Best Practice in the Management of Physical Aggression at Emmaus Nursing Home

Carolyn Rooney RN, Bachelor of Nursing

Clinical Leader Emmaus North, Emmaus Nursing Home, Port Macquarie

Introduction

Emmaus is a High Care centre providing care to 115 residents. It is part of the Catholic Care of the Aged, located in Port Macquarie and has been open since 2005. Emmaus provides a home like environment for elderly people who may require supervision, care assistance and assistance with daily activities.

During 2013 and 2014, staff members at Emmaus Nursing Home participated in the following project led by Carolyn Rooney to assess current practice, establish and outline strategies to overcome barriers and to promote and implement best practice in managing physical aggression in dementia residents, therefore reducing resident aggression, staff injury, reducing anti-psychotic medication use and improving staff knowledge.


Background

Dementia describes a collection of symptoms that are caused by disorders affecting the brain. It is not one specific disease. Dementia affects thinking, behaviour and the ability to perform everyday tasks. Brain function is affected enough to interfere with the person's normal social or working life. Changes in the behaviour of people with dementia are very common. Sometimes this can include aggressive behaviours such as verbal abuse, verbal threats, hitting out, damaging property or physical violence towards another person.

In 2011, there was an estimated 298,000 people living with dementia in Australia. Among Australians aged 65 and over, almost 1 in 10 (9%) had dementia. And among those aged 85 and over, 3 in 10 (30%) had dementia. As Australia's population ages, more people will be affected by dementia. With the projected rise of Australia's aged population, it is estimated the number of people living with dementia is projected to triple to around 900,000 by 2050. Dementia is one of the major reasons why older people enter residential aged care or seek assistance from community care programs.

The imperative for change came about after numerous admissions into the secure dementia unit in a 12 month period where the residents behaviours prior to/post admission had not been managed effectively. This resulted in re-admissions to hospital, staff injury, excess time allocation and staff resources, resident injury and use of anti-psychotic medications from admission.

The project leader (author's) choice to study was the secure dementia unit housing 18 residents in an aged care facility (ACF). The ACF is all high care and has a total of 116 residents. The project leader worked in this area of the facility and had direct access and knowledge of current practice, pre and post implementation. The area is staffed by Care Service Employees, Registered Nurses, Medical and Allied Health and Lifestyle staff.

This aspect of care was chosen to be audited as it had the greatest impact on staff time within the facility for Registered Nurses, care staff and medical staff. Not only this but to manage the safety of residents, prevent the over use of anti-psychotic medications, reduce staff injury and improve outcomes for all involved.

The Neuropsychiatric Inventory (NPI) (as referred to in baseline audit) is a comprehensive assessment of the psychopathology in residents with dementia living in ACF. It is a new assessment tool introduced to the ACF. It has two uses which are to assess for behaviours not identified during the admission and assessment process and dependent on results the facility is subsidized financially.

The evidence around best practice guidelines for managing behaviours of concern in dementia residents is large, however the results of the implementation of best practice are not available as the disease and associated symptoms itself varies in each individual resident and so the project leader could not find a report on the reduction in prevalence of physical aggression in an aged care facility. It was noted a reduction in PRN anti-psychotic use and reduction in falls with/without injury during this period however the resident dynamics changed and therefore was not a measurable outcome.

Project Aims and Objectives

The aim of the project was to assess current practice, determine and identify strategies to overcome barriers and to promote and implement best practice in managing physical aggression in the dementia resident and therefore reduce resident aggression, staff injury, reduce anti-psychotic medication use and improve staff knowledge.

Methods

This best practice implementation project used the Joanna Briggs Institute (JBI) Practical Application of Clinical Evidence Systems (PACES) AND Getting Results into Practice (GRIP) audit and change promotional tool. The PACES and GRIP frameworks involve three phases of activity:

1. Establishing a project team and completing a baseline audit based on criteria informed by the evidence
2. Designing the implementation of strategies to address areas of non-compliance and areas for improvement
3. A follow up audit to establish outcomes from best practice implementation

Phase 1 - Baseline Audit

The project team was chosen by the project leader based on experience and position within the facility. The Community Leader (who is the overall director of nursing care), was pivotal in the project as approval for funding and direction and support of the implementation was required. All care staff within the secure unit were involved in the education sessions and results of the baseline audit, as they were the implementers of the project at the resident level. Clinical and medical staff were informed of the project and continued within their positions.

The team included:

• Carolyn Rooney, RN, Clinical Leader Emmaus North, Emmaus Nursing Home
• Joy Walsh, RN, Community Leader, Emmaus Nursing Home
• Dr Sam Bouwer, General Practitioner
• Emmaus Team Leaders and CSE's within secure dementia unit
• Lifestyle Team

The role of the team members was as follows:

• Contributor of ideas, facilitator at in-service, auditor and collator of audit criteria
• Feedback to staff at team meetings provided approval for recommendations and searched for funding approval. Implemented extra staff to secure unit for activity based programs.
• Evaluator of medication profiles for anti-psychotic use, GP who provided care to majority of residents within this project time frame,
• Implementers of best practice strategies

The baseline audit was conducted in November 2013, and audited the 18
bed secure unit through resident care plans, documentation and medication
use, care staff through practices in place, training and education, Registered Nurses through education, documentation, practices and procedures and Medical through evaluation of Medication charts and ordering procedures. Audit was attended to by the project leader, and results collated and entered on PACES. Areas of concern were identified and a plan of action was put in place.

The following eight evidence-based criteria were used for the audits:

1. All staff have received education on managing challenging behaviours in the past 12 months
2. Is a standardized tool used to measure BPSD
3. All staff using the behaviour assessment tool have received training in understanding the tool and its use
4. Each patient has a management plan informed from information gathered through use of the behaviour assessment tool
5. A variety of non-pharmacological strategies (music therapy, exercise, etc.) are available to staff to use for the management of aggressive behaviour as needed
6. A regular schedule of re-assessment of identified strategies is included in the plan of care
7. The patients response to a behaviour strategy is documented in their plan of care
8. Anti-psychotics are only prescribed when the patient is in severe distress with risk of harm to self or others

All criteria audited were collated using Yes, No and Not Applicable with comments section available to highlight areas of concern or inaccuracies of answers.

Audit criterion	Sample	Method used to measure % compliance with best practice
All staff have received education on managing challenging behaviours in the past 12 months	11 Care service employees for baseline and follow up audit	Project Leader audited the training files of permanent part time employees in the secure dementia unit.
Is a standardized tool used to measure BPSD	18 Resident files for baseline and follow up audit	Project Leader reviewed the current assessment tool against other standardized tools and found relative comparative information was being gathered across all tools and so was decided to leave current tool in practice with the addition of the Neuropsychiatric Inventory tool.
All staff using the behaviour assessment tool have received training in understanding the tool and its use	18 Registered Nurses for baseline and follow up audit	The behaviour assessment tool in use was a standard nursing tool. The introduction of the NPI was where the focus on training was identified. Audit of training file used to obtain information.
Each patient has a management plan informed from information gathered through use of the behaviour assessment tool	18 Resident care plans for baseline and follow up audit	Audit of care plans and resident files as per documentation.
A variety of non-pharmacological strategies (music therapy, exercise, etc.) are available to staff to use for the management of aggressive behaviour as needed	18 Residents within secure dementia unit for baseline and follow up audit	Project lead observed the unit environment for demonstration of non-pharmacological strategies to manage physical aggression.
A regular schedule of re-assessment of identified strategies is included in the plan of care	18 care plans for baseline and follow up audit	Policy and procedure and 3/12 monthly review of care plans were in place and being attended to by the senior Registered Nurses. Audit of policy and practices in place.
The patients response to a behaviour strategy is documented in their plan of care	18 care plans for baseline and follow up audit	Policy and procedure in place and behaviours reviewed every 3 months during care plan review and as required when behaviours were identified and continued with no known source such as a delirium induced behaviour
Anti-psychotics are only prescribed when the patient is in severe distress with risk of harm to self or others	18 medication profiles for baseline and follow up audit	Medication charts and care plans reviewed

Phase 2 - Implementation

Implementation (GRIP) - Commenced in late November 2013 with emails and discussions with management, staff in-service and education session, letters to staff involved including medical staff to inform of project and its purpose. Recommendations using best practice information was put through to members of the project team through emails and verbal communication and distributed by the Team Leaders in this area. No further meetings were planned post implementation due to the time period and facility accreditation process as no time available by project team to attend.

Implementation was spread over a 4 month period from December 2013 to March 2014 with final audit being attended to in mid-March 2014.

Phase 3 - Follow up Audit

Follow up Audit - The same audit tool was used for the follow up audit criteria. No variations were made or required. All criteria remained relevant and sample sizes did not vary.

Results

Baseline Audit
The baseline audit indicates zero compliance in education for managing challenging behaviours in the 12 month period prior to audit, zero compliance in RN training for Neuropsychiatric Inventory (NPI) instrument and zero compliance for variety of non-pharmacological strategies for managing aggressive behaviours. 100% compliance was reported for the use of a standardized tool to measure BPSD, and 83% for residents with a management plan, regular schedule of re-assessment and patient response. The result would have been 100% but when audit attended there had been 3 new admissions where differing levels of the assessment period were reached and therefore incomplete.

The NPI instrument was new to the ACF at the time of audit and therefore no formal training or self-directed learning had been achieved. 21% of residents were receiving anti-psychotics at baseline audit.

From baseline audit and into the implementation period the areas of concerns were the main focus. An education session led by the project leader was established and discussion re project, best practice guidelines and staff input were discussed. The General Practitioner already attended to three monthly chemical restraint reviews, and throughout the implementation trials of reducing or ceasing these medications continued with varying results however resident and staff safety was maintained. The Registered Nurses received a self-directed learning (SDL) package for NPI which included an online video and supporting documents to read. Group sessions and 1-1 education sessions were arranged for staff to attend with the project team to ensure comprehension.

The criteria for audit questions 4, 6 and 7 was completed within a 3 week period post audit in line with facility policy and regular schedule of re-assessment processes was already in place and maintained at a high level by the Registered Nurse.

The main focus was the best practice recommendations for non-pharmacological management of physical aggression. From staff in-service and staff feedback and from the Australian Government Guidelines for a Restraint free environment6 the recommendations were established. The project team was involved in the approval during this period as re-staffing and costs were involved. The GRIP method was used and barriers identified and resolved so implementation could proceed. (Refer to Tab 1)

Table 1: GRIP Matrix Results

Barriers	Strategies	Resources	Outcomes
Cost to facility	St Agnes Education Fund provided 5hours per week and study leave for project leader outside of usual work load. Community Leader gained funding for extra 25 hours per week for additional staff within secure unit	Staffing hours CEO to re-budget	The project implementation was actioned with minimal staff disruption. Additional staffing hours will continue within the secure environment
Schedule of training for CSE's and RN's	Education in-service re implementation Educational material available to staff Further sessions being looked at post project/accreditation for specifics on managing physical aggression	Power point presentation Supporting a restraint free environment - Dept. of Health and Ageing SDLP set up	SDL package for RN's implemented Follow up training to be organised by Trainer in specific management of physical aggression
Variance to workload and expected staff outcomes/involvement	Identify staff to implement program Educate on documentation and legalities Educate on evaluation of programs	Team Meetings 1-1 sessions with staff involved in the implementation and documentation	Variety of staff involved in activities with a variance to participation and expected outcomes 3 staff educated on documentation

Follow Up Audit
Discussion

The project looked at current practice in place to manage physical aggression and behaviours and psychological symptoms of dementia. Baseline data was gathered, and barriers, actions and resources identified using the JBI PACES and GRIP tools.

The main limitations of the project were:

• Time period which included annual leave and public holiday period where there was high staff absence for planned leave as well as the six month period for the project
• Staff comprehension and ability to take ownership for the benefit of the residents during and post project completion
• Registered Nurse interest on top of usual clinical workload
• Funding approval for project leader and for extra staff support to implement project
• Facility 3 year accreditation during project period

As a result of these limitations members of the project team communicated through email and there were no planned team meetings post education and implementation in December due to the leave and impending accreditation.

The main success of the project was improving staff knowledge and building on staff morale in this area in a positive direction. Further to this the successful implementation of best practice into the secure unit where the regular care staff were in charge of the activities and staffing was added to 25 hours per week to allow for this project to occur. Including the care staff in this area was an ideal solution as opposed to lifestyle staff due to their hands on understanding of the resident's needs, resident familiarity with staff in this area and the ability in identifying residents with physical aggression and providing suitable activities. The documentation of resident activities and outcomes has improved however further training is required for care staff and lifestyle staff in this area.

Future directions for promoting best practice highlighted by the project as priorities are:

• Further training for Registered Nurses in assessing, completing and updating of care plans using the Neuropsychiatric Inventory
• Community Leader reviewing who is responsible for the continuation of best practices for the secure unit and ongoing effectiveness and further training in documentation
• Education and support packages being available to residents and families coming into the secure unit to dissipate relative stress, anxiety and the grieving process with particular focus on behaviours and end stage dementia symptoms and management
• Review of the admission process for new residents into the secure unit to establish suitability prior to admission
• Review of the auditing processes for clinical management in reference to falls, behaviour management and reporting of incidence of concern
• Review of training for care staff in the secure dementia care setting

Conclusion

The best practice outcomes for a variety of non-pharmacological strategies will require ongoing audit and evaluation into the future and ownership of who is responsible for this area. Future training has been identified and staff compliance in activity planning to manage physical aggression. Additional hours will continue to be supplied to the secure unit. This area is being audited by the Community Leader to establish who will take ownership of the program for the best management of staff time, documentation and to ensure suitable activities/plans are in place for residents.