Oportunidades en el desarrollo de software médico

Visitors to the CHs could be great resources. Many family members visited daily at regular times and helped staff by feeding their loved one, occupying them or helping to manage their behaviour. Some of the relatives appeared to be incredibly helpful in managing behaviour. Jim, a resident at Gage Hill is unsteady on his feet, but wanders a lot. He becomes agitated and grabs on to people very hard, sometimes injuring staff or residents this way. Jim’s wife arrives at Gage Hill most afternoons, the time of day Jim’s behaviour becomes worse; she spends time with him, feeding him, walking about with him, often with him grabbing her. The one-to-one attention she gives him supports the staff by freeing them to be able to look after the other residents and by assisting them to cope with Jim’s behaviour if he becomes very agitated. This daily help is almost like having another member of staff on hand, it provides Jim with better care and his wife stated that she was ‘pleased to have a role’.

Volunteers could also be invaluable to CH staff. In the different case study sites they helped by: driving the minibus on trips, sewing, manning a pop up shop, creating displays, helping with activities, flower arranging, or by generally helping out.

Mirabelle Way offers opportunities to work experience students annually and has also had Duke of Edinburgh award students volunteering in the home. Some staff helped with activities and trips in their own time. Volunteers did not generally help with the management of BPSD, but did help take the pressure off staff by enriching residents’ lives through socialisation and by physically helping with tasks and activities, thereby enabling staff to have more involvement with those residents with BPSD or catch up with outstanding duties.

Conclusions

This chapter has allowed an exploration of the CH dynamics of the four case studies and how these relate to the management of BPSD. The CH features, staff team

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characteristics, and the resources and support the CH staff have access to were all found to be important factors. Indirectly, the ownership, type of admissions, environment and resources all impact on staff practices. The differing forms of ownership of the homes dictated the support, resources and guidance the manager received. Individual owners allowed their managers differing levels of autonomy and control. The hybrid role of owner/manager brought the most work and responsibility without support and as such, appeared to be a disadvantage. The four case studies showed that CH owners can vary greatly in the role they play to support managers, provide direction and supply resources. The CH environment can impact on residents and on staff perceptions of behaviour. Multiple spaces were viewed as helpful in the management of BPSD. Admission criteria were important in reflecting the type of resident cohort that staff would encounter in the homes. Each of the four cases had a different clientele, and therefore different care and behavioural challenges for the staff team to cope with were apparent. Funding availability for residents also

depended on the type of admission each resident had experienced or their condition. A substantial proportion of the management of BPSD appeared to rely on the staff team and the individuals within it. Training, experience and personality all merge to contribute to the response residents receive when they are experiencing BPSD. Care experience was viewed as the most important factor to help staff manage BPSD. The need to be flexible and adapt to residents behaviours emerged as important factors, as well as the need for a mixed skilled staff team. Training was perceived to be helpful, although the benefit of dementia awareness training just covering the aetiology of dementia was questioned by some staff members. Practice based training was found to be more helpful and perhaps should be prioritised over learning about how

dementia manifests itself within the brain. Staff members often took on other roles to their own so that the CH could muddle through; an example of the team pulling together so that the CH could function. The nature of caring for vulnerable adults is that it is a job that needs to happen; therefore staff would be redistributed to different roles if necessary to enable the work to be carried out. This was the same with kitchen duties, where staff would be pulled from care roles to cook for the day. The basic need for meals meant that this role was prioritised over care; in the same

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way care or laundry was prioritised over activity duties. Staff shortages were a frequent occurrence. There were very good levels of support within the staff team, with the hierarchical staff structure being utilised if necessary.

External sources of support for the differing CHs were similar. Access to external resources in relation to the management of BPSD was generally to organisations offering biomedical assistance and medication prescriptions or reviews. Therefore, the majority of help on offer to CHs for BPSD would seem to lead them towards

medication gatekeepers. Volunteers were a great source of help at each case study and worked to take pressure off staff members. Generally, the data showed that many CH factors can indirectly or directly impact on the management of BPSD, whether this is at the level of the wider organisation, CH, staff team, or individual staff member.

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Chapter 7: Medication Use

Introduction

The multiple CH dynamics explored in chapter 6 proved to be important influences on the management of BPSD. The staff team, environment, residents’ conditions, CH ownership, and the resources on offer all impacted on the way BPSD were perceived and could be managed. This chapter moves on from indirect influences to an

exploration of the actual strategies used by CH staff to manage BPSD. Medication use is one such strategy and this will be explored in the current chapter. As established from the literature (see page 33)antipsychotic medication has been used to manage dementia behaviours. Attention from the media on antipsychotic use for PWD, guidance from NICE to use these medications as a last resort, and the

recommendation by the Department of Health in England to reduce their use indicate the relevance of examining the practice of using antipsychotic medication in this way. To investigate this area the case studies were designed with a medication mapping component to obtain data to illuminate the use of psychotropic medication in CHs for residents experiencing BPSD. Staff knowledge of medications, administration

practices, monitoring procedures and PRN use were also explored, but through interview and observation methods within the case studies. The findings are portrayed below.

Medication use in care homes

As a starting point for the exploration into the use medication for BPSD within CHs the survey responses from phase 1 were re-inspected for the four case study sites. Table 7.1 depicts the reported approximate level of antipsychotic prescriptions for all residents in each CH, regardless of diagnosis.

The data show the survey response from Gage Hill, undoubtedly, reported the highest antipsychotic prescription level (68%) for residents. This high prescription level can be explained in a number of ways. Gage Hill also had the highest observed frequency of BPSD out of the four cases. The home’s registration is as a specialist dementia home, which admits residents with moderate to severe dementia. Gage Hill does not offer

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nursing care; the only nurse on site is the manager, so there are fewer medically trained staff members to monitor medications. Additionally as residents at the home do not require nursing care, they are more likely to be physically able and/or

medically fit than those at nursing homes, meaning their feelings and needs can be expressed through physical behaviour. The highly complex mental health needs of the residents and the small and densely populated living areas at Gage Hill may also contribute to BPSD being more pronounced there than at the other homes. The other 3 CHs reported far less antipsychotic use (between 8-17% of residents).

Table 7.1: Antipsychotic prescription levels from participating case study care home survey responses

Care Home Name Bullace View n (%) Gage Hill n (%) Mirabelle Way n (%) Cherry-Plum n (%) Number of residents 38 25 24 38 Number prescribed antipsychotic medications 3(8) 17(68) 4(17) 3 (8) Number prescribed PRN antipsychotic medications 1(3) 4(16) 0 (0) 0 (0)