dr lisa clinnick - acu - behaviour centred care versus person centred care: the challenge of bpsd...
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Behaviour Centred Care versus Person Centred Care: The Challenge
of BPSD Management
Dr Lisa Clinnick
Australian Catholic University
School of Nursing, Midwifery & Paramedicine
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Discussing
• What is person centred care and can it be achieved?
• Explore PCC and BCC focusing on the use of psychotropic medications in residential aged care.
• Key elements of PCC
• Nurse Behaviour Assistant – mobile application.
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Person Centred CareDefining PCC
-Kitwood (1997) – to be a person meant to have personhood.
-described by others as • maintaining personhood despite declining cognitive ability;
• collecting and using personal experiences of life and relationships to individualised care;
• prioritises relationships as much as care tasks;
• involve family members in care and shared decision making .
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Person Centred Careas “…the need for a recognition of, and connection with, the person, a focus on the person’s strengths and goals, an interdisciplinary approach, and a recognition of the centrality of relationships”.
(Nay et.al., 2014).
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Barriers• Despite its intuitive appeal, the philosophy of
resident-centred care has not yet been widely embraced.
• Resistance stems from both the institutional system and the direct care provider.
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Barriers• obstacles include –
– regulatory and sanction pressures
– the fear of litigation if one deviates from tight conformation to uniform protocols
– high staff turnover rates which make it difficult for staff to get to know and develop relationships with residents,
– and a lack of clear standards to guide the provision of more individualized, humanistic care .
– Staff convenience
– Facility/staff culture
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BCC vs PCC – psychotropic medsBehaviour Centred Care Person Centred Care
Psychotropic medication as 1st option Use non pharmacological intervention 1st
Quick easy fix Need to know the resident
Stopped behaviour ‘now’ Effective and calms the resident
No special skill required Increases staff moral & satisfaction
Nurse controlled the situation Promotes resident autonomy
Lack team work Interdisciplinary approach
No family relationship or involvement Family/resident involved as partners
Institutionalised culture Nurse advocate
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25%-50%
Rate of NH
residents on
psychotropic
medication
(1988)
47.7%
rate of Sydney NH
residents receiving
psychotropic medication
(2006)
UK 2009
Dementia Framework
submission –
“estimated that we are
treating 180,000 people with
dementia with antipsychotic
medication across the
country per year. Of these, up
to 36,000 will derive some
benefit from the treatment”
60%
of residents receive one
psychotropic medication
37%
receive two
11%
receive three or more.
(1988)
20%
The number of residents
receiving psychotropic
medications who did not have
a diagnosis (1994)
2003 Helsinki
study
79.9% of residents
prescribed
psychotropic
medications
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Psychotropic medications use in RACF• “Side effects of all benzodiazepines include
excessive sedation, psychomotor slowing, cognitive impairment, confusion, forgetfulness, morning “hang-over” effect, ataxia and falls”
• the overall side effect profile of both typical and atypical antipsychotics is vast. Side effects include increased risk of falls, sedation, orthostatic hypotension, anticholinergic effects, insomnia and weight gain to name a few.
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Research method
Research question Exploring nurses decisions when administering psychotropic medications to nursing home residents
Methodology• Qualitative research – Grounded Theory
Data Collection• X2 NH completed• Interviews – RN’s & EEN• Participatory observation – work with the nurses• Field work – 6-9 months each NH
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findings
• Nurses wanted to provide PCC but provided BCC.
The nurses –
Customs
Knowledge
Relationships
influenced the decision making outcome
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Customs
• What is a custom –
– an established and socially accepted practice.
– Assists to regulate the social group.
The custom was to administer psychotropic medications as first line management of unmet need behaviours.
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Customs - theme
• Controlling the residents behaviourWe’d use antipsychotic medication as we call it. It helps to control the behaviour of those residents who are very hard, you know, very, very – who’ve got dementia and very, very hard to control. (Participant 1, p. 1)
• Convenience Oh well they (the nurse) know it’s going to shut them up (Participant 3, p. 4)
• Accepted practice
• Responsibility of role
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Knowledge• Nurses’ knowledge of psychotropic medication
and chemical restraint
• Knowledge of nursing interventions and alternative strategies
• Knowing the resident - nursing assessment and evaluation
• Type of resident receiving psychotropic medication as chemical restraint
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Relationships• Rights – staff and residents
• Health professionals relationships
• Family involvement
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How can we move towards a PCC model?
Successful implementation of a PCC model needs –
• Cultural change including
– Staff empowerment – challenge accepted practices/customs/attitudes
– Effective Teamwork – health professionals and families
– Strong leadership and role modelling.
– Ongoing education and up-skilling
– Family/resident relationships and partnerships
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Nurse Behaviour AssistantProject Aim
• to identify an appropriate approach toward the provision of tools that could be helpful to nurses when making assessments and choosing BPSD intervention strategies when attending to a resident in a short time frame.
• be practically deployed
• encourage a decision maker to exercise discretion
• Developed NBA – Nurses Behavioural Assistant innovative and sophisticated psychologically-based mobile application and web-based system.
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Ripple Down Rules• using concepts of discretion from
jurisprudence helped to identify the ripple down rules
• A key feature of the RDR approach is that the rule base can be initially deployed with a relatively small number of rules drawn from best practice principles for assessment and intervention selection, and relatively easily have new rules added that act as exceptions to the first entered rules for specific situations.
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Findings & Future• Very well accepted application – positive feedback
• More of a focus on the NBA as a reporting as well as learning system, instead of an intervention system for problem behaviours.
• PCA and volunteers who have less formal training to be used in future trials.
• Greater staff involvement over a longer trial period, suggested up to 3 months.
• The use of all staff members (nursing, pca and voluntary) and all resident’s one facility to ensure all events are captured.
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Conclusion
PCC is the ideal care model in aged care.
“Excellence is not a destiny, it is a continuous journey that never ends” Brian Tracey