Dementia Gateway: Difficult situations

Case study: Teamwork and leadership: the solution for difficult situations

Teamwork, with strong leadership from the care home manager, was the key to unlocking new ways of working with Mrs Grant

Background

Mrs Grant had lived in the care home for about three months. Increasingly the staff team were feeling challenged by her behaviour: addressing her hygiene needs was particularly difficult and she was quite verbally aggressive to staff. Mrs Grant frequently disturbed other residents by banging on the locked door of the unit in which she lived. She could also be rude towards strangers visiting the unit. When staff were talking to each other she would often approach them and begin shouting. Some staff felt intimidated by her – she was a large woman and they felt their personal space to be invaded when she came up close to them and shouted at them. The whole staff team felt that 'something had to be done about Mrs Grant's behaviour'.

A whole team approach is very likely to bring better results than those that could be achieved single-handedly by even the most dedicated individuals

Read the full case study:

Understanding the situation 1 – the story so far Open

Staff were finding that the mornings were particularly difficult – often Mrs Grant had been incontinent in bed and staff would enter her room to find that she had stripped the wet sheet off her bed and hidden it. She usually refused personal care assistance, but also regularly went into other residents' rooms when staff were providing personal care. On some occasions Mrs Grant even tried to provide care to other residents, particularly those who were unwell. These matters were of particular concern, as other residents' privacy and possibly their safety were compromised.

The care home is run by Quantum Care, an organisation committed to person-centred dementia care. Its approach is based on the developments in dementia care over the past 20 years spearheaded by the Bradford Dementia Group. A key focus is to understand 'challenging behaviour' by a person with dementia as an indication of difficult feelings and unmet needs. Emma Corsbie-Smith, the manager of the care home where Mrs Grant lived, felt that developing a better understanding of Mrs Grant might enable staff to understand her and better meet her needs.
Understanding the situation – 2. Research and development findings Open

The whole care team had been trained in person-centred approaches and the manager had undertaken training in Dementia Care Mapping (for more on this, see 'Further reading' below). She made use of the Bradford Dementia Group's list of observable indicators of well-being and, over a few weeks, monitored the evidence of well-being shown by Mrs Grant, concluding that this woman's well-being was at a very low level.

The manager was also in the process of undertaking further training in dementia care leadership (run by the author), and understood that in order to support person-centred working in her care home it was essential to respect and value the experiences of the staff team and involve them in suggesting and implementing changes.
Understanding the situation – 3. Views collected from key people Open

The staff team were all finding that they did not enjoy spending time with Mrs Grant and tended to leave her alone when she was not causing problems. Many were feeling quite frightened of her and this was making it difficult for them to have empathy for her and think creatively about the best way of supporting her.

Through her own observations, Emma (the care home manager) realised that Mrs Grant had a very low level of well-being. As part of her coursework for the leadership course, Emma worked to develop an empathic understanding of Mrs Grant's perspective and needs. She concluded that Mrs Grant often felt embarrassed, frustrated and shut off from others. She didn't trust anyone in the care home, didn't understand why doors were locked, felt bored, purposeless and cooped up.

Mrs Grant's son and daughter were in close contact with their mother and the care home. Through discussions with them, the team learnt two important things about Mrs Grant's life history. The first was that Mrs Grant had had another son who had died at the age of 23 after a life of ill-health. Mrs Grant had devoted herself to caring for him. Staff realised that what they had seen as interference and intrusion into other residents' rooms and care actually represented Mrs Grant's important life experience of being her son's carer and spending time in hospital with him.

The team also learnt that Mrs Grant had moved from Scotland to England when her children were young and had never really been accepted or included by her neighbours or the parents of her children's school friends. This pattern of being and feeling excluded was now repeating itself in the care home and was becoming a vicious circle – for instance Mrs Grant would see two staff members talking and believe that they were saying bad things about her. In response she would speak abusively to them, and the result of this was that staff avoided her whenever they could.
Actions Open

Initially Emma, the manager, involved her team – with Mrs Grant's keyworker taking the lead – in sharing their thoughts about Mrs Grant's feelings and needs, developing closer relationships and generating ideas to enhance her well-being.

Mrs Grant's well-being would be monitored while new initiatives were put in place, using the observable indicators of well-being identified by the Bradford Dementia Group (see Bruce 2000 in 'Further reading' below). Frequent formal and informal discussions would take place within the staff team and the manager would pay particular attention to Mrs Grant's day-to-day life and care.

Emma and the keyworker then began to lead by example – spending more time with Mrs Grant and developing closer relationships with her. The rest of the staff team were encouraged and supported to be involved in implementing new ways of working with Mrs Grant, and staff meetings were used to share experiences and positive outcomes. The manager validated their positive work and, when staff came across setbacks, she helped them think about reasons.

Through being encouraged to think for themselves, staff were often able to make their own suggestions about what could be done differently. Here (below) are some the things that happened.

The manager sat down on the unit with Mrs Grant and encouraged staff to sit down with them and chat. A conversation followed in which one member of staff found that she had a birthplace in common with Mrs Grant and immediately this helped the staff member to develop a relationship with Mrs Grant.

Staff made sure that Mrs Grant was always included in any conversations going on in her presence.

Staff began to treat Mrs Grant as 'one of the team', for example asking for her help with housework tasks. Mrs Grant undertook such jobs very willingly and would sometimes ask, 'What do we need to do next?'

Mrs Grant was supported to feel involved in the care of other residents in ways that did not compromise anyone's privacy or safety. For example, as long as it was agreeable to the other resident, Mrs Grant would sit with a person who was unwell and staff frequently popped into the room to offer them both tea or to let Mrs Grant know that it was 'time for her break'.

When Mrs Grant approached the door of the unit, staff would ensure that it was opened for her. It quickly became apparent that Mrs Grant did not want to go anywhere in particular, but she just needed to know that she had freedom of movement.

When Mrs Grant expressed any concerns, staff were sure to pay good attention, make eye contact and show her they took her feelings seriously.

In working towards enhancing Mrs Grant's well-being, there was another issue that needed to be addressed. When she moved into the home, Mrs Grant was already on a regular dose of an antipsychotic. Initially it had seemed important for this to continue and concerns had been raised that she might be even more aggressive without it. But now the manager began to feel strongly that the antipsychotic was of no benefit to her and was making her drowsy, possibly impairing her cognitive abilities and almost definitely contributing to her incontinence. A referral was made to the psychogeriatrician to review Mrs Grant's medication.
Results Open

Mrs Grant's relationships within the care home improved. Staff now saw her as a person, rather than a problem, and had a clear understanding of her needs. The fact that the manager had encouraged so much of their own input into finding new strategies for their work with Mrs Grant meant that they felt ownership of the new approaches and were committed to continuing with them. Every success was a personal achievement for them, and was validated as such by the manager. When there were setbacks, they were determined to learn from them and find a way through.

The manager commented that Mrs Grant seemed now to feel that she was in the company of friends rather than strangers. Mrs Grant's well-being steadily increased and reports of aggression and verbal abuse decreased considerably. Some aspects of her behaviour that had previously been viewed as problematic (such as wanting to care for other residents) were now understood as evidence of her caring and compassionate nature, and these were skilfully handled so that she wasn't undermined and no-one was at risk of harm.

Mrs Grant no longer banged on the door because if she wanted to open it, staff immediately responded. On a few occasions, she went to visit another of the units in the home.

As more attention was paid to Mrs Grant, the manager and staff team began to realise that she had much more understanding and a higher level of ability than they had previously realised. This realisation prompted further ideas about helpful interventions that were immediately implemented.

Since Mrs Grant was alert and observant, she was aware of any unusual occurrence or unknown face. Staff realised that they had to give her advance notice of everything that would be going on in the unit– for example if a workman would be visiting to carry out repairs. To the surprise of staff, she was able to retain this information and was no longer abusive towards strangers visiting the unit.

Since Mrs Grant was clearly very aware and highly embarrassed about her night-time continence accidents, she was now provided with the means to attend to her own hygiene needs. A clearly labelled laundry bin was placed in her room, and she put her soiled sheets into it. She was also provided with a supply of clean bedlinen, and it quickly became apparent that she was in fact able to make her own bed. Now she was free from the daily humiliation that had plagued her every morning since she had moved into the care home.

All of these results were hugely positive for the staff team, who had made a truly collaborative effort. They were encouraged to keep going with their new approaches to Mrs Grant's care and were also motivated to work more creatively with other residents whose behaviour challenged them. They felt that their experience had been valued by their manager.

Once Mrs Grant had her appointment with the psychogeriatrician, the antipsychotic was stopped. The concerns that staff had initially expressed proved unfounded, and further positive results emerged. She was less drowsy in the morning and most of the time now she got out of bed to use the toilet. Thus her sheets were dry, her embarrassment was further reduced and her self-esteem improved. Without the influence of the antipsychotic, some of Mrs Grant's other abilities returned too, and she was much less frustrated.
Advice for others Open

The care home team's work with Mrs Grant was grounded in reflective practice – a process of learning through reflecting on experiences with each person with dementia. Through their reflective practice, the team were able to gain insight into Mrs Grant's needs, develop empathy for her feelings, and make suggestions about how her care could be developed further. The manager played a key role in ensuring that new approaches were sustained – her involvement, encouragement and support were vital in helping staff keep their momentum even when there were setbacks.

When the efforts of individual team members are recognised and validated, it is much more likely that they will be continued and, as new challenges emerge, they too will be approached with optimism and commitment.

A whole team approach is very likely to bring better results than those that could be achieved single-handedly by even the most dedicated individuals. This is because the process of trying to understand and find ways of addressing an individual's needs is a complex task which is bound to be enhanced when more people's creative thinking has contributed. Additionally, new strategies need to be understood and used by all staff involved with an individual's care otherwise the possibility of success would be undermined by inconsistency.

Person-centred dementia care leadership involves a supportive and facilitative management style that brings the best out of a team. Through taking seriously the views, feelings and experiences of staff and involving them in the process of change, they are empowered to use and build on their in-depth knowledge of the people with dementia with whom they work. It is also particularly important that managers should have a hands-on approach, so that they can role-model positive communication and demonstrate their own commitment towards individuals.
Financial implications Open

The staff team's approach was made possible by their employer's investment in training. Staff were educated in person-centred approaches to dementia care and it was recognised that managers needed not only training in person-centred care, but also in person-centred dementia care leadership. In this way, the investment in staff training bore maximum benefits because their manager could enable them to implement their learning in their work within the care home.