CH staff appeared to draw on many aspects to inform their approaches to residents with BPSD. Experience in the job, rather than training, was viewed as the main feature in guiding staff how to manage BPSD. Experience was gained through working with residents with BPSD, from watching and listening to other staff members, and from getting to know the residents. Past experience of looking after family members with dementia and life experiences (such as being a parent) were also viewed as helping factors for staff to be able to cope with BPSD. There was a general sense that there was no definitive right or wrong way to manage behaviour; instead you had to find your own way within the confines of the policies and procedures provided. For example Elaine states:
‘we are learning all the time, everyday you come in here and you cannot say to
someone ‘I know it all, I know how to do it’ ... every resident can be so different each day.’ (Elaine, Carer, Mirabelle Way)
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Here Elaine suggests that even for experienced care workers, learning in the job and about the residents is a continual process. The changing nature of residents’
behaviours mentioned in Elaine’s interview reflects a need for a flexible and adaptive care approach.
Staff training had mixed reviews; although most staff said it was helpful for everyday practice, reducing fear of dementia and providing staff with new ideas. Other staff believed that training did not make you a good carer. For example, Carla states in this excerpt:
‘I’ve had the training for dementia and, and, but just the dementia awareness, it’s a lot more that you learn actually being here (laughs) ... the way you treat people is in you (taps chest) no form of training can make you feel what you feel inside or the respect ... yes I’ve had training in dementia awareness, I’ve had training in safeguarding and vulnerable adults, but that doesn’t make you a carer ... It doesn’t make you the carer you are, there is something inside us that’s the certain type of person that can’ (Carla, Senior Carer; Gage Hill)
The person you are, your background, your personality, your own common sense judgements and experiences were seen by many staff as more important to make you a proficient carer. These individual characteristics of staff members impacted on the management of BPSD. Different staff perceived behaviours in different ways; with some seeing them as problematic and some not. For example, one carer, Jen, at Cherry-Plum was a Christian and found swearing very offensive, whereas other staff did not. Each staff member also had their own approaches, level of confidence, standards and ideas of what was acceptable. Some staff stated that they really enjoyed the challenging nature of caring for residents with dementia and were
confident in managing any behaviour. For instance, Elaine, a carer from the EMI home Mirabelle Way states:
I prefer the challenging side of it, yeah I love the challenge ... I know that sounds more ... Um bizarre I suppose, but no I prefer that side of it ... Yeah I do like the physical and the mental side of it, I do ... I couldn’t do residential, I
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couldn’t do residential, I could not make them cups of tea all day and take them shopping, no, that’s not me (laughs) (Elaine, Carer, Mirabelle Way)
This type of statement was not uncommon from carers in the specialist homes
(Mirabelle Way and Gage Hill); staff acquired high levels of job satisfaction and stated that they would not wantto work in non-dementia homes. Overall staff who preferred dementia care appeared to like the feeling that they were doing something ‘specialist’ rather than just carrying out a service role. This was reflected by many carers stating that dementia care had more ‘kudos’ than old age care alone. If you mentioned you worked in a dementia home or an EMI home the general public viewed you with a higher regard. For example, Elaine talks about public perception of the care role here:
‘they might think it’s a little residential home and it’s not, it’s a very acute home you know. ... It’s hard, it is hard, yeah and if the truth be known, in actual fact I was talking to a woman outside the other week, she was a carer in ‘town name’ she was waiting at the bus stop and she was talking to another woman ... and she looked at me and she said ‘oh where do you work?’ I said ’Mirabelle Way’ and she said ‘you deserve £100 an hour’ she’s a carer out there in the community and they know about this home ... Because um, in actual fact ... another member of staff used to say ‘oh I’m just a carer’ I said ‘’carer’s name’ you’re not just a carer, you work in an EMI and tell them you work in an EMI’’
(Elaine, Carer, Mirabelle Way)
This excerpt from Elaine illustrates the importance she connects to distinguishing between dementia care and old age care, especially in light of a more positive public perception of the role. This, in part, reflects the nature of dementia care as being far more mentally and emotionally demanding than old age care. Anne, the assistant manager at Bullace View moved from a specialist home to the predominantly residential home; here she talks of the change:
‘I used to work in an EMI home where they were really, our home took what no-one else could have ... I loved it, I absolutely loved it and coming here was so boring ... it was so boring because I was like ‘well I’ve got nothing to do’ they were all, well, you know, and I was actually really worried about, I know it
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probably sounds wrong, but I was worried coming to talk to normal people because I was so used to having the most randomist conversations about the most randomist people that I didn’t quite know ... obviously I’ve got used to it, but I find the difficult, the better, I love it, it really, they, I’d go straight back into a dementia home now if I could I really would’ (Anne, Assistant Manager,
Bullace View)
Anne appears to find the challenge of looking after residents with dementia more stimulating than looking after those residents without it. The status of working in a home with residents no other home could take may have also been an appealing factor. The higher standing, deferential public perception, stimulation and personal challenge of dementia care all appear to be factors that staff valued about the role. Other staff were more wary of residents with dementia and felt uncomfortable, scared or nervous when difficult behaviours occurred. Overall, the confidence of the staff team appeared to be important for managing BPSD.
Although experience and the person inside were thought of as helpful aspects in the care for residents with dementia, training was thought to have a place too. However, much of the dementia specific training focused on informing staff about what happens to the brain and about the different types of the syndrome. Some staff implied that learning about the aetiology of dementia did not help you look after PWD better. For example, Janice states:
‘To be quite honest, to me, yeah that’s nice to er know what sort of dementia somebody’s got, but really, that doesn’t alter how you should treat them does it?’ (Janice, Night Carer; Cherry-Plum)
Staff approaches to residents with BPSD were less frequently covered by training. Mirabelle Way provided the most comprehensive training; this included arming staff with strategies and techniques to manage behaviour safely. As well as dementia awareness training, break-away, self defence, de-escalation, personal safety, and safe restraint techniques were all covered in the training programme for staff at the home. Gill, the manager, at Mirabelle Way believed very strongly that if the knowledge base of staff is sound, proper care can be provided, confidently.
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‘if you’ve got a good sound knowledge base and you actually know that your knowledge base is sound and it’s good and it’s current, up to date thinking or it’s really good research based then ... you know you’re on good firm ground’
(Gill, Manager; Mirabelle Way)
The high level of training at the home reflects Gill’s ethos as well as the acute mental health needs of the residents at Mirabelle Way. Occasionally there were limitations in implementing training. For example, June, the assistant manager at Bullace View, had been trained in Dementia Care Mapping, but had no time within her role to put it into practice, so although she felt it was a good approach, it was not used in the home. The two homes providing nursing care, Mirabelle Way and Cherry-Plum, both employed general and psychiatric trained nurses. General nurses were viewed as experts in details, task completion and biomedical aspects of nursing. As Janice states here: in
‘general nursing you’re taught to be efficient, on the ball, always get ahead because you never know what’s going to come’ (Janice, Night Carer; Cherry-
Plum)
In contrast, psychiatric nurses were perceived in two contradictory ways. One was as taking a slower approach with residents, listening, giving residents time and not placing as much emphasis on efficient task completion as general nurses. Another perception was that as nurses with mental health training, they were used to controlled and secure psychiatric units where a strong approach to behaviours was sometimes necessary. Typically, the mix of both, general and psychiatric nursing skill sets within the homes was a great advantage, since a lot of knowledge could be exchanged; allowing each type of nurse to learn from the other. With many CH residents currently having highly complex physical and mental nursing needs, aspects from each discipline are required in CHs. With the current and projected increase in dementia, perhaps future nurse training should develop the incorporation of both, psychiatric and general skills to provide nurses with the mixed skill sets needed to meet the complex needs of today’s residents.
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