Project RELATE: managing the person with Alzheimer's disease; this facility is studying staff training techniques for person-centered Alzheimer's care.

Dealing with residents with dementia can be a trying experience for all involved. Unfortunately, in the rush to make the afflicted residents as comfortable as possible, the strain on caregivers and family members is seldom considered. Some caregivers can fall into the trap of treating these residents as objects, forgetting that they are still people with feelings and emotional needs. Could specialized training and a person-centered approach for caregivers lead to improved quality of life for these residents?

That's exactly what Iris Boettcher, MD, CMD, and her team of researchers set out to investigate with Project RELATE (Research and Education for Living with Alzheimer's Disease: Therapeutic Eldercare). The pilot study took place in 2001 at a 165-bed licensed SNF in Grand Rapids, Michigan, managed by Spectrum Health, a Michigan-based regional healthcare system. Dr. Boettcher, medical director of geriatrics for Spectrum Health, explains that the project initially had very personal reasons behind it. "Several years ago I was approached by a philanthropist in the community whose wife has Alzheimer's disease, and he was interested in funding some sort of project related to older adults," says Dr. Boettcher. "Knowing that his wife had Alzheimer's disease and that there were a number of caregiving issues related to providing for her care, and recognizing my experience in caring for persons with dementia, he agreed to fund a project looking at specific caregiving techniques to use and apply in the process of caring for residents with dementia."

[ILLUSTRATION OMITTED]

With the funding firmly in place, Dr. Boettcher and her team started to research dementia care from the perspective of both the residents and the caregivers. "In designing the project, Betsy Kemeny, one of the team members, culled the literature, looking for evidence-based practice techniques for caring for persons with dementia," Dr. Boettcher explains. "We took some of the principles from [famed British researcher] Tom Kitwood, who had writton about person-centered care and its approach to people with dementia. We didn't find much evidence-based material at all, so we designed a training program to implement organizational change in the approach to caring for residents with dementia, and designed an evaluation program to measure the effectiveness of the training.

"One of the principles we wanted to incorporate into the project was sustainability over time," she continues. "We put together sessions specifically for direct caregivers, in this case the CNAs. On top of that, we developed specific sessions for nurses, who would mentor the CNAs in providing care. There had been some literature to demonstrate that if you didn't do the mentoring piece, or the coaching piece, you wouldn't be able to sustain results over time, so we included both."

With the background work completed, Dr. Boettcher and company ran five different sessions for CNAs--one per week. The sessions covered:

* Practical information about residents with dementia

* Communication techniques

* Beginning and sustaining life activities specific to the individual

* Assisting residents with need-driven or agitated behaviors

* Interacting and relating to their mentors (the nurses), and generally recognizing their role in the larger organization

In addition, nurses attended four sessions on how to mentor the CNAs. "We picked out observation skills, giving feedback, and goal-setting skills as the three main components that we wanted them to learn in providing mentoring to nursing assistants," says Dr. Boettcher. "We observed interactions between CNAs and residents prior to the training, as well as between nurses and CNAs, and we compared those observations to what we found after the training. We used what is called a BARS, or a behaviorally anchored rating system, looking for specific behaviors that we wanted from the CNAs and the mentors that would improve person-centered care. The BARS were developed using a three-stage process. First, the experimenters listed the key CNA behaviors being taught in the person-centered care training sessions, creating low, acceptable, and superior examples of these behaviors. Second, subject matter experts were asked to rate these behaviors to ensure that the experimenters placed them in the right performance level categories. Third, the behaviors were categorized into seven dimensions and placed in the BARS format." These key behavioral dimensions of person-centered care were:

* Nonverbal initiation of person-centered interactions

* Assistance with independence-oriented tasks

* Conversation

* Interaction with residents using unique details of their lives

* Initiating lifestyle activities

* Responding to residents' calls for help

* Person-centered interaction with family

"The pre- and post-training behavioral ratings were conducted by independent observers, targeting two pretraining and two post-training assessments per CNA," Dr. Boettcher continues. "Consensus ratings were determined by the discussion of the two researchers about their observations and agreement on a rating for each dimension. When agreement could not be reached through discussion, the average of the two individual ratings was recorded as the consensus value." This completed the quantitative portion of the study.

For the qualitative portion, the project used the principles of Donald Kirkpatrick, ABI, MBI, PhD. "He talks about four levels of training success for organized change," explains Dr. Boettcher. "The first is that the trainees like what they are learning; the second, that they actually learn it; the third, that they transfer it to the job; and the fourth is measurable improvement in the workplace. We measured those four levels and got very positive results in the first three. We didn't do as well on the fourth level--that is, improvement in the quality of life for persons with dementia--probably because of sample size as much as anything, because we really didn't have enough folks to demonstrate a significant change or improvement."

Still, a positive trend was a pleasant surprise to the researchers--particularly since they hadn't expected to see any trends in the residents with dementia from this trial. To this extent, the study was even more successful than the researchers had anticipated. "We saw a trend toward reduced agitated behaviors, and also a reduction in depressive symptoms," explains Dr. Boettcher. "We also saw a trend toward families noticing that the care was different, which also translates into improved and favorable."

For the caregivers, the improvements were reassuring. According to the data from the study, CNAs were implementing many of the skills they learned in the sessions, with a high degree of retention seen three months after training concluded. Caregivers also expressed a more positive attitude toward their jobs and improved relationships with supervisors. In addition, there was a 30% reduction in turnover in the facility following the sessions, a significant finding. "With the model that we had drawn out and the expectations that we had, we felt that if it did work, it should reduce turnover as it relates to how people feel about their job, their role clarity, all the things that go into job satisfaction," explains Dr. Boettcher. "As it turned out, the staffloved the training. They found it to be very applicable to their daily needs and situations that they encountered on a daily basis, and they now apply those skills regularly. They felt it improved their ability to care for people with dementia."

With positive results for caregivers, residents, and families, Project RELATE can be looked at as a promising success. Dr. Boettcher attributes this to the project's person-centered approach to care: "I think it was the combined approach of incorporating and empowering CNAs to approach residents with dementia as people as opposed to demented people. The focus is on the person and not the disease, and that's the one thing we tried to emphasize over and over. That was the bottom-line, take-home point in every session: This is a person. Put another way, it was like the Golden Rule: How would you feel if you were in this position? We needed to get our workers to think in those terms. We tried to teach them that you can make that connection and we gave them techniques and tools to help them connect to the person-side of people with dementia."

The positive results of the pilot study have led Dr. Boettcher and her team to start work on a second phase of Project RELATE. "We did the pilot just to see if we could pull it off in a SNF," she says. "We applied all of our measurement tools and we really didn't expect many results at all, but we decided to analyze data just because we had them. So we were very pleased that we had such success with the initial pilot. What we didn't see in the pilot was follow-through or sustainability with the mentors, unfortunately. We revamped the curriculum and incorporated the mentoring tools earlier in the training, so that we are teaching person-centered mentoring skill sets to nursing staff, while teaching person-centered care skills to CNAs. We're in the process of testing that approach to see if we can sustain behavior change over time and sustain an organizational change."

With the care and treatment of residents with dementia sure to remain a significant area for caregivers, studies like Project RELATE will continue to be vitally important to long-term care. With curative therapy probably years and possibly decades away, the person-centered approach to care could prove to be the best management strategy we have for a long time to come.

For more information, contact Dr. Iris Boettcher at [e-mail]. To comment on this article, please send an e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].

BY TODD HUTLOCK, ASSISTANT EDITOR