Easing into the night.

A program that meets the special needs of the evening tour

THOSE OF US IN LONG TERM CARE RECOGNIZE THAT THE NEED for education and exposure to creative and innovative approaches to care is crucial to all tours, but there is a tendency for many of these opportunities to be focused on the day shift. To redress this balance and to ensure that residents as well as staff benefit from training, the "Sweet Dreams" project at Cobble Hill Health Center's Alzheimer's Resource Center (ARC) in Brooklyn, N.Y., was designed to allow the spotlight to shine on the evening shift of nurses and CNAs.

The ARC, first established in 1990, Consists of two 40-bed Alzheimer's Special Care Units and two 40-bed Late Stage Care Units. It serves as a center for the development of meaningful activities, staff development, and family education and support. The knowledge gained in the ARC has been integrated into the overall operation of the facility, as residents with dementia also live on other units.

The "Sweet Dreams" project's goals were twofold: to focus education and training on the evening shift, and to make bedtime a more pleasurable experience for those in the ARC units by expanding the use of massage therapy techniques within the facility. It has been well documented in the literature that the evening, preparation for bedtime in particular, is a difficult time for many residents with dementia. Recent studies suggest that massage therapy has shown evidence of aiding the impaired population in the relaxation process.' Our experience is that often residents are more agitated with periods of increased confusion and restlessness at bedtime. This precipitates the need for the evening CNAs to respond to the effects of "sundowning," fatigue and over-stimulation after a full day of activities, fear of bathing, changing from day attire into sleepwear, etc.

Putting the plan into action

In Phase I, the Alzheimer's and dementia care evening-shift nurses and CNAs underwent four hours of training in basic massage therapy techniques (massage of the hand and arm), held over two consecutive weeks. The training was conducted by a licensed massage therapist assisted by two day-shift CNAs who had completed this training. Using the day-shift CNAs as assistants was a crucial part of the program. It provided the following benefits:

* peer models that enhanced not only the staff members' learning experience, but also their relationships with other staff members

* staff members' self-esteem was enhanced by an increased confidence in their ability to learn and implement new tasks

* improved continuity of care and communications across the shifts resulted in more resident-centered care

* reinforced teamwork and the "train-the-trainer" approach to staff development increased the level of enthusiasm from both the trainees and the trainers

* provided a basis for ongoing training and support so the benefits of massage therapy techniques can continue to be provided to the residents.

Phase II of "Sweet Dreams" was to incorporate massage therapy techniques into the resident's bedtime care. This was done on the unit under the supervision of either the massage therapist or one of the day-shift CNAs. This phase lasted 14 weeks, thereby giving the staff time to master the technique. During this phase, massage therapy's impact on the resident was assessed. Data collected before and after the massage intervention looked at the following areas:

* residents' sleep patterns

* number of incidents during preparation for bedtime

* use of psychoactive medications to address nighttime agitation and sleeping difficulties

* frequency and duration of family visits in the evening

* staff members' and families' satisfaction in their interactions with the residents.

The results indicated that while there was a slight decrease in such behaviors as agitation, verbal disruptiveness, resistance to bedtime care, and the need for nighttime medications, the most significant change was in the visitation patterns of family members and their relationship with the CNAs.

While massage therapy training had been offered to family members, few took advantage of it. Once they saw the CNAs performing the techniques, however, they asked to be trained. Family members reported that their visits were often strained or very brief because it was too painful to spend time with someone who no longer recognized them. Families also often expressed frustration at not being able to talk to their loved ones. Training these families in massage therapy techniques gave them, in effect, a new language with which to communicate with their loved ones. In this way, "Sweet Dreams" focused on the interaction among CNAs, residents, and their families and served to deepen the emotional connections between them.

A lesson for administration

Two grants of $20,000 each received over two years from the United Hospital Fund provided Cobble Hill Health Center with funds for the "Sweet Dreams" project. It covered the expenses of the massage therapist, the two day-shift CNAs, and a coordinator to manage the project. But most importantly, it provided the money to cover an administrative oversight discovered during the first year of the project.

In providing the 14 weeks of one-on-one training on the units, we did not allow for coverage of the CNAs-in-training. We were asking them to learn and demonstrate a new skill, while still expecting them to perform and complete their assignments for the evening. This became evident when we reviewed interviews with the evening CNAs midway through the first year. In the second year, coverage was provided so that the CNAs could devote themselves entirely to their training.

This not only served to improve the quality of the training, it also sent a very important message to the staff involved: Administration supports this project and the needs of the evening tour. At the completion of the project, many CNAs reported that the most positive aspect for them was the feeling of validation from the facility, an acknowledgment that their jobs are often exhausting and overwhelming.

Peer recognition: the highest honor

We are all fighting the same fight--trying to provide the highest quality of programs and services to the elderly in an often unsympathetic climate. In 2000, Cobble Hill was honored with the American Society on Aging (ASA)/Brookdale Center on Aging of Hunter College Best Practices in Human Resources and Aging Award for its "Sweet Dreams" project. In accepting the award at ASA's annual meeting, I recognized one of the most important people in long term care, the one who knows more about the residents, works the hardest hours, gets the least opportunity to vent frustration, and is often the lowest paid: the CNA,

Since we began the "Sweet Dreams" project in 1998, I have often been asked how to go about implementing this type of program. First, it is crucial to enlist the facility's administration. The administration needs to put together a training team, provide for unit coverage while offering the training, and continuous coverage during the training sessions. Administration's support also serves to underscore the importance of such projects, showing the staff that their wishes and needs are as important as those of the residents.

Catherine Thurston, CSW, is the director of Alzheimer's Programs at Cobble Hill Health Center, Brooklyn, N.Y.

Reference

(1.) Field TM. Massage therapy effects. Am Psychol, 1998;53(12):1270- 1281.