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Type and Title of Submission


Title:

Implementation and audit of Cognitive Stimulation Therapy on an acute admission/ assessment unit for people with dementia

Description:

This report evaluates the introduction of Cognitive Stimulation Therapy (CST) to a mixed-gender acute admission / assessment ward for people with dementia. The report reviews the literature relating to dementia care with specific reference to inpatient care, psychological interventions for dementia and the development of CST. It outlines the initiation of CST on an acute admission/ assessment ward for people with dementia and offers an evaluation based on the perspective of nursing staff running CST groups on the ward. The results offer an insight into some of the challenges of running CST but highlight the benefits of doing so for the individuals with dementia who are admitted to the ward.

Category:

Clinical

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG42 - Dementia

Category(s) that most closely reflects the nature of the submission:

Service implementation and audit

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

The aim of the implementation initiative was to introduce a programme of structured activity to the mixed-gender acute admission / assessment ward for people with dementia. In addition to implementing NICE / SCIE guidance, the rationale for introducing a programme of structured activity included promoting the health and wellbeing of individuals on the ward, increasing opportunities to implement person-centred care and making better use of nurse protected time.

Objectives

1. To introduce cognitive-stimulation therapy (CST) to the ward to be run daily in nurse protected time. 2. To evaluate the introduction of CST and develop its use in response to feedback

Context

Prior to the introduction of CST there was not an established programme of structured activity on Grove Ward, effectively making the baseline 'zero'. The intervention was needed because of recognition that patients on the ward were not being routinely engaged in stimulating activity to promote their health and well-being through interactions with others. The importance of relationships and interactions with others to the person with dementia, and their potential for promoting well-being are recognised as fundamental to the basic principles of dementia care. In addition, environments that do not offer stimulation and engagement are likely to be conducive to challenging behaviour as a result of people responding to boredom. This can potentially lead to a higher number of serious untoward incidents within ward environments. The absence of structured activity on the ward was a missed opportunity to promote health and well-being of those being cared for. The need for psychological interventions for dementia is clearly recognised in the NICE / SCIE guidelines and in the dementia-care literature. Although there is virtually no literature about their use in inpatient environments, there is a clear argument for people with dementia in such environments having access to such interventions. CST is the intervention that has been subject to more research than other approaches, and there is a growing evidence base supporting both its use and cost-effectiveness in community settings and residential care homes. CST groups offer staff a clear opportunity to work in a person-centred way and apply Kitwood's (1997) principles of 'Positive Person Work', which include warmth, holding, including, belonging and fun. Consequently, CST groups have the potential not only to bring benefits for people attending the groups, but also interactions on the ward more broadly. It was for these reasons that CST was chosen as the basis for a programme of structured activity on the ward.

Methods

1) In eight one-hour CST sessions evaluated, 40 patient contacts were made. 2) The vast majority of those attending were perceived by nursing staff to: a) Show some or great interest b) Show some response or communicate well c) Show some enjoyment or enjoy the session greatly and d) Show some signs of good mood or appear happy and relaxed. 3) Challenges for those attending groups were sensory difficulties, particularly sight and hearing, needing some prompting, distractions and a dominant group member. 4) Benefits for those attending were social interaction and communication, laughter smiles and humour, reminiscence, sharing, being more awake, improvement in mood, stimulation of the brain, a happy atmosphere and exercise. 5) Challenges for facilitators were found to be an absence or reluctance of other staff, a dominant group member, keeping patients awake, not being clear about the structure or finding the group exhausting (but enjoyable). 6) Benefits for facilitators were that groups were fun and / or enjoyable, enabled participation and interaction with patients, gave an opportunity to see group members participating and created a relaxed atmosphere. 7) Staff reported that CST was enabling them to notice things about patients through seeing interactions with others and they felt they knew the patients better as a result. CST was seen to give staff opportunities to conduct clinical assessments during dedicated patient time that they would not otherwise have, providing valuable information to the multidisciplinary ward review to inform decision making. 8) Staff members who had not felt confident about running sessions initially gained the confidence and skills to do so and enjoyed doing so. 9) Recommendations for future groups were elicited, which focused on practical aspects of running groups and also managing the selection of participants and group interactions.

Results and evaluation

Staff running the CST groups were asked to complete feedback sheets at the end of each session in order to evaluate the group. Feedback sheets rated staff perceptions of patients' interest, communication, enjoyment and mood during the group and included a specific request for recommendations for future groups. Although long-term patient outcomes were not measured, the results suggested that participation in the CST sessions had immediate positive outcomes in relation to interest, communication, enjoyment and mood, as outlined above. Whilst not measured directly, the results also suggested that the implementation of CST on the ward broadened clinical assessment and availability of information on which clinical decisions were made. The results are to be submitted for publication in The Journal of Dementia Care

Key learning points

1) A programme of structured activity on acute admission / assessment wards for people with dementia is both possible and beneficial for both patients and staff. 2) The benefits for patients are in line with the basic principles of dementia care and can have a positive impact on the ward environment beyond the limits of the one-hour group. 3) CST sessions can be fun and enjoyable and offer an opportunity to get to know patients in a way that nursing staff would not otherwise be able to. It is likely to have an impact on promoting person-centred care in other aspects of ward life and routine. 4) CST offers opportunities to conduct clinical assessments and contributes to multidisciplinary decision making and care planning. 5) CST sessions enable nursing staff to develop clinical skills and confidence. 6) The prioritisation of other tasks over structured activity for patients poses a significant challenge, particularly at times when resources/ staff are in short supply. Using nurse protected time can overcome these challenges and promote activity for patients. 7) Staff are likely to develop faith in activity and its benefits as they see it occurring. It is sometimes necessary to give a high level of support early on in implementation 8) CST sessions on an inpatient ward can be demanding for staff members. When resources are limited flexibility in the way sessions are run is needed in order to promote continuation. For example, the type of activity or the length of session can be adapted in order to meet the needs of the group members on any given day. The pace, content and process of sessions may also need to change daily depending on attendance 9) There is a need to be particularly aware of and sensitive to sensory impairments of group members and make adjustments where necessary. 10) CST could have a role in promoting recovery and discharge from the ward, as well as the benefits experienced by group members within sessions

Contact Details

Name:Wendy Harlow
Job Title:NICE & SCIE Implementation facilitator
Organisation:Sussex Partnership NHS Foundation Trust
Address:Aldrington House, 35 New Church Road
Town:Hove
County:East Sussex
Postcode:BN3 4AG
Phone:07917592984
Email:wendy.harlow@sussexpartnership.nhs.uk

 

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This page was last updated: 29 September 2009

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Selected, reliable information for health and social care in one place

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.