“One of the reasons I hate visiting my patients in nursing homes is because I find them all lined up, sitting at the nurse’s station, and they look like they are just waiting to die”

(Dr. Mark Izard personal communication February 14, 2004)

Managing behaviors and calming residents on a dementia unit can be difficult. Etiology of behaviors is a critical thinking process initiated by a nurse that includes input from the interdisciplinary team. Nurse’s have the ability to observe, trend and predict outcomes that directly influence patient safety and quality of life. The practices and protocols included in this pilot study are currently being applied in a Long Term care facility in New England on a secure dementia unit with forty two residents.

Will a prescribed nursing intervention based on Maslow’s Hierarchy in combination with a simple conceptual framework of meaningful activity show a decrease in the quality of life problems triggered on the resident level quality measure report in Stage 5 (moderate) through Stage 7 (severe) Alzheimer diagnosed individuals admitted to a secure dementia unit?

A prescribed nursing intervention based on Maslow’s Hierarchy in combination with a simple conceptual framework of meaningful activity will show a decrease in the quality of life problems triggered on the resident level quality measure report in Stage 5 (moderate) through Stage 7 (severe) Alzheimer diagnosed individuals admitted to a secure dementia unit.

A GROUNDED THEORY OF DISCOVERY IN THE DATA REVEALED THAT MEANINGFUL ACTIVITY FOR MIDDLE TO LATE STAGED ALZHEIMER INDIVIDUALS WHEN COMPARED TO CHILD ART AND ACTIVITY IS CONCEPTUALLY PIAGET IN REVERSE

Stage 4

Stage 5

Stage 6

Stage 7

11 yr & up

7-11 yr old

2-7 yr old

Birth-2 yr old

Writing

Books, News Lit Chores, folding, cooking

Serration,Flower arrangingFlashlights

Dough rolling

Tootsie pops pops

Sensory Music

Formal operational

Concreteoperational

Pre-operational

Sensory-motor

Mild Alz

Moderate

Moderate/Severe

Severe

Harold

Myrtel

Bubba

Cloey

Glorey

Louise

Greta

Mara

FASTPIAGET IN REVERSE CASE STUDIES

ACTIVITIES THEY MASTERED

Movies

Movies

Currently meaningful activity is a complex process of discovery of need

Self Esteem for a cognitively impaired person is subjective

Self Actualization for a cognitively impaired person is subjective

Permission for the study was obtained from the long term agency representative.

Family conservators were asked for verbal permission to allow participation in this study following an information session.

Risks were identified as minimal Adequate provision was made to ensure the

participant’s safety and because of the vulnerability of this study population additional safeguards were used to protect the rights of the individuals.

Convenience sample of 42, Stage 5-7 Alzheimer diagnosed residents on a special care unit in a long term care facility

Inclusion- all residents residing on unit whose advanced directives indicated do-not-resuscitate or palliative care status

Exclusion- acutely ill, and residents residing on unit whose advanced directives indicated a full code status

This pilot study used a mixed method research design composed of nursing intervention research and direct observation of behaviors.

The prescribed nursing intervention was developed by the researcher and reflected the use of the HALT + pain assessment guide and Montessori based activity boxes.

The primary researcher observed patient behaviors twice a day and recorded these observations in a series of field notes following the interventions. Staff nurses documented intervention outcomes in the daily nurses notes.

Outcome analysis data was collected from the agency required MDS assessment tool on a weekly rotating schedule compiled on a quarterly basis for all individuals residing on the secure unit.◦ Quality indicators measure quality of life in long term care agencies. A score of 4 or

more indicators on this report shows a need for improvement. ◦ Individuals on a secure dementia unit often have scores of 4 or more indicating a

need for nursing intervention to improve quality of life.

Daily review of medical charts, nurse’s notes, 24 hour house communication sheet, Intake and output flowsheets.

Quarterly quality indicator report based on Minimum Data Set (MDS) analysis pre and post interventions.

Daily log of observations pre and post interventions by one primary researcher

Alzheimer art projects post therapy sessions

2 hour in-service staff training with daily reinforcement of learned technique by primary researcher for three months after intervention was introduced

Activity’s scheduled at 11:00 am and 2:30 pm for 45 minute sessions three times per week,

Expressive Art Therapy at 11:00 am and 2:30 pm for 45 minute sessions two times per week

Memory Boxes and art supplies on unit as a 24 hour E-box for problem behavior intervention

Documentation of problem behaviors and intervention effectiveness in nurse’s notes under P Section of the nurse’s S.O.A.P. note

2-7 minutes of calmness with three to four verbal cues

15 minutes of calmness and full distraction from behavior with 1 :1 attention

5 out of 12 domains in MDS decreased showing improvement in quality of life.

Chronic care sample report identified that 22 of 37 residents scored with<4 of 26 possible quality problems on the roster three months post intervention.

Small sample size Only one agency in the northeast was used The population sample had multiple other

variables such as race, age, gender which should also be taken into consideration.

Limitations to the studyLimitations to the study

This pilot study utilizing Maslow’s Hierarchy, Piaget in Reverse, and the FAST Stage Assessment tool as a prescribed nursing intervention of meaningful activity for individuals on a secured dementia unit in long term care improved quality of life for residents

This pilot study demonstrates the need for further study to test the reliability and validity of the study design and to replicate the study itself.