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
8:30 – 9:15 / Skill #1:
Positive Physical Approach / · Exercises comparing effects of common approaches v. approaches that 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:
Observing behavior of others objectively / · Exercise to practice observation of new skills & use of simulated patients to allow controlled observations
2:00-2:30 / Coaching Skill #2:
Giving constructive feedback / · Exercises to practice giving feedback to others that is specific, 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
Facilitator’s Guide for Dementia Basic Skills i-1
Content presented at DVA Conference: Transforming Care for Veterans with Challenging Behaviors Chicago 8/27/08
Getting Started with Dynamic Assessment… Approach and Abilities Match
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= YesN = Not seen
NA= not applicable / Comments
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
Looks up as you come near / They attend to the sounds, sights, & activities around them / Adjust environmental lighting and sound - with 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 & close / Don't expect the resident to listen to your voice 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 can track movement some / Use visual cues such as gestures, pointing, combine verbal with visual cues
Loses you as you move to the side / They lack peripheral attention and focus only on what is 'right' in front -
They may have trouble tracking demonstrations, visual cues, verbal instructions / Re-establish or always maintain physical contact, if you or the task requires movement
Use guidance and hand-under-hand assistance
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 immediately in front / They may need help to focus attention on any tasks / Prepare objects and set-ups for use prior to 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 auditory or tactile contact / Move slowly and keep voice and movements slow and 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
They have grossly intact hand function / Provide work surfaces with objects and utensils that are familiar to do tasks
Provide social contact before engaging in tasks
Looks at you, then your hand and back before taking it / May have trouble seeing the 'whole' picture or task. Processes in pieces / Present objects and tasks one step at a time
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 helpers as things to be explored and handled or mouthed / Organize the visual environment for safety
Provide objects and tasks that are designed to be 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 someone is trying to get their attention / Use verbal cues that support visual or tactile cues
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
They may not be alert YET… / Wait 10 seconds and try again
Combine name cue with touch for attention prior to doing tasks
Expect to provide dependent care and some hand-under-hand assistance
Skill 1: Positive Physical Approach 1-3
Content presented at DVA Conference: Transforming Care for Veterans with Challenging Behaviors Chicago 8/27/08
Session 2: Systematic Cueing
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
Verbal then
Tactile
OR
Show – Tell – Touch) / Visual – point, show props or objects, gesture, demonstrate
· 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 / TactileBuilding caring relationships
Engaging veteran in meaningful time use / 1. Smile
2. Wave
3. Offer hand
4. Signs for social events / 1. Hi!
2. Good morning!
3. Good to see you!
4. Nice shirt you're wearing!
“I’m ---(give your name). / 1. Shake hands
2. Firm touch on shoulder
3. Hug
Oral care completed / 1. Pictures on vanity or drawer showing oral care supplies
2. Place toothbrush and toothpaste in view
3. Put paste on toothbrush & point
4. Show person toothbrushing motion / 1. Would you like to brush your teeth or wash your face?
2. "Time to brush your teeth"
OR
3. Step-by-step instructions:
"Pick up the toothbrush"
<pause> "Put the toothbrush in your mouth."
<pause> "Brush" <pause>
"Spit" / 1. Hand the person the toothbrush
2. Using hand-under-hand support, place toothbrush in veteran's hand and move toothbrush toward teeth
Eating / 1. Show person dining area set for food / 1. "Let's go eat." OR
2. "It's lunchtime" OR
3. Step-by-step instructions:
“Pick up the cup”
<pause>
“Drink” / 1. Hand the person a sandwich
2. Using hand-under-hand support, place cup in veteran's hand and move cup or other food toward mouth
Dressing / 1. Place clothes out in view of veteran.
2. Point to shirt.
3. Demonstrate or mime putting on shirt / 1."Mr. X -- please put on that shirt" OR
2. Mr. X - its time to get dressed -- put on the shirt now OR
3. Step-by-step instructions / 1. Hand shirt to veteran
2. Using hand-under-hand hold, guide the veteran’s arms through each sleeve.
Bathing / 1. Show person bathing area set up for a bath (towels, soap, shower). / 1. “Mr. X – time to wash up”
2. “Step by step instructions / 1. Hand washcloth to veteran
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”
2. “Step by step instructions: / 1. Assist with transfer onto toilet
Taking Medications / 1. Show person pill cup & water / 1. Do you want your pills one at a time, or all at once?
2. Time for your pills / 1. Give person pill cup & water
See separate handout on cueing according to level of cognitive function.
Skill 2: Systematic Cueing 2-3
Content presented at DVA Conference: Transforming Care for Veterans with Challenging Behaviors Chicago 8/27/08