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Exploring a Key Barrier to Buy-In and Follow-Through

Exploring a Key Barrier to Buy-In and Follow-Through
Not getting buy-in from your colleagues? You may be surprised at what I believe is one of the most significant barriers. Read on.

One of my primary professional roles is that of a consultant/trainer. I consult to nursing homes and assisted living facilities that provide dementia care. My task is to implement or enhance a dementia care program and provide dementia training to improve the quality of care and outcomes. And, I provide consultation to therapy companies who desire to build a quality dementia program.

A somewhat common problem that I face, and I hear many of you face, is resistance to these teachings. The resistance appears to come from a disconnect at a very foundational level. The disconnect is in our "paradigm." What is a paradigm? One definition found in a dictionary is "a prevailing belief or point of view." There are many paradigms in dementia care that are highly destructive to our work and our hopes of achieving positive outcomes through successful professional partnerships.

What are the "prevailing beliefs or points of view" of a person who has Alzheimer's disease or a related dementia?

Activity: Take a moment and please jot your thoughts on a piece of paper. Please share your thoughts in our Current Educational Topic Discussion Forum.

Below is a sampling of the prevalent beliefs I have heard from therapists, CNAs, nurses, owners, and managers:
  • She has Alzheimer's . . . she can't do ANYTHING anymore.
  • She acts that way (hitting, cursing, resisting care, etc.) because she has Alzheimer's. That's just what happens.
  • He's not appropriate for therapy because he can't learn.
  • He wanders all day because he has Alzheimer's. That's all the activity he can do.
  • The best we can possibly do is keep them clean, dry, quiet, and free from injury.


If that is their belief, what do you think their care approaches will look like?

If that is their belief, what do you think the outcomes of care will be?

If that is their belief, what do you think the potential for the person with dementia is in ADLs, mobility, communication, and quality of life?

If that is their belief, what do you think their response to you and your teachings will be?

Current Common Paradigms
Let's look closer at each of these paradigms.

  • She has Alzheimer's . . . she can't do ANYTHING anymore.


My Comments: This is a totally false belief! When you perform the Allen assessment you are identifying remaining abilities. Their Allen Cognitive Level is a description of their remaining abilities. Abilities remain at EVERY stage of dementia. These abilities can be utilized in all activity, through the proper care approaches and activity modifications.

This false belief will likely lead to:

  •  
    • "Excess disability" for the vast majority of resident/patients.
    • Mental and physical inactivity which can cause contractures, loss of mobility, pressure sores, falls, weight loss, behavior issues, low self-esteem, greater burden on staff, TERRIBLE QUALITY OF LIFE . . .
       
  • She acts that way (hitting, cursing, resisting care, etc.) because she has Alzheimer's. That's just what happens.


My Comments: This is a totally false belief! Yes, a small percentage of behaviors are caused from chemical imbalances inside the brain and are difficult to reduce, even with medications. However, most of the behavior problems someone with Alzheimer's exhibits have a trigger. The behavior is communication. It has meaning. Just as a child throws a tantrum if tired or hungry or another basic need is not met, a person with Alzheimer's may decline in mood and have an outburst if over tired, frightened or in pain/discomfort.

 

This false belief will likely lead to:

    • Total disregard of the behavior with no attempts to understand or minimize—other than use of medications—which have many negative side effects that cause other problems.
    • Ostracizing these individuals from a more normalized social environment, moving them to the back of the building, behind the locked doors, or in the unit in the basement.
    • Emotional pain and dissatisfaction from family and other loved ones.
    • Staff burnout, possible resident neglect or abuse, and TERRIBLE QUALITY OF LIFE.
       
  • He's not appropriate for therapy because he can't learn.


My Comments: This is a totally false belief! Yes, many of our typical interventions ask the patient to learn, such as learning a new technique to stand or go up stairs, learning to use a walker, learning to use a swallowing or communication technique, and learning a compensatory ADL technique. But, if the person has new learning impairments, the therapist must find another method to improve the person's function or safety. It requires creativity. It requires understanding not just the person's deficit (i.e. new learning) but their remaining abilities (i.e. can follow a one-step direction). The plan, approaches, and goals are then written to incorporate the person's cognitive strengths and to compensate for their deficits. 

 

This false belief will likely lead to:

    • Lack of therapy services offered to this population which will encourage decline in all areas of function and decline in physical, cognitive, and communication skills.
    • Low Med B therapy case loads and loss of Med A revenue.
    • TERRIBLE QUALITY OF LIFE.
    • In addition, without the therapist's interventions the person with dementia can be at great risk for injury related to falls, pneumonia, contractures, low activity engagement, and behavioral problems.
       
  • He wanders all day because he has Alzheimer's. That's all the activity he can do.


My Comments: Guess what? Yes, another totally false belief. People with dementia often "wander" for a reason. Again, something triggers this behavior, and it can be reduced.

 

Examples of triggers:
 

  • The person is looking for activity and the facility offers too few structured activities.
  • The person may be looking for a bed or toilet or food.
  • The person may be looking for "home" or "mom" because they feel insecure, lonely, frightened due to lack of emotional needs being met.
  • The person has a desire for movement not being met through activities, ADLs, or restorative programs.


People who do wander/"walk and explore" are often in Allen Level 3 or middle stage dementia or High Allen Level 2 or late stage dementia. They most certainly have the ability to participate in ADLs, exercise, leisure activity, and social relationships. They do need to be engaged. Left unattended for periods of time, or brought to activity not appropriate to their cognitive needs or interests, may indeed trigger wandering.

 

This false belief will likely lead to:

    • Weight loss, falls, and social discord (because of exploring in unwelcomed areas).
    • Low activity participation.
    • Elopement attempts.
    • TERRIBLE QUALITY OF LIFE.
       
  • These people have Alzheimer's. The best we can possibly do is keep them clean, dry, quiet, and free from injury.


My Comments: No, no, no. This type of belief system reduces this person to a "thing." They are people who can still feel and express emotion, people who still have cognitive, physical, and communication abilities, people who have some functional capacity, people who can connect to memories, and people who can still enjoy and participate in life.

 

This false belief will likely lead to:

    • Existence, not living.
    • CNA and nursing care that is devoid of social relationships and riddled with "tasks."
    • Behavior problems, decline in function, decline in physical, cognitive, and emotional health, and decline in communication skills.


These common beliefs/paradigms appear to stem from an underlying perspective of "disability." When a person is functioning in middle to advanced dementia (Allen Level 3 or lower), disability becomes the prevailing label.

 

Think about it.  We often don't see the ABILITY.
Who watches a person with dementia wander and rummage through another resident's room or at the nursing station and sees the ABILITY to walk, sees the ability to focus attention on an activity, and sees the ability to use the hands to hold and explore objects and tools?

 

Who watches a person with dementia hold the toothbrush upside down or put it in their hair during an ADL and sees the ABILITY to use their hands to hold an object or tool, sees the ability to focus attention on an activity, and sees the ability to follow a one-step command to be redirected to the appropriate movement pattern?

 

Who watches a person with dementia repeatedly use the pick up walker like a rolling walker, even after being taught the correct technique over and over, and sees the ABILITY to connect with a long-term procedural memory (they likely once used a rolling walker)?

 

Who watches a person with dementia show anger or distress and sees the ABILITY to communicate their feelings which might provide clues as to what their needs are?

 

A Significant Paradigm Shift is Needed for Quality Dementia Care

 

New Paradigm:
People with Alzheimer's disease have many abilities remaining that can be utilized in all activity in order to live in well-being.

 

This is our challenge, friends. The challenge is to change the belief systems that have existed for so long and are prevalent and fostered at all levels. Then and only then can we expect to get follow-through of our teachings from other therapists, CNAs, nurses, administrators, activities, or even some families.

 

I have significantly changed my consultation and teaching to address this issue early and head on. I think it is an issue each of you, either on a 1:1 individual basis or as a part of a corporate training initiative, must explore or address in order for your teachings to be received and positive outcomes to be fully realized.

 

 

 

 
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