Bringing teamwork up-to-speed for dementia.

Managing the behavioral difficulties posed by patients suffering from dementia is complex and challenging. It takes interdisciplinary teamwork, to be sure, but teamwork of a very special sort - a sort of "free-flowing" teamwork, taking into account many variables. It is a concept that is easier to explain through illustration. This article uses real case scenarios in which only the names are changed.

Scenario 1: Sharing Insights

Mrs. Archer is a dementia resident who often becomes unexpectedly and suddenly assaultive when staff approach to offer care. Russ, a member of the recreation staff who works with Mrs. Archer, notices that she becomes assaultive when he touches her, but that if he offers a hand, she will take it and hold it briefly. Russ wonders if nursing staff might be able to adopt this technique, but then shrugs off the notion and goes about his work.

Fortunately, though, Russ shares his observation in passing with a team member who is more open to understanding behavior problems and their possible solutions. Based on her comments, the nursing staff begins to explore the idea of providing care with minimal touching. They proceed to outline care procedures step-by-step and have Mrs. Archer do as many steps as possible by herself. More and more staff use this approach as experience accumulates, and Mrs. Archer's physical assaults decline.

Russ almost lost the opportunity to improve Mrs. Archer's situation through a sense of futility, but in this case a team member "picked him up" and saved the day.

Scenario 2: Improving Expectations

Mrs. Bishop was a tall, thin dementia resident who normally could be found occupying a geriatric chair. She would often become agitated with a wild look in her eyes, and would grab passers-by with her long arms and try desperately to drag them closer. Most staff responded by avoiding this resident as much as possible.

One nurse discovered, though, that if she would allow Mrs. Bishop to pull her close and give her a big hug and a sloppy kiss, Mrs. Bishop would then happily and contentedly let her go. Other staff were skeptical that this would work, and it took six months before the entire team was implementing it with good success. Meanwhile, the discovering nurse felt guilty that she had not known to do this sooner.

This was teamwork, but not optimal teamwork, for several reasons. First, the staff's initial critical reaction almost stifled the creative experimentation necessary to find solutions to difficult situations. Second, change in dementia residents often occurs slowly, as was the case here, but the team was as slow to change as the resident. Finally, by feeling guilty, the nurse failed to appreciate that she had come up with a very bold, caring and effective solution to a very intimidating and difficult behavior problem.

In short, the team's expectations of itself in difficult situations such as this were pitched too low. The solution took time; it was a learning experience.

Scenario 3: The Root of the Problem

Mrs. Wilson is a dementia resident who would stand, joke and carry on entertaining conversations for long periods with staff. However, when staff tried to get her to come with them for caregiving, she would scream in a loud, frightened voice, resist being led and become assaultive. Staff were dumbfounded at this behavior from such a "capable" resident, and wondered why she was being so manipulative.

In this scenario, staff initially failed to understand Mrs. Wilson's basic cognitive deficits: While she had relatively intact verbal and social skills, testing of her cognitive abilities showed a moderate-to-severe level of impairment in most other areas of cognitive functioning, including poor problem-solving, poor ability to make choices and an impaired ability to initiate actions.

As staff discussed this and began to understand and compensate for her cognitive deficits, they avoided putting her in a position where she had to understand the situation and make choices. Staff began to initiate a conversation first to build rapport and tap into her strengths, followed by taking her arm, then saying "let's go" in a way that was gentle but firm, and did not confront her with a choice to make. This procedure proved to work well.

Scenario 4: Another "Secret Solution"

Mrs. Dunlap was a resident on a secured special care unit who frequently stood by the exit door anxious, upset, shaking the door and demanding to go home to her family. This made entering and leaving the unit very difficult and stressful for staff. The charge nurse and social worker, having run out of ideas, became frustrated, and eventually called in a consultant for suggestions.

As the consultant proceeded to explore the problem, a nurse's aide who acts as Mrs. Dunlap's primary caregiver spoke up: "Oh, that's no problem. I just ask if she would help me in the kitchen, then I take her to the dining room, have a cup of tea, and chat for a few minutes. After that, she goes happily on her way and forgets all about going home." Staff found that this intervention was easily adopted and worked consistently.

In this scenario, the solution had already been "discovered," but a lack of communication with all team members had resulted in unnecessary frustration.

Scenario 5: "Isn't There a Pill for That?"

Mrs. Carlson was a resident on a dementia ward in a state psychiatric hospital. She was overweight and had quadriparesis, making caregiving difficult. On top of this, she had a generally helpless and demanding attitude. When her needs were not met to her satisfaction, she would yell or wail in a loud, unsettling manner. The nursing staff, feeling helpless and frustrated themselves, responded by placing her chair near the ward physician's office in hopes that he would hear her yelling and do something about it.

The team had, in a time of crisis, pointed the finger to one team member, the physician, and said in effect "You take care of it." However, due to the team's perceived authoritarian structure, other team members were reluctant to give feedback to the physician, who thus received ambiguous and incomplete information. Nursing staff had forgotten that management of behavior problems is their job too, and stopped considering what their role in solving this problem might be. The solution, not surprisingly, required a true team effort. Careful diagnosis revealed that Mrs. Carlson, underneath her helplessness and complaining, had a serious depression. She was started on an antidepressant, and received counseling to work on her loss issues and assertiveness. She learned to ask for what she needs in appropriate ways - and nurse's aides were advised to watch for appropriate requests - and, as a result, Mrs. Carlson had more of her needs met.

In two to three months, Mrs. Carlson's functional behavior and mood improved, her episodes of complaints and yelling were dramatically reduced, and - addressing a contributing factor to her depression - she was placed in a community facility near a boyfriend she missed greatly.

Meanwhile, staff had learned the benefit of teamwork in action.

Scenario 6: The "Behavior Rounds" Approach

The team is quickly reaching a crisis point with Mr. Baker. He is very active, pacing the floors and talking in a fluent but nonsensical manner. He becomes very suddenly assaultive, will follow staff at times as if in pursuit of them, and has recently begun to be assaultive to staff from behind with no warning. Several staff have become afraid to work with him.

In this case, the normal approach the team has used for learning and sharing about ways to manage behavioral problems is too slow - the problem is just too volatile and threatening. The team decides therefore to convene behavior rounds to review the issue. The entire team, including all floor staff, meets for a half-hour to: a) describe the problem in detail; b) share observations; c) review intervention efforts to date; d) brainstorm possible new interventions; and e) form a general consensus about how to proceed.

During the meeting, several staff report that, if Mr. Baker does not feel that he is receiving proper attention when he speaks, he tends to become assaultive to staff or other residents. However, briefly acknowledging his comments, no matter how nonsensical-seeming, in a sincere tone, as if he had made a relevant comment, has proven to satisfy his need, after which he goes contentedly on his way. The team psychiatrist reports medication changes that are underway and will hopefully produce noticeable results soon. One nurse notes that some minimal effects from medication changes are apparent, a positive early sign. Efforts to manage occurrences of pain, which are unreported by the resident but are known to exacerbate his agitation, are discussed. Finally, circumstances that would necessitate the resident's removal from the unit altogether are reviewed.

Based on this focused discussion of an alarming problem, the team is left with some sense of optimism, direction and an increased readiness to work with Mr. Baker.

Scenario 7: Conflict Resolution

The team has been increasingly aware of tension between two team members that is straining the working relationships of the team. Clarification reveals that when a nurse's aide, Betty, and two other aides were working with a difficult dementia resident, the charge nurse, Laura, stopped to comment about procedures she believed were inappropriate. Betty was offended by the manner in which the nurse's comments were offered. She feels that her experience in working with dementia residents was being minimized and unfairly criticized by a nurse who had much less experience in dementia care.

Other nurse's aides are consulted. They report that, to some extent, Laura has used an overly authoritarian, punitive approach with them. It also becomes apparent, however, that Betty has not spoken to Laura because Betty is both too angry and too uncertain of her capabilities to speak up in a constructive manner. The alternate charge nurse takes Laura aside and speaks with her about the more supportive, educational approaches she has learned to use in her long experience on dementia units. Otherwise, though, it is decided that immediate action is not necessary. Rather, when Betty has had a chance to ventilate her excessive anger to more neutral team members and to discuss ways to address it, she is able to discuss her views in a way that resolves the conflict.

The team's approach illustrates several conflict resolution principles. By taking the attitude that both team members have a valid perspective, and that coming to a working agreement is a necessary and healthy aspect of teamwork, the team is now in a position to achieve better communication and increased harmony, and can focus on team tasks in a more productive way.

Scenario 8: Morale Awareness

Mona has been working on an Alzheimer's unit for some time. At one point, the subject of Alzheimer's disease comes up and a friend asks, "Why do you bother working with them (Alzheimer's residents) anyway? They will never remember anything you do." Mona laughs, but thinks to herself that dementia caregiving does at times seem to be an impossible and pointless task. Her morale begins to sink.

At a staff potluck luncheon the next day, though, a team member comments on how well Mona works with a certain type of resident. Later that day, Mona enjoys a pleasant interaction with a long-term resident whom she used to think would never change, and reflects on what a difference she and her team have made in this resident's life. With a new perspective, she begins to respond to questions about "Why bother?" by sharing the story of this resident. The more she does this, the more she looks at her work with a renewed sense of challenge and pride.

It only took acknowledgment and encouragement from a fellow team member to give Mona's morale a needed boost.

Conclusion

The concept of staff teamwork is a somewhat ambiguous and elusive one, especially in the dementia field, where proper care is just beginning to be defined. As this article is intended to illustrate, effective teamwork with dementia residents depends on a variety of factors: staffers' underlying beliefs, working principles, individual contributions, ability to recognize and overcome barriers to teamwork, use of procedures for coordination and conflict management, and recognition of the importance of maintaining morale. All of these come into play in varying degrees, depending on the case at-hand. The key to using them to enhance teamwork is a commitment to the team concept.

Donald G. Slone, PhD, is a clinical psychologist, Maureen Robinson Prather, Pharm. D., is a clinical psychopharmacy specialist and Donnie Olin, RN, is on the nursing staff, all at Western State Hospital, Tacoma, WA.