The following is part of an assignment I completed for the University of Wollongong Masters of Science in Dementia Care degree I graduated in last year, and highlights how allowing residents in aged care to walk regularly, can positively impact their life, as well as reduce what others see as ‘challenging behaviours’!
Specifically, we were asked to use the BEET tool workbook (this tool allows clarification of the question behind the issue, idea or problem, including behaviours of concern, by ascertaining the reasons for seeking engagement and change, evaluating the evidence, identifying who else we need to engage with and describes a process by which everyone concerned can meaningfully engage in partnership. In this way, it strives to be person centred, as it is inclusive of the client or resident.
The structure of the BEET tool is designed to allow clarity around the issue, to involve all stakeholders, to be clear about any remedial relationship work that is required, to end up with a simple positively framed question to take out to your engagement partners, and to come up with ideas about how to make the first stage of engagement start positively. The following are the four steps:
- Puzzle and purpose – identifying the question to be answered and the reasons behind the engagement
- Evidence – assessing the strength of the proposal for engagement
- Context – considering the workplace and people within which engagement will occur and identifying who else needs to be involved
- Facilitation – how to bring people together constructively
This is a précis of what happened;
For this task, and as a volunteer in an aged care facility I requested to work specifically with one gentleman (Mr G) who I already had a basic relationship with, and who I knew the staff were very concerned about his wandering. He is in the early stages of vascular dementia, and has other co-morbidities; he is overweight, and has type 2 diabetes, both conditions Professor Illfe in London (2014) believe may undo the positive steps currently underway in dementia prevention or cure (Illfe 2014). Mr G’s ability to abscond is high, and he said to me he feels like he has been “locked in jail”. From his perspective, absconding and wandering are simply the things he did before moving into residential care and with a walking partner there is no rational reason he should not be able to continue walking. Using the BEET tool was helpful in engaging all stakeholders.
Identifying the question was relatively easy, however engaging others was quite challenging. The question we ended up with was this: “How can we allow Mr G to continue walking safely?” We had put this puzzle question to the PUGQ test (positive, unconditional, generative, question). The question is not critical of anyone or anything in any way, but instead exploratory or questioning of a solution. It is also completely unconditional and without pre designed solutions, important in engaging all. Thirdly, it is open to a rage of different solutions, that may allow staff, volunteers, and family members to be involved, but more importantly, the client. Finally, it requires more than a yes or no answer, as it asks how.
The issue we all wanted to explore was wandering. The staff wanted to explore it as they felt “burdened and anxious” about Mr G’s wandering. His family felt this anxiety as well. Mr G wanted to explore it as he felt “trapped” and “unable to pursue his usual activities”. He felt it was stopping him from sleeping well, causing disruptions and “angst” between him and the staff providing care for him. Specifically, he did not believe it was “a behaviour of concern”, as he had been told it was, but that it was an issue of his “human right to exercise, just like I used to”. He did not think it was behaviour at all, but an exercise and recreational activity. Oddly (!) I was able to easily see it from his perspective. Initially, the staff simply said they wanted to stop him from wandering as they believed it was in his best interest for safety, for himself and other residents. Interestingly, this man was not wandering into other residents rooms unless invited.
The purpose of ‘fixing;’ this was twofold. Most staffs were worried about this man “escaping”, and the man wanted to exercise, both seemingly polar opposites. However, with the implementation of a walking program with a small group of other residents also identified by the staff as having the label of wandering in their case notes, and including one man in a wheelchair who had this label because he wheeled himself into other residents rooms, I volunteered to start the program, and engaged with some of the other coffee shop volunteers to assist, as well as the woman who ran the activities program. The daily walking group, which went for at least an hour, improved behaviours of concern, helped many of the group to sleep better, and following feedback after a four week program, is to be continued.
The most important outcome, from the clients perspective, was around reclaiming their lives and not to be seen as behaviours was:
“not to be negatively labelled”
The evidence around wandering is less about how to improve outcomes for residents than how to manage them for staff or family carers. We focussed on the positive physical and emotional benefits of exercise, and it was this evidence I brought to the attention of the staff, rather than using the BPSD guidelines. Based on the strength of this positive evidence, and my personal discussions about seeing the person first, they were willing to engage. This may also be due to the fact they did not have to spend time on the activity, nor were they the ones filling in the BEET tool workbook. We considered the possible negative and positive outcomes, and held a meeting reviewing them with all stakeholders. Mr G attended, as did his sister and best friend (he is widowed). The manager, the Clinical Nurse Consultant , the head Enrolled Nurse and his regular carers from the facility also attended this meeting, and it was easier to ‘sell’ the solution because I was involving volunteers who had already had police checks, and were willing to give up more time. This allowed us to put the program in place constructively, and the only negatives were discussed in this meeting were the varying abilities of residents to go walking, their motivation, and if it was successful, whether they would they have to make the time to do it after the four weeks.
The action plan was relatively simple. Talking to residents to see who wanted to join the walking group, which initially we did through Mr G as he was friendlier with some residents than others. Finding volunteers was reasonably easy as I have been volunteering there for over four years, so have a god relationship with most of them. Drawing up a roster, done by the activities co-ordinator was simply a case of adding a column to her volunteer roster, and then finally using a chart to rate attendance of the group, and a simple chart of client outcomes based on well being scales. It was, overall, very easy to set into action.
The main drawback that I could see, and implied by paid staff was around the time they would need to be involved, as it was clear they already felt burdened and over stretched in their daily task oriented demands.
However after the four weeks in our review meeting, they all felt very positively about the program, and many spoke of actively ensuring a walking program continued. When I asked why, they said the people in this group had had less falls, were exhibiting fewer ‘challenging behaviours’, and some had trialled not taking either their sleeping tablets or anti anxiety medication, with success. Specifically, Mr G was no longer taking sleeping medication at night, which he had felt had not been not working anyway.
Interestingly, engaging his doctor and the registered nurse to de-prescribe was perhaps the most difficult of this whole exercise.