Validation Therapy for people with dementia


All staff who care for people with dementia, particularly advanced dementia, are very aware that it can be a particularly difficult challenge. With the progression of the condition service users withdraw into themselves more and more, they don’t let anyone come near them and they no longer remember recent events.

However, in order to meet people’s needs, staff must have some means of communicating with the person – either verbally or non-verbally. Dementia Support suggest there is another method that can help those who care for people with dementia to make a positive connection with them. This method, developed by Naomi Feil in the 1980s, is known as Validation Therapy, and it enables staff to react effectively in response to a service user’s behavior.

By using the Validation method, staff can reduce tension between themselves and those in their care, and begin to develop a closer relationship with them. One critical element of validation, for example, is that it shows that you have respect for who they are and that you accept their current feelings and expression of their emotions.

The central belief and goal of Validation Therapy is that people with dementia should always be taken seriously – no matter what they say, feel or how they act.

Objectives and goals of validation therapy

Whenever you use the Validation method, you are making a connection with the feelings of those in your care. Knowing their Life History, therefore, plays an important role in providing this advanced level of care.

The objectives of Validation Therapy will give staff an understanding of what the approach is trying to achieve:

Cognitive Goals: Improves the persons capabilities
Physical Goals: Improves their wellbeing
Emotional and Personal Goals: Resolves any past conflicts
Social Goals: prevents social isolation of the person

In order to achieve these goals staff should aim to meet the following intermediate goals:

Convey the persons esteem
Reinforce their identity and self-respect
Maintain dignity
Reduce stress
Improve wellbeing
Revive past emotions
Establish effective communication
Communicate at the emotional level.

The aim of Dementia Care & Support, is always to give managers practical, step-by-step advice so that they and their staff can learn quickly and effectively how to apply advanced care techniques in their daily work. Rather than offering unnecessary theory, here are their fast-track tips for implementing the Validation Method in your care service:

First, observe the person in your care

Within a short period of time, you’ll notice certain behavioural patterns that recur time and again. You’ll then be able to draw on these later.

Convey to them a feeling of their own esteem

Esteem is a prerequisite for gaining their confidence. You can express your esteem for them by:

• Giving them your full attention
• Showing them that “I have time for you”
• Adopting and reflecting back to them their manner of expressing themselves and their body language
• Being tactile and being close to them.

But don’t overdo it and be sure to express only genuine feelings. Even if people with dementia often give the impression of being confused and disoriented, they’re still exceptionally sensitive to feelings and moods. They will pick up on the exact tone of your voice and the intention behind it.

When using Validation Therapy, there are a set of rules of communication that you can follow that are especially appropriate to the feelings and behavior traits of people with dementia. Dementia: Care & Support have put together the following checklist for you to use in your care home.

Validation therapy also encourages carers not to contradict the person with dementia and to instead enter their world, rather than trying to bring them (usually unsuccessfully) into your own.

‘Validation is about being in the moment with the person,’ explains Julia Pitkin, one of the first validation practitioners in the UK. ‘Being corrected can make a person feel devalued.’ Whether you call it special care or validation therapy, both approaches recommend using distraction techniques rather than lying.

So, for example, if a service user keeps asking where her husband is, instead of reminding her he died five years ago, you could say, ‘it sounds like you’re really missing him, how did you meet? Can I see some wedding photos?’

Empathy and respect are what matters, say supporters of both approaches. Feeling listened to and supported, they argue, helps people with dementia regain their dignity and feel a greater sense of calmness and peace.

Summary

Managers and staff are always on the lookout for new approaches to engaging and communicating with people who suffer from dementia. Validation Therapy is not new, but the benefits of this approach are now being recognized. There is a great deal of literature available on this topic if managers are interested. Including: Dementia Care and Support for Care Home Personnel.

There is also a video by Naomi Feil available on YouTube here.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director

The importance of exercise to service users in care and nursing homes


The importance of keeping people who use social care services active is highlighted in a recent study published in The Journal of Physiology. Older people who are inactive or sedentary for any period of time can rapidly lose muscle mass and mobility. Researchers have been able to document for the first time how the same period of inactivity has a greater and more severe impact on the muscle power of the lower limbs of the elderly than young people, which is essential for movements like climbing the stairs.

The disuse of muscles due to a sedentary lifestyle or short periods of inactivity caused by hospitalisation can dramatically enhance the decline in muscle mass, metabolic health and functional capacity. This loss of muscle power caused by disuse can be especially detrimental in the elderly.

The research, conducted by the University of Udine in conjunction with the University of Padova, involved studying the impact of complete inactivity in a group of elderly subjects that were bedridden in a hospital environment for 2 weeks, and their results were compared with young subjects.

In the elderly subjects, there was a difference in single muscle fibre response to disuse, a more pronounced loss of muscle mass and a change in how muscle contraction is controlled by the nervous system compared to young individuals. Furthermore, the recovery phase was more difficult in the elderly group.

Carlo Reggiani, the lead investigator on the project commented on the findings: “While clinical and epidemiological data on inactivity in the elderly are abundant, experiments on disuse and inactivity are seldom performed in elderly for several reasons. The results obtained are relevant not only to understand the inactivity-dependent enhancement of the decline (in muscle mass, metabolic health and functional capacity) but also to design new rehabilitation protocols where timing and intensity of the sessions are optimized.”

It is not uncommon for service users in care homes to sit for long periods of time, and in some cases because of ill health can be confined to their beds. As the aforementioned report shows inactivity and lack of exercise can have serious consequences for service user’s health and wellbeing and ultimately their quality of life.

The value of physical activity

Further evidence of the importance of an exercise program for service users comes from a taskforce report, under the auspices of The International Association of Gerontology and Geriatrics. Its recommendations on physical exercise concludes that beside activities of daily living dependency service users in social care services face other important medical challenges. Dementia care, behavioral and psychological symptoms of dementia falls, pain, the use of potentially harmful drugs (e.g., antipsychotics), and mood (particularly depression), and quality of life are often recognized by staff and experts as crucial issues for the care of service users.

Exercise training has the potential to improve many of the above-mentioned issues. Recent studies also suggest that exercise is of benefit for the mobility and physical function of people with dementia.

One of the key challenges for staff is to maintain service users’ functional ability, which is made up of subjects’ intrinsic capacity and environmental characteristics and the ability to cope with their functional limitations for as long as possible.

Overall physical activity has been shown to protect against activities of daily living disability. Experts in care home research and clinical care, with the support of the International Association of Gerontology and Geriatrics and the World Health Organization, have already recognized the importance of exercise for the quality of care of people who live in care homes.

Scientific evidence has shown that exercise training, i.e. a subset of physical activity that is planned, structured, repetitive, and purposeful, being generally used to improve/maintain physical and functional capacities, has been found to have positive effects on the ability to perform activities of daily living.

Motivation

Motivation and pleasure are the key aspects to take into account when attempting to increase overall activity levels of service users. To increase service users’ motivation, it is important to build awareness of the importance of replacing sedentary time with physically demanding activities, even if those activities are of light-intensity (e.g. walking slowly). Staff should attempt to promote service users’ physical engagement during social and daily life activities. Building awareness should target both the service users themselves as well as staff, other healthcare professionals (including the primary care physician), service users’ family, and policy makers.

Proposed recommendations to increase overall activity levels

According to the International Association of Gerontology and Geriatrics, when considering the crucial importance of enhancing the overall levels of activity in the daily life of service users, the manager should consider:

1)   To adopt strategies for breaking the sedentary time of service users. Establishing short breaks (2-5 minutes) twice or three times a day is probably feasible in a care home setting.

2)   To systematically use simple strategies to stimulate service users to move: walking to the lunch/dining hall rather than using wheelchairs for people who are able to ambulate, and organizing events that require service users going out from their rooms.

3)   To avoid chemical and physical restraints as much as possible since they result in bed and chair-rest.

4)   To optimize the utilization of the architecture and equipment in order to promote mobility.

5)   Staff, should organise group activities that are motivating and pleasant, for example promoting chair exercises and dancing where appropriate.

6)   To use innovative solutions, such as using animal interventions and new technologies, in order to increase service users’ motivation and pleasure and, then, overall activity levels. Animal interventions have been shown to be effective in increasing physical activity in institutionalized older adults.

7)   The use of robots which have been shown to decrease feelings of loneliness and improve participation in activities.

Summary

The importance of exercise to service users in care and nursing is now supported by numerous health advisory studies worldwide. Managers of care and nursing homes should ensure that assessment of service user’s physical activity and a program of appropriate physical exercise forms part of the service user’s person centred care plan.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

The unfair practice of self-funding residents subsidising residents supported by local authorities

The published report of the Competition and Markets Authority’s market study into residential and nursing care homes for older people makes interesting reading for those working in this sector.

The study found that public expenditure on adult social care of all types (including non-elderly care and care outside care homes) has been under pressure. For example, aggregate expenditure has declined in real terms by 8% between 2009/10 and 2015/16 in England.

The sector has reported facing challenges to its sustainability, due primarily to the low fee rates being paid for state-funded residents – those challenges being exacerbated by increased cost pressures due largely to wage costs. In its annual assessment of the quality of health and adult social care in England (October 2016), the Care Quality Commission (CQC) said that the sustainability of the adult social care market is approaching a tipping point.

The Competition and Markets Authority have undertaken an extensive profitability analysis of the sector using information provided directly by care homes and taken from company accounts. It is understood to be the most complete study of profitability in the sector in recent years.

In their assessment, they found that the average fees paid by Las are below the full costs involved in serving these residents. Our financial analysis of the sector shows that, looked at as a whole, the sector is just able to cover its operating costs and cover its cost of capital. However, this is not the case for those providers that are primarily serving state-funded residents.

Many care homes, particularly those that are most reliant on LA-funded residents, are not currently in a sustainable position. Our analysis shows that while many can cover their day-to-day operating costs, they are not able to cover any additional investment costs. This means that while they might be able to stay in business in the near term, they will not be able to maintain and modernise facilities, and eventually will find themselves having to close, or move away from the LA-funded segment of the market.

This shows that the fees currently being paid by Las are not sufficient to sustain the current levels of care under the current funding model. The implication is that public funding needs to increase if the current model of funding is to continue, or alternatively, if current levels of funding do not increase, the funding model for care will need to be changed.

Our analysis suggests that about a quarter of care homes have more than 75% of their residents LA-funded, and that these are the ones most at risk of failure or exit because of a funding shortfall. We estimate that LA-fees are currently, on average, as much as 10% below total cost for these homes, equivalent to around a £200 to £300 million shortfall in funding across the UK. This finding is based on an average result – there will already be a proportion of operators that are struggling and at risk of closure.

The large majority of care homes offer places to self-funded as well as LA-funded residents. Many care homes are relying on higher prices charged to self-funders to remain viable, even when providing the same services. Self-funded residents in mixed homes are meeting a much greater proportion of homes’ fixed costs. Without this, the public funding shortfall would have a substantially larger impact than it currently has.

Our assessment based on larger providers is that self-pay fees are now, on average, 41% higher than those paid by Las in the same homes. This represents an average differential of £236 a week (over £12,000 a year). We understand that fee differentials for smaller providers are slightly lower but still significant.

This difference between self-funded and LA prices for the same service is understandably perceived by many as unfair. The large majority of self-funders are not wealthy; the current thresholds for support are currently drawn so that practically anyone who owns their property will be ineligible for state funding, regardless of income. Moreover, there is very poor visibility of the size of these fee differences so the public is generally unaware and Las do not have to justify their approach to the fees they pay to care homes.

In addition to this, however, the situation may not be sustainable. Where LA rates are below total cost, those care homes that can attract self-funders are likely to move away from serving a mix of residents. We already observe that nearly all new care homes being built are in areas where they can focus on self-funders. While we would expect that many mixed homes with differential pricing could continue to operate for some time, there will be a need for additional funding to support further care homes that would not be sustainable without the benefits of this price differential.

Our assessment is that if Las were to pay the full cost of care for all residents they fund, the additional cost to them of these higher fees would be £0.9 to £1.1 billion a year (UK wide, and assuming this money is directed specifically to those homes where LAs pay fee rates below total costs).

Summary

The Competition and Markets Authority’s market study into residential and nursing care homes for older people, confirms what we have known for some time a seriously underfunded social care sector. However, what is interesting from their analysis is how the care home sector is propping up their services. To remain viable it is asking self-funded residents to pay the real cost of care and thereby subsidising local authority sponsored residents who are paying much less for the same care. This is grossly unfair. It is time for Local authorities to pay the real cost of care. Equaity should mean equality.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

 

It that time of year again – Looking back over 2017

Looking back over the year 2017 I have tried to bring to your attention articles and blogs that you might find interesting in the world of social care. I have covered topics ranging from the crises in social care funding to the use of yoga in care homes.

The central purpose of my blogs is to keep you informed of innovative practice that may improve the quality of life of people who use social care services. In addition, I also include new requirements placed on providers by the Care Quality Commission.

Overall the year 2017 in social care is ending as it began. Social care is still in crises because of underfunding, and has reached a tipping point. A number of care homes have decided to call it a day, and some domiciliary care providers have even handed back their contacts to local authorities because they are uneconomically viable.

Looking forward positively, we are promised a Green Paper on social care funding in the summer of 2018. On the one hand, this may be seen as a method of kicking the problem in the long grass, and further delaying tactics. Alternatively, it may at last be recognised as a problem, where the solution can only be found outside the cut and thrust of party politics and consensus on way forward is agreed by all parties.

All the best to you and yours for 2018.

Happy Christmas!

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

 

Bullying and harassment in the social care workplace

In the past few weeks there are not many of us who have escaped media coverage on sexual harassment and bullying. The Harvey Weinstein affair and the behaviour of members of our political institutions has done much to concentrate the mind. This is not an issue however that is confined to the rich and famous. It does happen in the workplace and no doubt in the social care industry. ACAS are an organisation that I greatly respect for their guidance and expertise, and in this blog I provide a short review on their guidance to managers on bullying and harassment.

What is bullying and harassment

Bullying and harassment means any unwanted behaviour that makes someone feel intimidated, degraded, humiliated or offended. It is not necessarily always obvious or apparent to others, and may happen in the workplace without an employer’s awareness.

Bullying or harassment can be between two individuals or it may involve groups of people. It might be obvious or it might be insidious. It may be persistent or an isolated incident. It can also occur in written communications, by phone or through email, not just face-to-face.

Examples of bullying / harassing behaviour could include:

  • spreading malicious rumours, or insulting someone
  • exclusion or victimisation
  • unfair treatment
  • deliberately undermining a competent worker by constant criticism.

Under the Equality Act 2010, harassment is unwanted conduct which is related to one of the following: age, disability, gender reassignment, race, religion or belief, sex and sexual orientation and is therefore unlawful.

People do not always feel able or confident enough to complain, particularly if the harasser is a manager or senior member of staff. Sometimes they will simply resign. It is therefore very important for managers to ensure that staff are aware of options available to them to deal with potential bullying or harassment, and that these remain confidential.

What can staff about being bullied or harassed?

If staff are being bullied or harassed, they should take any action you decide upon as quickly as possible. It is always best to try to resolve this informally in the first instance as sometimes a quick word can be all it takes. However, if this fails there are a number of options for staff to consider:

  • see someone that staff feel comfortable with to discuss the problem, perhaps someone in HR or company counsellor
  • talk to your trade union or staff representative
  • keep a diary of all incidents, record: dates, times, witnesses etc
  • keep any relevant letter, emails, notes etc.

Why a manager should act against bullying or harassment?

Bullying and harassment create an unhappy and unproductive workplace, that has:

  • poor morale and poor employee relations
  • loss of respect for managers or supervisors
  • poor performance / lost productivity
  • absence / resignations
  • tribunal and other court cases and payment of unlimited compensation.

What can be done to prevent bullying or harassment taking place in the service?

There are a number of key considerations that should help to prevent this behaviour:

  • develop and implement a formal policy: this can be kept simple, but you should consider involving staff when writing it
  • set a good example: the behaviour of employers and senior managers is as important as any formal policy
  • maintain fair procedures for dealing promptly with complaints from staff
  • set standards of behaviour with a service statement about the standards of behaviour expected; this could be included in the staff handbook.

Is workplace bulling getting worse?

A study in 2011, by public sector union Unison, reported that six out of 10 public sector workers in the UK had either been bullied themselves or had witnessed bullying in their workplace. The findings also suggested a strong link between the increased incidence of bullying and the economic downturn, with one in four workers believing that staff cutbacks had been a direct cause of workplace bullying.

The majority of those polled in the Unison survey – 53% – said they would be too scared to raise concerns over bullying in the current climate, compared with just 25% two years ago.

Individuals on the receiving end of unwanted behaviour described conduct such as being yelled at, eye-rolling, verbal abuse, being ‘talked down to’ in a humiliating way in front of colleagues, as well as more concerted patterns of ill-treatment such as ostracism (‘being sent to Coventry’).

Issues raised often centred on ill-treatment by direct supervisors, frequently building to the point where individuals dreaded going to work, and where their home and family life had been affected. Many were on leave or had recently taken leave to ‘escape’ the workplace, to allay the work-related stress and anxiety they were experiencing.

Summary

Harassment and bullying in the workplace may not receive the attention it deserves. To those who suffer the consequences, they find so stressful that it leads to them giving up their job. This is not only damaging to the individual, but the service. To prevent it services need to adopt a culture that not only identifies harassment and bullying, but has procedures in place to prevent it and support staff who suffer from it. Managers should refer to the ACAS website for more information on this topic.

Albert Cook – BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy