Nursing Practice Discussion
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The model in practice A care plan is a complete portfolio of life history (Buron, 2010). It is compiled with the resident, relatives and significant pro- fessionals. It is a positive document indi- cating how to use enhancers and eliminate detractors to move away from “no cure, no help, and no hope” (Kitwood, 2007). The care plan includes words or proce-
dures suggesting how talk can be framed in a positive way. It is not a rigid schema of stages to be delivered in a fixed order – we use it as a flexible trigger to encourage interaction while attending to residents’ physical needs, framing nursing care through interactions. The emphasis is on recognising and promoting personhood. The care plan’s language is descriptive
and it clearly shows how actions are to be framed to preserve personhood and con- nect with the person. In practice, the instruction to carers is: “You are about to give a wash to resident A; please bear in mind our definition of dementia care and make this moment a memorable one.” We have a 10-minute discussion on
our model every morning, followed by a fortnightly one-hour reflective session, which all staff (including ancillary staff ) attend. The aim is to reinforce the care plan in practice and make it a practical document. This reflective openness and analysis raises the level of awareness in the quality of interactions between carers and residents, and develops insight into practices and formulates actions for future practice.
Effects of introducing the model The first anchor builds a cohesive team. Consistency empowers staff to take a deeper personal interest in residents’ welfare and build relationships with relatives. Staff understand better how to use enhancers. Residents feel more at ease as staff around them have developed a reassuring and motivating bond. There is a dynamic interplay between
what we espouse as our ideology and the level of understanding necessary to trans- late this ideology into practice. Therefore, when we appoint staff, we discuss learning and attendance at reflective sessions at length and make them aware of our learning culture right from the start. Our central constructs for new staff are:
unity of purpose; linking theory and prac- tice; and knowledge for reality. The dynamic interplay between these con- structs enables carers to collaborate with residents and relatives. The result is a vibrant atmosphere in which residents are engaged in thinking and talking, grounded
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in social interaction and occupation. Staff value their own practices in terms
of experiential knowledge and their ability to generate knowledge appropriate to our culture and practices. This has changed staff perceptions and their ability to be critical thinkers. They have found this empowering, and their increased confi- dence and skills have made them better able to care for people with challenging behaviour. Our residents experience a supportive
mode of care in all spheres of human inter- actions. We improve interaction, eradi- cating patterns of dominance and submis- sion in carer-resident relationships. Our model has helped staff to think about what a care home is; it is the residents’ home and staff are privileged to enter it and provide a service. Their behaviour and attitude are guided by this concept. This interpreta- tion of the home appears to shift the power base from staff to residents.
QUICK FACT
3 Segments in care
behaviours: thinking; feeling; and behaving
Care behaviour development Palm Court has created a method of behav- iour development imbued with thinking and feelings. Actions and interactions have both cognitive (thinking) and affec- tive (feelings) components, both of which affect behaviour. Thinking about and feeling the emotions in our actions and interactions influence our behaviour. The outcome of this is ethical behaviour. This approach maps relations between
actions, interactions, conversations and social structures in our organisation. Our development of care behaviour has pro- vided us with a theory to work with. It helps carers to analyse interactions and what resi- dents are thinking and feeling, and help them make this special connection. Care behaviour is cultivated and ampli-
fied when carers and nurses work on their thinking and feeling. For example, if I think of sympathy and feel it, then I am more likely to behave sympathetically. The more I behave sympathetically, it influences my thinking and feelings accordingly. It is a circular development of care behaviours, which is desperately needed to reassure people with dementia. Our care behaviour development model cements care practice energised by the STEP toolkit. The feedback from residents is that carers show interest in them, talk to them
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in a friendly manner with affection and show better understanding of them. Resi- dents and relatives often use words such as “dedicated”, “caring”, “patient” and “unbe- lievable” to describe carers’ behaviour.
Conclusion Dementia care is a specialist subject. It is better understood with a model such as Kit- wood Plus, which lays bare the key issues (relationships and experiences) in dementia care. It is by conferring personhood and making the special connection that we enable the person to be. The tools for caring are: smile; touch;
eye contact; and positive talk. This is what carers must be taught as basic skills to connect with people with dementia. Dementia care hinges on STEP and the car- er’s ability to connect with the person with dementia. Care should be carried out in a way that makes it interesting and memo- rable. We find the quality of daily experi- ence is enhanced with our four anchors; other care homes and hospitals could improve dementia care practices by adopting them. Care behaviours consist of three dis-
tinct segments: thinking, feeling and behaving. Our aim is to develop the affec- tive and cognitive domains of care, pro- ducing carers with appropriate behaviour. Communication and care practice are strengthened when supported by good care behaviour. Kitwood Plus and our approach to care
behaviour development have the potential to be used in other care settings, particu- larly mental health and learning disability services. NT
References Bohlmeijer E et al (2007) The effects of reminiscence on psychological well-being in older adults: a meta-analysis. Aging and Mental Health; 11: 3, 291-300. Brooker D (2003) What is person-centred care in dementia? Reviews in Clinical Gerontology; 13: 215-222. Bryden C (2005) Dancing with Dementia: my Story of Living Positively with Dementia. London: Jessica Kingsley Publishers. Buron B (2010) Life history collages: effects on care home staff caring for residents with dementia. Journal of Gerontological Care; 36: 12, 38-48. Department of Health (2012) Dementia. tinyurl. com/DH-dementia-page Dewing J (2004) Concerns relating to the application of frameworks to promote person- centeredness in nursing with older people. Journal of Clinical Nursing; 13: 39-44. Ford P, McCormack B (2000) Keeping the person in the centre of nursing. Nursing Standard; 14: 46, 40-44. Kitwood T (1997) Dementia Reconsidered: the Person Comes First. Maidenhead: Open University Press. Shipman D et al (2011) Healthcare organizations benefit by promoting BSN education. Nurse Education Today; 31: 4, 309-310.
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