Nursing Times Award, Nursing in the Community category 2013
A specialist behavioural support service has been developed to support staff in residential and nursing homes to care for people with dementia who display behaviour that staff perceive as "challenging". The aim is to avoid the use of psychotropic medication in line with current government guidelines and to educate staff in relation to best practice in this area. We also use a cognitive behavioural model to work with staff to reframe "problem behaviour" into 'needs' that can be met. We work on the assumption that behaviour that staff find challenging is due to an unmet need, and that it is our challenge to ensure we do everything possible to meet that need. We promote psychosocial interventions and one of the main purposes of the introduction of the new service was to reduce admission to hospital psychiatric in-patient wards and moving the person unnecessarily. We aim to reduce the distress of people with dementia and maximise their potential to lead as fulfilling a life as possible. A key message is that with the right care and support people can "live well" with dementia. Allowing people with dementia to remain distressed and failing to meet needs also leads to situations that can be unsafe but also very undignified for the individual concerned.
We work hand in hand with our other new service – The Residential and Nursing Home Team. While the behaviour support service works solely with people with a diagnosis of dementia, we know that people do not fit into neat packages and referral criteria. By jointly screening referrals we decide which service is the most appropriate and often share patients with the most complex needs. The Residential and Nursing Home Team has particular expertise in management of delirium, and can be more medical in focus.
Benefits for staff
This way of working is very relevant to nursing practice and education. Modern nurses must role model best practice and demand the highest standards of care for older people. This is particularly important in light of recent scandals to damage the profession. We need to break down barriers and work together. It is also an educational approach which recognises the value of providing opportunities for staff to contribute directly and have a sense of ownership of the results of their input. It is collaborative and from a management perspective recognises the importance of staff feeling involved, valued, and supported instead of criticised and threatened.
The initiative is entirely person centred. It locates the person with dementia at the centre, and their values beliefs and perspective are all important. People with dementia feel heard and have their needs met in a very carefully considered way. While we may be unable to always ask people what is upsetting them or what we can do to make them feel better, this approach provides us with the best possible understanding of what might be causing them distress.
In contrast with other nursing initiatives designed to improve the care of older people, this approach is also very concerned with the well being of staff. Involving them in the process, empowering them to make suggestions and then formulating their ideas into a plan of care gives them a sense of ownership and achievement. Staff are therefore more likely to follow the plan and work in a consistent way. We know that consistency is a key to successful interventions.
Assessing behaviour in situ enables us to understand environmental and cultural triggers to behaviour.