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SIGN Vol 20, Issue 6 Nov/Dec 2013

President's Message
By Mary Rita Hurley, RN, MPA, FNGNA
 
Hello NGNA Members,

I am Mary Rita Hurley, your new NGNA Board President for 2013-2015.  It is an honor to be leading our esteemed Board of Directors as we represent you on behalf of NGNA.  Serving and giving back to the profession that has given so much to me over these past 34 years is one way I can use my voice. How are you using yours? It is so important for us to identify ourselves as nurses in every setting we practice because we are the patient, resident, and client advocates. We walk the talk every day in our role(s) in our practice settings. We are an amazing force of three million strong in the country. Can you even imagine what we could do if we harnessed our energy into one collective voice? I can. We would see older adults treated with consistent dignity and respect. Quality of life discussions would be the norm. Care providers would be acknowledged and applauded for the care and compassion they demonstrate day in and day out. This is not a dream but a reality in many places. We at NGNA are striving to make this the default all over the country. We do this by being involved locally, regionally, nationally and internationally. Check out our website and the resources offered there, attend Gero specific conferences, write a letter to Congress addressing your concerns and offer a solution, and volunteer with us or other professional organizations that speak to your heart.  We know you are all busy and have trouble finding a spare minute, however, if you stop for just a second and listen you will find you have more to say than you know.
 
I have been a member of NGNA for many years for one simple reason: I belong here. Why? Because this organization is the only Gero nursing practice organization in the country. We are the only ones that have our LPN and CNA colleagues included in the ranks. We are inclusive. Given the state of our healthcare system and the ever changing landscape, it is important to “rally the troops” and keep our focus steady: quality care of older adults. It’s what you and I do every day. Our 28th annual conference in Clearwater, Florida last month really brought this to light. An energetic gathering of 200 + likeminded Gero nurses came together to share their stories, best practices and collaborative spirits. It was wonderful to reconnect with dear friends and colleagues but I especially loved the students that attended. We had more this year than in our history! Their optimism, positive energy, and natural curiosity got me all excited about being a nurse again. These are very bright and talented young people. I am so glad they chose to affiliate with NGNA. We were inspired by our keynote speakers, shed a few tears, and laughed so hard – we had to catch our breath. That is what I love about NGNA, you can be you and be renewed and refreshed in 2 short days. Priceless!
 
Enjoy the upcoming holiday season and feel free to contact me or any of the Board with your ideas and suggestions. And, remember your voice is powerful. Use it!
 
All the best, 

 Mary Rita Hurley, RN, MPA, FNGNA
President
    

Association News


Congratulations to NGNA’s Newest Board Members!

The following NGNA members were formally installed in their new Board of Directors positions during the recent convention in Clearwater. We thank these individuals for their continued service and leadership to NGNA.
 
President
Mary Rita Hurley, RN, MPA, FNGNA
 
Immediate Past President
Amy Cotton, MSN, GNP-BC, FNP-BC, FNGNA, FAAN
 
Vice President
Joanne Alderman, MSN,RN,BC,APRN, FNGNA
 
Secretary
Elizabeth "Ibby" Tanner, Ph.D., RN, FNGNA
 
Director-at-Large
Jackie Close, PhD, RN, GCNS-BC, FNGNA
 
Director-at-Large
Monica Diehl, RN-BC, CHPN


 Convention Recaps: October 3-5, 2013 – Clearwater, Florida

Personal Reflections on the NGNA 2013 Convention
Submitted by Beth Mastel-Smith, Ph.D., BSN, MS, FNGNA
 
As I sat in the taxi on the way to the Tampa airport after the NGNA convention, I felt AWESOME.  For those of you who don’t know me, I usually feel pretty great so this was significant.  I thought, “Why are you feeling so high?”  It occurred to me that I had spent three days with colleagues from around the country who care as much about older people as I do.  Now, I REALLY love the team of people with whom I work every day.  And, I feel equally close to my NGNA colleagues.  How can that be, I wondered?  I see the NGNA folks only once a year with intermittent phone conversations to complete committee work.  Amy Cotton, our past president, talked about how NGNA is an inclusive organization; we boast of all levels of nursing in our membership.  It hit me that members come together on common ground for the love of older adults and we truly appreciate and respect each other’s contributions – whatever form those contributions take.   This, I believe, is reflective of NGNA leadership over time and I want to recognize all those who have maintained this core feature of our organization.   As one colleague stated, “The people are the reason I keep coming back to NGNA!” 
 
According to Rath’s book on Strengths, I am a “learner”.  From the time that I hit the registration desk in Clearwater Beach, I was in my element!  There was so much to glean from colleagues who care for older adults, teach nursing students about aging, create innovate evidence-based programs, or do research!  We were challenged to think about concepts used in other disciplines but that aptly apply to nursing such as “social regard” for patients or residents with dementia.  What a great example for a graduate student’s concept analysis paper!  I came away with ideas for doctoral students’ dissertation topics such as the effects of simulation experiences on nursing students’ attitudes and knowledge about older adults and dementia.  A comparison of Taiwanese and American caregivers provided insight into similarities and differences and reminded us of the need for nurses’ cultural awareness.  I co-facilitate a program for care partners and people in early stage Alzheimer’s disease.  At the convention, I got activity ideas for implementation with these groups.  The use of technology in the form of a medication reminder was shared, as was findings from a program for rural caregivers.  There were impressive examples of evidence-based practice that showcased innovative approaches to care of older adults including the winning program, Development and Implementation of the VA Coordinated Transitional Care (C-TraC) Program: Lessons Learned and Challenges, presented by Laury Jensen.  We also had the wonderful opportunity to put a face with a name.  Dr. Judith Braun, a name many of us have heard for years, presented the research award to a very deserving colleague, Cherie Simpson, for her research entitled, The Dynamic Experience of Dementia Caregiving.  These are but a few of the pearls of wisdom I gained at this year’s convention.  The one regret is that I was not able to clone myself and attend concurrent sessions in order to achieve even more knowledge! 
 
I also have to say a particular thank you to the students who attended this year’s convention.  You bring us hope for the future of gerontological nursing and NGNA.  You also bring up hard questions about nursing and nursing education such as, “Should I get some clinical experience or enter a BSN to PhD program after graduation?”  Healthcare and nursing are changing swiftly and dramatically.  As a profession, we must be ready to respond to the changing tide.  We must also be prepared at all levels of nursing to support, care, and advocate for older adults, a population whose numbers are exploding exponentially.  NGNA provides the forum for conversations such as this and the future is bright because of our student membership who challenges us to meet future sociopolitical, environmental, and patient needs. 
 
Finally, I am grateful to each and every one of the NGNA members, whether you attended the convention or not.  The organization is what it is because of you.  I feel your presence even as I write; you are there when I need you and that is such a great feeling!  


NGNA Heads West! NGNA on the Riverwalk: Spur Your Passion for Older Adults!
 Submitted by Marilyn Daly Newton, RN, BC, CRRN, FNGNA, Planning Committee member



NGNA had a very successful convention in Clearwater, Florida in early October. It was a busy schedule for everyone who attended – with a little time for recreation!  The hotel accommodations and amenities were great!  Lots of learning and lots of fun were had!
 
October 2-4, 2014 will take our 29th annual convention to the beautiful city of San Antonio, Texas. Our planning committee co-chairs will be Marcia Shad and Colleen Steinhauser. Mary Rita Hurley will serve as the Board Liaison.
 
The planning committee will convene in December to begin preparing for the next convention. If anyone was unable to attend the committee meeting in Clearwater, and would like to become a member of the convention planning committee, please contact Courtney Devine  at NGNA Headquarters.
 
San Antonio has so much to offer in historical attractions, theatre, city parks, arts & culture. It’s a must to visit the famous Alamo while visiting San Antonio!
 
The call for abstracts will be listed online shortly on our website. We encourage you and your fellow peers to submit an abstract for review. Registration for the convention will be available in May 2014.
 
Watch your SIGN newsletter and Member Alert emails for updates from the committee and national headquarters. We promise to continue to offer excellent presenters, preconference workshops, concurrent sessions, social events and of course, the Silent Auction, which is always a fun event! Start planning now for 2014! See you in San Antonio to once again “Spur your Passion for Older Adults!”
 


University of Maryland Online Dissemination and Implementation Institute
 
This year, the University of Maryland School of Nursing (UMSON) Online Dissemination and Implementation Program, funded by a grant from the John A. Hartford Foundation and UMSON, held a series of four online webinars to assist junior faculty and postdoctoral students in the development of their manuscripts for publication.

The sessions were led by an interdisciplinary group of journal editors and faculty members with extensive expertise in publications relevant to geriatrics. Topics included:
  • Reporting Research: Background, Guidelines and Development of the Introduction Section
  • Reporting Research: Methods for Quantitative & Qualitative Research
  • Results: Quantitative & Qualitative Findings and Treatment Fidelity
  • Discussion Section and the Submission Process
Below are the Power Point slides used for the presentations, along with links to each of the recorded webinars. These are available to NGNA members, on the NGNA website.

Recorded Webinars Power Points  Please take advantage of the opportunity to view these slides and webinars!
 

 
Mission Advancement Fund Needs Your Support!
 
Submitted by Sharon Henderson, MSN, RN-BC

NGNA is the only nursing organization in the country dedicated to improving nursing care provided to older adults by supporting all levels of nurses practicing in all settings. Our organization provides the tools and resources needed to provide and plan care for our older adult patients. NGNA is also an advocacy organization for the needs of older adults and as well as the geriatric nursing profession. Some of the benefits provided by NGNA include educational products such as webinars, the annual NGNA convention, Geriatric Nursing journal, and networking opportunities. NGNA also supports professional advancement by providing scholarships to nurses and students to continue their education.
 
Please donate today to the Mission Advancement Fund so that NGNA can continue to provide these valuable benefits. You deserve the support of a strong organization that represents your voice and your vision for the care of older adults. A contribution to the Mission Advancement Fund provides resources to maintain the financial well-being of our organization and fulfill our joint commitment to the older adult population. 
 


Thank You to NGNA’s Recent Donors!
 
Fellow Member Donations
Jane Marks
 
Research Fund Donations
Sandra Weeks
Rosina Bloomingdale
 
Scholarship Fund Donations
Rosina Bloomingdale
Judith Roy
 
Research Fund
Janice K. Kuiper-Pikna
 
Mission Advancement Fund
Rosina Bloomingdale
Beth Culross
Melodee Harris
 
We appreciate your contributions to the success of our organization!

 

Announcing a New Toolkit for Behavioral Health in Senior Living Communities

Submitted by Ann Kolanowski PhD, RN and Kimberly Van Haitsman PhD
 
In senior living communities (assisted living/nursing homes), antipsychotic drugs continue to be routinely used  for the Behavioral and Psychological Symptoms of Dementia (BPSD) despite Food and Drug Administration (FDA) warnings to the contrary. The extent of the problem was highlighted in May 2011, when Inspector General for the Department of Health and Human Services, Daniel R. Levinson, issued a report that found one in seven nursing home patients were given antipsychotic drugs for uses that are not approved by the FDA.1 Most troubling was the fact that 88% of the time these drugs were prescribed for residents with dementia. These findings prompted the then-director of the Centers for Medicare and Medicaid Services (CMS), Donald Berwick, to call for a bold plan that, by December, 2012, would reduce antipsychotic drug use in nursing homes by an additional 15%.  On March 29, 2012 CMS launched the Initiative to Improve Behavioral Health and Reduce Antipsychotic Use in Nursing Homes. This national action plan is using a multidimensional approach to the problem, and includes public reporting, raising public awareness, regulatory oversight, technical assistance/training and research.

But reducing antipsychotic drug use is only one part of the equation. A vast void in care will be evident if drug reduction is not supplemented by alternative approaches to the BPSD. Non-pharmacological approaches (NPA) are a first priority for responding to the BPSD due to the high risks and limited effectiveness of antipsychotic medications for treating these behaviors.2 But staff in group residential living sites voice concern that a major barrier to alternative approaches is a lack of education on non-pharmacological approaches.
 
Based on this critical need, the goal of this project was to convene a national, interdisciplinary group of geriatric behavioral experts who collaborated on the development of a behavioral health toolkit for staff: Promoting positive behavioral health: A non-pharmacologic toolkit for senior living communities. This toolkit was conceptualized as a compendium of peer-reviewed/expert-endorsed existing resources that would assist staff in the implementation of non-pharmacological strategies for BPSD.
 
Who is the Toolkit for?
The Toolkit contains resources relevant to any type of senior living community, including nursing homes, assisted living facilities, and continuing care retirement communities. There is information targeted to professional and paraprofessional staff in all departments, including the executive director, administrators, department supervisors; nurses, physicians, mental health professionals, social workers, and recreational therapists. 
 
What is in the Toolkit?
The Toolkit uses a comprehensive framework that focuses on a person-centered philosophical approach to care, and an overview of evidence-based resources addressing the following major areas:
  • Person-Centered Philosophy
    This resource provides a rationale for approaching BPSD behaviors through the lens of person-centered care, including a summary of what types of behaviors are included in the definition of BPSD.
     
  • Systems Integration issues
    A review of systems-level considerations that should be examined prior to initiating any new initiative. 
     
  • Evidence-based leadership and direct care giver education programs
    Available education programs that have demonstrated effectiveness in training leaders and direct caregivers on topics relevant to approaching BPSD. 
     
  • Behavior Assessment tools
    Available measures to ensure that staff appropriately identifies BPSD.
     
  • Clinical decision-making algorithms
    Strategies ensuring that staff members comprehensively examine the causes of BPSD.
     
  • Evidence-based approaches to ameliorate or prevent BPSD
    Approaches that have been proven to be effective in rigorously designed research studies. 
     
  • Specific Behavior approaches
    Procedures for appropriate responses to acute and emergent behaviors that put the senior or others at risk.
Acknowledgments
This Toolkit was supported by a grant from the Commonwealth Fund and a generous gift from the Hartford Foundation. Ann Kolanowski, RN, Ph.D., and Kimberly Van Haitsma, Ph.D., served as the coordinators of the expert panel who compiled much of the information contained in the toolkit.
 
Electronic Access and Copies of Toolkit
This toolkit may be downloaded free of charge from: 
nursing.psu.edu/hartford/toolkit
 
Please note: This is a temporary link that will be up-dated using a more interactive website in the near future.
 
Recommended Citation
Kolanowski, A., & Van Haitsma, K. (2013). Promoting positive behavioral health: A non-pharmacologic toolkit for senior living communities. 
 
Members of the Expert Panel
Philosophy- Karen Love, Jackie Pinkerton
System Integration- Marie Boltz, Carmen Bowman, Patricia Parmelee, Al Powers
Education & Leadership Development- Cornelia Beck, Brenda Cleary, Ann Bossen, Judy Lucas
Assessment- Laura Gitlin, Katherine Marx, Byran Hansen, Christine Kovach
Non-pharmacological Approaches- Rita Jablonski, Andrea Gilmore-Bykovskyi, Darina Molkina, Natalie Baker, Ann Bossen, Sharon Nichols, Lois Evans
 
Specific Behaviors- Andrea Gilmore-Bykovrskyi and Justine Sefcik
Dissemination Plan- Barbara Resnick 
 
1 Levinson, D. (2011). Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents

2 Alzheimer's Association (2012). Alzheimer's disease facts and figures. Alzheimer's and Dementia: The Journal of the Alzheimer's Association 8:131–168.


Reality Therapy for Long Term Care Quality Improvement
Submitted by Pam Seale, MSN,RN,GCNS-BC and Sandra Kuebler, MS, PhDc, RN
 
Introduction 
It is an unprecedented time of change in Long-Term Care (LTC). The Centers for Medicare and Medicaid’s (CMS’s) directive to decrease the use of antipsychotic medications (APM) has given birth to numerous initiatives, educational resources, and assessment tools. The buzzword is “Person-Centered Care” (PCC) and the CMS surveyors are being educated as to how to look for it. It’s a time that is exciting and long overdue. But what does this change really mean if it’s to be successful?

PCC by its very nature is focused on the dignity of the other person. In an environment where there is a shortage of RNs and a large number of overworked Certified Nursing Assistants (CNAs), communication between the administration and the staff can often be strained. How can we intend to change how we communicate with those with dementia who have obvious communication deficits when we have not  yet succeeded in communicating well with our leadership team, staff, or coworkers? More than any other worker, the CNA spends the most time with the resident. Are they capable of evaluating or understanding the inner needs of their residents? And if not, how can they best learn?

This article proposes that Reality Therapy will provide the culture change needed. A form of Lead Management, it will improve not only the quality of care for the nursing home resident with dementia, but all the nursing home residents, their families, the staff, and the administration. Beyond that, those that take the course will find benefits in their personal lives as well.
 
What is Reality Therapy? 
In 1960, William Glasser, a behavioral psychiatrist and theorist, stated that mental health results from the satisfaction of internal needs. He believed that people generate behavior and make choices for a purpose: to change their environment to be more like they envision it to satisfy an innate need. Glasser’s theory, Choice Theory, lists five internal needs: Survival, Love and Belonging, Power (or self worth), Freedom (or independence), and Fun (enjoyment).

Realty Therapy is the delivery system of Choice Theory. In Reality Therapy, WDEP is the pedagogical tool that frames Reality Therapy making it easier to use, remember, and teach to others. The “W” asks the question, “What do you want?” The “D”, “What are you doing about it?” The “E” stands for the evaluation, which answers the question, “How is that working for you?” And the “P” represents the new plan for the future behavior.

Lead Management is an application for Reality Therapy that is used for employee motivation. The leader is always helping people evaluate what they are doing. The intent of this paper proposes Reality Therapy education with the understanding that the leaders in a facility will learn it and then both teach it and use it with the staff. The person with dementia will not be using it but will benefit from it in the culture change. As staff learns the WDEP tool, they can begin to use it to assess and evaluate their own behaviors and see the resident in a new light. Tested in the fields of education, professional counseling, and correctional facilities, Reality Therapy, with the WDEP system, has been shown to improve the communication culture. Its time has come to enter the healthcare industry. 
 
Examples of Innate Needs to be assessed in Dementia Care 
Survival: This inner need is the most obvious and long-term care facilities are already doing a good job of helping those with dementia by monitory nutrition, bowel function, skin, vital signs, and more. Safety precautions are provided by staff to compensate for the resident’s inability to use good judgment.
 
Love and Belonging: Meals are served for most people in the dining room. Activities run all day. Is someone excluded because of his behavior? Maybe he is “too” friendly and can’t keep his hands to himself. Is he brought to the nurses’ station in view of everyone? This certainly could make that person feel he does not belong with the others. Can he go with one CNA before the group gathers so he doesn’t have to feel excluded? This is only one example of how evaluating love and belonging can make for better care planning for the patient with dementia. The goal would always be to have the resident in the activity if they so choose. 
 
Power (or self-esteem): Power is an important topic in dementia care because the resident is significantly limited in his ability to perform routine tasks. The staff has to realize the resident is not necessarily looking for someone to do everything for him. The family interview is very helpful here. Was the mother the last one to leave the kitchen when the family gathered because she needed to get all the clean-up done?  Or was the father a handy man always finding a project around the house? These people will have more of a need for further work than a resident who found their joy in reading, the arts, or taking long walks.  The people who find their self-esteem in productivity are at a higher risk for negative behaviors when not provided with meaningful activity.  Teaching the family that activities such as folding towels, caring for a doll, or using a busy board are not denigrating to this resident but helpful in building their sense of power and accomplishment. It is sometimes hard for the family to realize their loved one no longer evaluates a scene as they do, but when they are shown a happy and contented loved one, they usually can appreciate it.
 
Freedom (or independence): “You need to eat this”. “It’s time for your bath”. These words are said by well-meaning caregivers. There is a problem if the caregiver is expressing their personal need for power. Using Reality Therapy as a facility culture will help reveal this issue and improve it as CNAs learn better ways to fulfill that need. As for the resident, in many cases the resident is unaware of their impairment. Therefore, the resident expects to have the same freedom as always to live their life and make simple decisions. Considering this, it is rather amazing we don’t have more verbal abuse than we do in our facilities!
 
Fun: May we never forget that fun is a felt need! I have had patients that seemed to not be able to hold themselves back when they would grab someone to dance with. When it ended poorly, I would ponder: “Maybe I could have helped by directing that person earlier to a dance partner that I knew would probably enjoy the encounter.” The desire for fun can also be used as a distraction from an escalating event. Escalating aggressive behavior can often be calmed with a soft serve ice cream cone! Fun is a useful tool!
 
Who Are the CNAs? 
Across the U.S., the staff member in the LTC facility who provides the day-to-day bedside care is the nursing assistant. There are multiple titles for this job, CNA being the most commonly recognized. Other legal titles for this position are; licensed nursing assistant, registered nurse aide, state tested nurse aide, Nurse Aide, Nursing assistant, Geriatric nursing assistant, and Nursing home nurse aide. Regardless of title, this person knows what the resident likes to wear or what their favorite snack is. They know which resident’s sister likes cats, which likes dogs, and for many residents this person who cares for them every day is considered a family member, a confidant, often trusted with family secrets.

CMS defines the Nurse Aide as any individual who is providing nursing or nursing-related services to residents in a facility who is not a licensed health professional. There is no federally mandated number of training and education hours for the CNA however, there is a requirement that a minimum of 16 hours of training in the following subjects be provided prior to any direct patient contact:
  • Communication and interpersonal skills
  • Infection control
  • Safety and emergency procedures, including the Heimlich Maneuver
  • Promoting resident’s independence
  • Respecting resident’s rights
  • Basic nursing skills
  • Personal care skills
  • Mental health and social services of residents
  • Care of cognitively impaired residents
  • Basic restorative services
  • Resident’s rights
 Each state sets the requirements for training and certification for nurse aides. The number of hours required ranges from 75 to 180 across the U.S.  The training includes classroom and clinical hours. This training takes place in various educational and industry settings. Once employed the facility must complete a yearly performance review and provide regular in-service training based on the outcomes of those reviews. According to CMS, this training must ensure continuing competence of the nurse aide and consist of a minimum of 12 hours per year.
 
The job of a CNA is physically and emotionally taxing, and unfortunately at times underappreciated. According to the Bureau of Labor Statistics (BLS), the average salary rate for nursing assistants in 2012 was $11.46/hr. The lowest 10% earn $8.80/hr. That equals an annual salary of $18,300. Many are paid for 7.5 hours a day thus reducing the annual income. According to the 2007 National Nursing Assistant survey, 90% are female, 28% live in poverty and receive public assistance, and many have no health insurance. In a study done by the Department of Health and Human Services in 2011, of the CNA’s who were offered health insurance by their employers 39% reported not being able to afford it due to cost.

Other employees in a LTC facility who see residents daily include those who work in housekeeping and dietary departments. Some of these employees aspire to taking a CNA course in order to have a better future. If culture change is the goal, then every employee, including non-licensed staff, needs to be considered in the solution.
 
How Reality Therapy Supports Quality Outcomes 
The Centers for Medicare and Medicaid Services (CMS), the Advancing Excellence in America’s Nursing Homes Campaign (AE), and other resources are working full time at improving the quality of care in our nation’s nursing homes. Reality Therapy by itself or as an adjunct activity meets many of the needs called for.

CMS’ mandate to decrease the use of APM has already started to see positive results. Inappropriate use of APM in LTC will no longer be tolerated. The CMS website teaching resource promotes interdisciplinary care planning as one of the steps in this goal. Knowing the resident often sees the lowest paid employees for more time daily than anyone, a facility wide culture change like Reality Therapy is a great proposal to meet this need. Reality Therapy, used as a management tool, will help employees be more involved in the organization and more able to understand what is happening in their interior life and the life of the dementia resident. Can we really expect to improve residents’ negative behaviors without CNAs and other unlicensed staff understanding their internal motivating factors?

The AE Campaign has 9 stated goals. Three of them are directly affected by implementing Reality Therapy into the facility culture: Improve Staff stability (reducing staff turnover), Increase Use of Consistent Assignment, and Increase PCC Planning. When overall communication is improved workplace culture improves. Employees like to come to work, feel appreciated because they are listened to, and take more ownership in the organization. This will improve staff stability. As CNAs learn about their innate needs and how to satisfy them through positive behaviors, there will be less need to change assignments due to people not getting along. Families will have fewer complaints as the culture of acknowledging needs and meeting them in acceptable ways becomes second nature. Reality Therapy promotes a culture of PCC by focusing on finding the needs of another and helping them meet those needs as independently as they are able to. It gives respect and dignity to the individual and addresses the whole person in the needs assessment. Even the goals of increased mobility and improved pressure ulcers will be met as APM usage is decreased and Reality Therapy grows in the culture of a facility. 
 
Understanding Alzheimer’s dementia with respect to Reality Therapy is truly eye opening. The felt internal needs last until late in the disease process, yet unfortunately, due to a lack of executive function, the ability to plan for and act appropriately to meet those needs leaves early on.  This is why caregivers need to learn to consider which of these needs is attempting to be met. They can then help the resident by providing the executive function the resident lacks in order to help plan a way for the resident’s needs to be met. 
 
Conclusion 
In the last decades many strides have been made to make the environment more pleasant for the dementia resident.  Activity corners, gardens, safe outdoor paths, pets, music and more are making nursing homes a better place to live. I am proposing a new way to help the staff change the way they look at their behavior and the behavior of their patients.  I am convinced that Reality Therapy is the perfect complement to all the pioneers have been building. In teaching the basic needs and WDEP to our staff we will be helping them understand their own needs better. What better management tool is there than one that helps the employee to better manage their life and the lives of those entrusted to their care?

The only risk is the monetary investment and the time to attend the course. The benefits can be remarkable for everyone involved: Administrators, Staff, residents, and their families. The benefits will reach into personal lives. Research is needed to measure the effectiveness of Reality Therapy in the healthcare environment. Funding for research and pilot studies is available now as CMS seeks immediate solutions to the problems in LTC. It’s a great time for LTC to look at Lead Management through Reality Therapy.
 
References:
  1. Advancing Excellence in America’s Nursing Homes. www.nhqualitycampaign.org. October 8, 2013.
  2. An introduction to the national nursing assistant survey, U.S. Department of Health and Human Services, series 1, number 44, March 2007.
  3. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2010-2011
  4. Eliopoulos, Charlotte. Affecting culture change and performance improvement in Medicaid nursing homes: The Promote Understanding Leadership, and Learning (PULL) Program. Geriatr Nurs, 2013;34:218-223.
  5. Gaugler, J., Hobday, J., and Savik, K. The CARES Observational Tool: A valid and reliable instrument to assess person-centered dementia care. Geriatr Nurs 2013;34:194-198.
  6. Khatutsky, G., Wiener, J., Anderson, W., Akhmerova, V., & Jessup, E. A. (2011). Understanding Direct Care Workers: A Snapshot of Two of America's Most Important Jobs Certified Nursing Assistants and Home Health Aides. U.S. Department of Health and Human Services.
  7. Palmer, Janice, L. Preserving personhood of individuals with advanced dementia: Lessons from family caregivers. Geriatr Nurs, 2013;34:224-229.
  8. Reality Therapy Website. http://www.realitytherapywub.com. October 8, 2013
  9. Wubbolding, Robert. Reality Therapy for the 21st Century. Brunner-Routledge, Philadelphia, PA. 2000.
  10. Yu, Fang. Improving recruitment, retention, and adherence to 6-month cycling in Alzheimer’s disease. Geriatr Nurs. 2013;34:181-186.
 
Experiential Learning: Raising Interest and Awareness in Nursing Students Regarding the Care of Older Adults
Submitted by Dawn Hippensteel, MS, BSN, RN, CCRN, GCNS and Tamara L. Burket, MSN, RN, ACNS-BC, GCNS-BC, FGNLA

Significance:  The estimated proportion of older adults is estimated to be 20% of the population by 2030 (Gilje, F. L., Lacey, et al., 2007). Older adults comprise over 48% of hospital patient days, 25% of visits to ambulatory care, and about 85% of long term care residents (Burbank, P. M., A. Dowling-Castronovo, et al., 2006).  Nurses care for increasing numbers of complex older patients.  The American Association of Colleges of Nursing recommends improved education in geriatrics and gerontology for both nurses and nurse educators (Gilje, F., L. Lacey, et al., 2007). Evidence indicates that older adults receive better care and have better outcomes when care is provided by nurses with skills and knowledge in geriatrics (Stierle, L.J., Schaumann, M.J., Esterson, J., Smolenski, M.C., Horsley, K.D., Rotunda, N., et al., 2006).

Rationale for an innovative experience for nursing students:  Inter-professional collaboration across the health care continuum has been shown to increase the quality of care for older adults.  Evidence suggests that a dementia experience is a valuable tool to increase awareness and empathy in medical students and caregivers for older adults (Beville, P. K., 2002. & Pivnick, S., 2011).  Innovations in nursing schools might include didactic experience and time with older adult patients in varied clinical settings.  Interactive classroom encounters engage learners in different ways.  It was suggested that nursing students participating in an inter-professional geriatric team conference and a dementia simulation might develop increased awareness and empathy for older patients. 
 
Background:  Two gerontological nurse educators coordinated opportunities for BSN nursing students to attend a transdisciplinary Geriatric Consult Conference (GCC) at the clinical site hospital and participate in simulated sensory and loss experiences. These experiences were hoped to increase understanding of some of the many difficulties experienced by aging adults. 

The activity: Four to six students participated weekly over one month in 5 activities provided by the educators.  Experiences were: 
  • a one hour multidisciplinary GCC session where geriatric patients were discussed in a case study format,
  • a virtual dementia experience (Beville, 2002), 
  • a sticky note activity demonstrating sequential losses, 
  • a feeding exercise, and
  • a view of ageism in cards and books that stereotyped or poked fun at the issues of old age. 
Students were greeted in the hospital lobby and completed a Myths of Ageing questionnaire from the Hartford web site for geriatric nursing (Palmore, E.B., 1998).  Results were reviewed with the students and their comfort levels with older adult care giving were discussed. 
                       
They were escorted to the GCC and participated in a transdisciplinary case review.  Team members included medical and BS/MS nursing students, physicians, advanced practice nurses, staff nurses, a pastoral care provider, and a nutrition consultant.  Geriatric vulnerabilities such as falls, polypharmacy, functional impairment, cognitive decline, and the chronic and acute illnesses of patients were discussed.  When debriefed, some students expressed that the conference moved too quickly, but others engaged in asking questions.  All students acknowledged and remarked upon the benefits of a team approach and group interaction to facilitate the best care for the patients.

After the conference students were split into groups rotating through the other activities.  Activity two was a dementia exercise inspired by The Virtual Dementia Tour© (Beville, 2002).  The group experienced and identified difficulties imposed by physical and sensory impairment in simple activities of daily living. 

 Activity three provided the experience of each student feeding a blindfolded “buddy” pudding or applesauce from a bowl, and then being fed.  Students being fed expressed “the food came too fast!”  The person feeding felt their buddy needed to eat faster. 

Activity four went as follows.  Students received 11 sticky notes. One item was written on each (5 possessions, 3 loved ones, and 3 privileges).  The group leader explained that the student was now 85 years old and being placed in a nursing home and that one loved one had died. Then the leader began to request from the students other items lost due to age or loss of independence.  The nursing students were able to articulate the losses encountered when loved ones, valuables, and privileges are removed.  Particularly disarming to this generation were the loss of cell phones, laptops, and the privilege of driving.  The cards and books (the fifth activity) were viewed and entertained the students between activities.  Students acknowledged the impact of ageism in perceptions of older adults by the general population. 
 
Discussion:  This was not a formal research study, but a focused learning intervention utilizing knowledge provided in the course.  Student participation implied consent.  Debriefings after each exercise, and pre- and post-survey data were utilized by the educators to determine the value of specific experiential learning activities in geriatric education for students.  Students commented that the experience was interesting and “fun,” and they thought the exercises were of value for nursing students.  Students need innovative experiences to raise awareness and empathy, increase confidence, and improve self-efficacy in elder care. Research and further validation of these educational techniques might include formal consent and appraisal of individual learning activities among control groups.   
 
References
Beville, P. K. (2002). Virtual dementia tour helps sensitize health care providers. American Journal of Alzheimer’s Disease and other Dementias 17(3): 183-190.   
  
Beville, P. K. (2002). The virtual dementia tour: a call to action for sensitivity training. American Journal of Alzheimer’s Disease and other Dementias 17(5): 261-262.     
 
Burbank, P.M., Dowling-Castronovo, A., Crowther. M.R., Capezuti, E.A. (2006). Improving knowledge and attitudes toward older adults through innovative educational strategies.  Journal of Professional Nursing 2(2): 91-97. 

Gilje, F., Lacey, L., Moore, C.  (2007). Gerontology and geriatric issues and trends in U.S. nursing programs: a national survey. Journal of Professional Nursing 23(1): 21-29.

Palmore, E.B., 1998, The facts on aging quiz, Springer Publishing Company, Inc., New York. From the Hartford Institute for Geriatric Nursing, Topic 1: Attitudes about Aging.

Pivnick, S. (2011). ‘Dementia tour' helps caregivers empathize. Inside Keesler AFB. Retrieved 1/27, 2013, from http:www.keesler.af.mil/news/story.asp?id=123257493.              

Stierle, L.J., Schaumann, M.J., Esterson, J., Smolenski, M.C., Horsley, K.D., Rotunda, N., …Gould, E. (2006). The nurse competence in aging initiative. American Journal of Nursing 106(9): 93-96.
 
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