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System Integration of Non-pharmacological Approaches

This section of the toolkit is focused on system-wide implementation of non-pharmacological approaches (NPA). The National Institutes of Health defines implementation as "the use of strategies to adopt and integrate evidence-based health approaches and change practice patterns within specific settings."[1] Accordingly, this section addresses the techniques and resources that have been found to affect a positive influence upon the quality of care and quality of life of the nursing home resident, and uptake of alternatives to anti-psychotic use.

Nursing homes are complex systems comprised of people (residents, families, administrators and staff), who learn and relate to each other and the environment in a nonlinear way.[2] Providing creative and individualized care for nursing home residents requires an organizational commitment to "looking at the whole picture," i.e., all the factors that influence how the resident feels, functions, and responds to care. These factors include intrapersonal characteristics (e.g., resident's health and cognitive status); interpersonal influences (e.g., resident's relationship with staff, degree of family engagement, staff knowledge and attitudes); physical and social environment (comfort, functionality, and capacity to "cue" the person with cognitive impairment); and policies (e.g., those related to staffing, communication, care evaluation, and decision-making).[3-5]

The organizational leadership (Administrator, Director of Nursing, Medical Director) plays a critical role in supporting resident well-being and quality-of-life, which includes clinically appropriate, responsible, and humane use of anti-psychotic medication. To that end, their initial steps in catalyzing change to a new paradigm of care include:

• Articulating the vision of resident-centered care and incorporating the vision into strategic planning
• Identifying one or more champions
• Facilitating the development of a quality team that will steer the initiative. [5] Members ideally include representatives from all disciplines/all levels of staff (including direct care staff), residents, and families.

The file below contains a blueprint for organizational strategies. These strategies are organized to address the "social-ecological"[3] factors that influence the resident's well-being, and offer examples and resources to support the goal of providing safe and effective alternatives to antipsychotic use for Behavioral and Psychological Symptoms of Dementia (BPSD).

• Blueprint for Organizational Strategies

References

1. National Institutes of Health Fogarty International Center.
2. Anderson RA, McDaniel R. Taking complexity science seriously: New research, new methods. In: Lindberg C, Nash S, Lindberg C, editors. On the Edge: Nursing in the Age of Complexity. Bordentown, NJ: Plexus Press; 2008. pp. 73–95.
3. Stokols D. Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist 1992; 47: 6-22.
4. M Smith, LA Gerdner, GR Hall, Buckwalter K. History, development, and future of the progressively lowered stress threshold: a conceptual model for dementia care JAGS 2004; 52 (10) 1755–1760.
5. Berta, G.F. Teare, E. Gilbart et al. Spanning the know-do gap: Understanding knowledge application and capacity in long-term care homes Soc Sci Med 2010;70:1326–1334.
6. Planetree Long-Term Care Improvement Guide website
7. Sloane PD, Mitchell M, Priesser JS et al. Environmental correlates of resident agitation in Alzheimer’s disease special care units. J Am Geriatr Soc 1998;46:862–869.
8. Calkins MP,Weisman GD. Models for environmental assessment. In: Schwarz B, Brent R, eds. Aging, Autonomy and Architecture. Baltimore, MD: Johns Hopkins University Press, 1999, pp 130–142.
9. White DL, Newton-Curtis L, Lyons KS. Development and initial testing of a measure of person-directed care. The Gerontologist, 2008; 48: 114–123.
10. Edvardsson, D., Sandman, P. O., & Rasmussen, B. Construction and psychometric evaluation of the Swedish language person-centred climate questionnaire—staff version. Journal of Nursing Management 2009; 17:790–795.
11. Teri L, McKenzie GL, LaFazia D, Farran CJ, Beck C, Huda P, van Leynseele J, Pike JC. Improving Dementia Care in Assisted Living Residences: Addressing Staff Reactions to Training. Geriatric Nursing 2009; 30 (3), 153-163.
12. Putting the P.I.E.C.E.S. Together website. http://www.piecescanada.com/
13. Resnick B. Cayo J. Galik E. Pretzer-Aboff I. Implementation of the 6-week educational component in the Res-Care intervention: process and outcomes. Journal of Continuing Education in Nursing 2009; 40(8):353-60.
14. Rodwell J, Noblet A, Demir D, Steane P. Supervisors are central to work characteristics affecting nurse outcomes J Nurs Scholarsh 2009; 41:310–319.
15. Van Haitsma, K. The assessment and integration of preferences into care practices for persons with dementia residing in the nursing home. In Rubinstein R., Moss M., and Kleban M. (Eds). 2000. The Many Dimensions of Aging. New York: Springer.
16. Pioneer Network website
17. Westbury J, Jackson S, Peterson G. Psycholeptic use in Tasmanian aged care homes. International Journal of Clinical Pharmacy and Therapeutics 2009; 35(2):189-93.
18. Westbury J, Jackson S, Gee P, Peterson G. An effective approach to decrease antipsychotic and benzodiazepine use in nursing homes: the RedUSe project. International Psychogeriatrics 2010; 22 (1): 26–36.