

• Demonstrate HUH assistance with simulated patient

Learning Activities

1. Eating simulation with physical assistance with and without hand-under-hand assistance

2. Practice getting into hand-under-hand clasp

(fileref: 4-handholds.doc)

3. Practice using hand-under-hand clasp to assist with care tasks

4. Explore challenges in implementation of hand-under-hand assistance

Handouts

1. HUH Skills checklist (below)

2. Hand-under-Hand (HUH) Job Aid

(fileref: 4-Hand Holds)

Skills Checklist for Hand-Under-Hand Guidance & Assistance (HuH)

|Criterion |Demonstrated Y/N |Comments |

|Demonstrates correct Hand-Under-Hand (HUH) Clasp | | |

|Demonstrates use of HuH for assisting with carein simulated situation for | | |

|both dominant (D) and non-dominant (ND) hand of caregiver | | |

|Demonstrates HuH during observed social interaction with resident | | |

|Demonstrates HuH while assisting veteran with physical care task | | |

|Demonstrates modified HuH during ‘special’ care situations – contractures,| | |

|tremors, paralysis, severe arthritis | | |

Rationale for Hand-Under-Hand (HuH)

1. Connects the resident to the caregiver in a positive and friendly way

2. Protects the caregiver from sudden physical actions and squeezing of hand or arm

3. Protects the resident from an automatic reaction from the caregiver if grabbed or hit

4. Engages the resident in the task – rather than having the task done to the person – uses familiar brain pathways

5. Preserves motor skills as dementia progresses, by allowing the person to do ‘some’ of the task

Learning Goals

• Describe systematic approach to working with veterans who are showing signs of distress

• Discuss rationale for each step

• Demonstrate each of 7 key steps in working with someone in distress

Learning Activities

1. Present overview of how to work with distressed patients:

(fileref: 5-Transforming Care for Veteran's with Challenging Behaviors-Snow Slideset-Dealing with Distress.ppt)

2. Exercise comparing empathic with non-empathic responses to distress

3. Exercises for recognizing different emotional states

4. Practice with skills checklist

5. Explore challenges in implementation of new responses to distress at unit-level

Handouts

Skills Checklist for Responding to Distress

|Criterion |Demonstrated Y/N |Comments |

|1. Use PPA to approach resident | | |

|2. Connect – visually, verbally, and physically | | |

|3. Repeat resident’s words with a ‘QUESTION MARK’ at the end | | |

|- PAUSE | | |

|4. Make EMPATHETIC statement – “It sounds like…, It seems | | |

|like…” – figure out the emotion or need being expressed | | |

|5. Respond with “Tell me about your….” | | |

|(use words veteran is using to show you are listening) | | |

|6. Listen for & watch for symptoms or signs of pain, hunger, | | |

|fatigue, need to void or have BM, need to be changed, thirst…| | |

|7. Respond to identified need OR move the person to a new | | |

|location, a new conversational topic, and offer a new | | |

|activity for engagement | | |

|8. Does NOT use: | | |

|- reality orientation OR | | |

|- lying | | |

Note:  PPA = Positive Physical Approach

Learning Goals

• Describe rationale for engaging in positive verbal interactions

• Demonstrate ability to engage in positive interactions with simulated patient with chronic cognitive impairment

Learning Activities

1. Provide overview of positive verbal interactions:

(fileref: 6-Transforming Care for Veteran's with Challenging Behaviors-Snow Slideset-Positive verbal interactions.ppt).

2. Exercises to raise awareness of negative affect from unsystematic verbal cueing & to build skill in providing simple verbal cues.

(fileref: 6a-VAPositive Verbal Interactions-train the trainer-Bunn).

3. Practice with strategies to engage in positive verbal interactions (see list below)

4. Explore challenges implementing positive verbal interaction skills at unit-level

Handouts

1. Seven strategies for engaging in positive verbal interactions

2. Skills checklist for positive verbal interactions

Positive Verbal Communication Skills for Task Engagement

1. Provide information about task to be done – keep it short and simple

2. Offer two choices or options related to task performance

3. Ask the person to “try”

4. Ask the resident to “help” you

5. Provide step by step tasks rather than whole task request

6. Offer positive feedback and comments with any attempt or effort

7. Express appreciation for participation, engagement, or task completion

If technique is NOT working: STOP, BACK OFF, TRY AGAIN with another strategy

Skills Checklist for Positive Verbal Interactions

|Specific Measure |Demonstrated Y/N |Comments |

|Demonstrates giving short, simple verbal cues | | |

|Offers structured realistic choices rather than "do you want | | |

|to..." (may not know) OR rather than telling people (seems | | |

|bossy) according to cognitive level | | |

|Demonstrates use of key positive verbal communication | | |

|techniques in simulated situation | | |

|Responds to resistance or refusal of care with "lets try" or | | |

|"could you help me?" | | |

Learning Goals

• Demonstrate ability to notice key elements of dementia care skills behavior in colleagues using simulated patient

• Describe strategy for dealing with complexity of making accurate observations

Learning Activities

1. Exercise to practice observation of new skills & use of simulated patients to allow controlled observations:

• Have staff divide into groups of 3 as below:

• 1 person as a patient (simulating one of the “GEMS of dementia.”

(fileref 7-The Gems of Caregiving.ppt OR

Cues by Level-final.doc)

• 1 person as caregiver

• 1 person as observer

• Have caregiver demonstrate performing positive physical approach or hand-under-hand technique

• Have observer rate performance of caregiver

• Have observer share written feedback with caregiver, and check in with the other two participants to explore

2. Participants receive feedback on accuracy of observations & practice with basic skills checklists from sessions 1-5

3. Explore challenges in developing cadre of preceptors who are proficient in observing behavior of others

Handouts

Skills checklists for Positive Physical Approach, or Hand-under-Hand

Learning Goals

• Demonstrate ability to give positive feedback in a manner that is direct, and specific

• Demonstrate ability to give negative feedback in a direct, specific, and constructive manner

• Describe impact of not giving feedback on skills performance

Learning Activities

1. Exercises to practice giving feedback to others that is specific, constructive, and timely

(fileref: 7a-Teaching Outline for Giving Feedback-Snow.doc and

7b-Giving Feedback-Hancock)

2. Additional practice with basic skills checklists

3. Explore challenges in coaching preceptors to give feedback in constructive manner

Handouts

Skills checklist for:

• Hand-Under-Hand Assistance

• Systematic cueing

• Responding to Distress

• Positive Verbal Interactions

Beck, C., Heacock, P., Mercer, S. O., Walls, R. C., Rapp, C. G., & Vogelpohl, T. S. (1997). Improving dressing behavior in cognitively impaired nursing home residents. Nursing Research, 46(3), 126-132.

Burgio, L. D., Allen-Burge, R., Roth, D. L., Bourgeois, M. S., Dijkstra, K., Gerstle, J., et al. (2001). Come talk with me: improving communication between nursing assistants and nursing home residents during care routines. Gerontologist, 41(4), 449-460.

Burgio, L. D., Stevens, A., Burgio, K. L., Roth, D. L., Paul, P., Gerstle, J., et al. (2002). Teaching and maintaining behavior management skills in the nursing home. Gerontologist, 42(4), 487-496.

Farran, C. J., Gilley, D. W., McCann, J. J., Bienias, J. L., Lindeman, D. A., Evans, D. A., et al. (2007). Efficacy of behavioral interventions for dementia caregivers. Western Journal of Nursing Research, 29(8), 944-960.

Livingston, G., Johnston, K., Katona, C., Paton, J., Lyketsos, C. G., Old Age Task Force of the World Federation of Biological, P., et al. (2005). Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. American Journal of Psychiatry, 162(11), 1996-2021.

Logsdon, R. G., McCurry, S. M., Teri, L., Logsdon, R. G., McCurry, S. M., & Teri, L. (2007). Evidence-based psychological treatments for disruptive behaviors in individuals with dementia. Psychology & Aging, 22(1), 28-36.

Rogers, J. C., Holm, M. B., Burgio, L. D., Granieri, E., Hsu, C., Hardin, J. M., et al. (1999). Improving morning care routines of nursing home residents with dementia. Journal of the American Geriatrics Society, 47(9), 1049-1057.

Stevens, A. B., Burgio, L. D., Bailey, E., Burgio, K. L., Paul, P., Capilouto, E., et al. (1998). Teaching and maintaining behavior management skills with nursing assistants in a nursing home. Gerontologist, 38(3), 379-384.

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