3.7 Self reported daily care practices
3.8.4 Summary:
‘Making meal times better for those with a Dementia’ an innovative feeding assistance programme designed to meet the unique characteristics of the varied HCA workforce demonstrated that delivery and method of training are key components to successful
improvement of knowledge, competency, attitudes and daily care practices in HCAs working with a dementia and oral feeding difficulty.
The specialist role and distinctive contribution of HCAs as key health providers is
increasingly notable in the literature as is the need for substantial training programmes to develop the skills and attitudes necessary to provide excellent care to individuals with a dementia in nursing home settings (All Party Parliamentary Group, 2009). Research has questioned the readiness of HCAs to provide personalised dementia care and in particular to
153 provide feeding assistance and management of those residents with an oral feeding difficulty (APPG, 2009; Simmons, 2007; Simmons, 2001). The need for feeding assistance training for HCAs to meet the challenges of this population is a priority (DoH, 2009). Although the key characteristics of this pivotal group alongside the increasing need for professional
development and regulation of HCAs are apparent, the methods of improving the practice and competencies of this varied workforce regarding management of a dementia and oral feeding difficulties is less certain. The key characteristics of the HCAs in this study reflect the key characteristics of those presented in the literature base. The cohort is overwhelmingly female; they have lower levels of education, typically from Black or Ethnic Minority Groups with English as a second language, are non traditional learners and therefore require specialised engagement with training. This research provides evidence regarding the delivery of training and methods of engagement necessary to demonstrate improved knowledge, competency, reported daily care practices and attitudes of HCAs based on a substantial training
programme, ‘Making meal times better for those with a dementia’.
The MMB feeding assistance programme, incorporated into an ongoing training and development programme, encouraged a learning culture and reflective practice within the HCA cohort, which in turn enabled them to produce a collaborative management strategy for residents with challenging oral feeding difficulties. Training took account of the
characteristics of the HCAs such as their potentially low interest in academic learning and employed less theory-based didactic teaching and instead focused on experiential and reflective learning, drawing upon the existing skills of adult learners. Visual learning materials and in particular video footage of residents known to havechallenging oral feeding difficulties encouraged collaboration and consensus among HCAs to produce highly
individualised care plans promoting good dementia care with the ultimate aim of improving the lives of the individuals with a dementia.
154 The effectiveness of this feeding assistance programme is limited by the small purposive sample of three specialised dementia care settings. The very nature of the HCA population working with those with dementia makes it difficult to access using a randomised control trial. The selection of nursing homes based on several characteristics (containment of a specialized dementia unit, unit size, staffing and staff to resident ratio) and the large numbers of HCA participants (n = 106) aimed to compensate for shortfalls in research methodologies. Future evaluation of the effectiveness of the MMB feeding assistance programme will aim to utilise a controlled research methodology and recruit from a larger number of nursing homes across a widespread geographical location.
Due to resource limitations this study did not expand the role of nursing home management or local collaborators. The importance of management and local collaborators to ensure the effective training of HCAs cannot be underestimated in the management of advanced
dementia (Department of Health, 2009 & Sackley, 2009). Institutional barriers to provision of training for HCAs were at times very challenging. The lack of support to enable HCAs to leave the ‘floor’ to participate in data collection and training forums plus the logistical requirements of training such as training rooms were at times almost insurmountable, and required delicate negotiations with managerial teams. Several institutional barriers
preventing a learning culture and reflective practice were noted by the researchers during the course of research that merit further research. Furthermore, defining features of the HCA population, particularly high staff turn-over, served to militate against effective training interventions; a significant proportion of HCAs were lost to drop out rates and replaced by untrained personnel in the dementia care units.
HCAs exposed to the most training demonstrated increased awareness and insight to the needs of residents and were able to identify theoretically beneficial changes to the residents with oral feeding difficulties as evidenced by increased knowledge, competency and the
155 ability to utilize these strategies into daily care practices. The outcomes of this study are novel in suggesting a substantial method of training delivery using a learning style suitable for non traditional learners, effective in sustaining improved knowledge, competency, daily feeding care practices and attitudes longitudinally whereas without continued support the results reflect the wider body of evidence in the literature base, which is that of initial improvement followed by a gradual loss of skill post training (Davison, 2007).
This study is part of continued efforts to identify and develop core competencies for HCAs caring for residents with an oral feeding difficulty in nursing homes settings consistent with their role. This project aimed to address a documented need for training in providing feeding assistance and holistic management of residents with a dementia and oral feeding difficulties by exploring innovative, effective training interventions for HCAs in nursing care facilities that can be realistically implemented and sustained with the support of nursing home
management as part of a larger national accredited training programme for HCAs. This study demonstrates that given the right support HCAs can demonstrate specialised knowledge, competencies and daily care practices regarding dementia and oral feeding difficulties necessary to provide good quality feeding assistance and dementia care.
The observational component of this study will evaluate the clinical outcomes that might result from improved HCA knowledge, competency, attitudes and daily care practices to the quality of life of residents in their care particularly during feeding assistance. Furthermore the observational comment will permit analysis of the unique contribution to individualised care made by HCAs and assess whether this is conveyed back to the inter-professional team or lost as a consequence of institutional barriers to the successful translation of knowledge in care institutions (Kontos et al., 2009, Lloyd et al., 2011).
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