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ISSN 2050–9561 (online) Volume 1 Number 5 Sep/Oct 2013

Coaching as a leadership style the power of collaborative and facilitative approaches In this issue

Implementing person centred communication within dementia care settings: the registered manager’s role

Maintaining nutrition for service users with diabetes: what to eat and not to eat

Making decisions under the Mental Capacity Act

Transforming, Inspiring, Leading and Managing the Residential and Domiciliary Care Sector The Modern Registered Manager – Vol 1 No 5 Sep/Oct 2013

A hands-on approach to Healthcare Law We have one of the largest healthcare legal practices in the UK, acting for private providers of healthcare in the independent sector, especially mental health providers and those operating care homes. Our niche expertise in operational matters, regulation issues and untoward incidents is highly regarded.

Contact: Andrew Parsons – Oliver Donald –

5 Great College Street, Westminster, London SW1P 3SJ • Tel: +44 (0)20 7222 7040

The Gift of Alzheimer’s is an incredible and remarkable new book that explores dementia from the perceptive of the person. The words, emotions and feelings conveyed provide one of the most powerful insights into the world of a person with dementia. The book advocates personhood at its very best, demonstrating the way in which the person with dementia attempts to make sense of the world around them. It shows how their uniqueness emerges into an incredible and most powerful portrayal of human emotions and feelings, and how significant these are when communicating with them. The author through really listening, discovers that many of the things people with dementia say,that could so easily be dismissed, have a significance and meaning. The author, Maggie La Tourelle, a psychotherapist, and a carer, enables the reader to embark on an emotional journey with her, and see a relationship blossom between mother and daughter. Maggie uses her own experience and knowledge as a psychotherapist, to interpret the ‘other’ and ‘inner’ worlds of her mother. It’s a powerful journey of self-discovery for Maggie, and her own subjective interpretations of what is happening to her mother provides an emotional insight into how people with dementia continue trying to communicate with us in different ways. The key theme throughout is the need for us, as care workers, to adapt the ways in which we communicate with people with dementia. This book enables us to search for, and examine closely, the meaning of the words people with dementia say, and how we can interpret these and make sense of their ‘other’ and ‘inner’ worlds, which have great significance from the perspective of the person (review by Pat Hobson).

Contents 4 Editorial

25 Legal Issues

Behaviours that challenge in dementia care

Making decisions under the Mental Capacity Act

Pat Hobson

Kate Bartlett

5 Leadership and Management

28 Training and Development

Coaching as a leadership style: the power of collaborative and facilitative approaches

Tracy Hide

The Code of Conduct for social care workers and healthcare support workers: implications for practice

9 Dementia Care

Mark Hobson

Implementing person centred communication within dementia care settings: the registered manager’s role

31 Networking in Care

Pat Hobson

Monitoring and managing hypoglycaemic episodes in care homes Jackie Watts

14 Nursing Older People

34 Evidence Based Forum

Maintaining nutrition for service users with diabetes: what to eat and not to eat Jackie Watts

Managing behaviours that challenge in dementia care: exploring research based evidence

17 Learning Disabilities

38 Reflective Corner

Service user involvement in care planning: key issues to consider

Nigel Leaney

Pat Hobson Fatal freedom

Mark Hobson

20 Mental Health Typical and atypical medication: a brief registered manager’s guide to managing side effects

Mark Hobson and Pat Hobson

The Modern Registered Manager – Vol 1 No 5 Sep/Oct 2013


Editorial Behaviours that challenge in dementia care

Editors Consultant Editor Pat Hobson Deputy Editor and Researcher Mark Hobson

There is evidence to suggest that behaviours that challenge, particularly aggression and agitation, remain an issue within care settings. Behaviours that challenge occur for many reasons, and can be distressing for care staff and service users, if not managed effectively. Factors, such as physical, environmental or physiological may contribute to behaviour changes; therefore, undertaking detailed assessments of the person’s needs will enable care workers and managers to identify reasons why certain behaviours may occur. This will require a focused approach based on person centred theories within dementia care. As the dementia progresses, the ability to communicate needs verbally becomes a challenge for the individual, therefore, certain behaviours, such as, aggression and agitation, may be more indicative of a desire to communicate needs, as the person attempts to make sense of what is happening to them.

The article in this issue will focus on examining research based evidence in an attempt to identify themes affecting the care of people with dementia. This will enable care workers and managers to gain an understanding of the key issues involved, and the implications this has for them and people with dementia. The need to ensure staff adapts their approach becomes an important factor in managing aggression and agitation, and will be a key in promoting the best quality of care, which encourages person centred care and reduces distress. Above all, upholds the person’s individualised abilities and their uniqueness. Managers can be a driving force in enabling staff to achieve this within care settings. Pat Hobson Consultant Editor

Behaviours that challenge are a symptom of what is happening to the person, rather than a person being the problem. By making a deferential diagnosis, in other words, ruling out other factors that may contribute to behaviour changes, care workers can identify different strategies to deal with the behaviour. Staff training becomes crucial in providing underpinning knowledge and skills to manage behaviours, such as aggression and agitation.


The Modern Registered Manager – Vol 1 No 5 Sep/Oct 2013

Publisher: PH Education Publishing Ltd 02392753301 ISSN: 1757-7845 (Print) ISSN:2050-9561 (Online) ©All Rights Reserved: 2013 No part of the Modern Registered Manager journal may be reproduced, stored or transmitted in any form without prior permission of the publisher.

Editorial Board Tim Dallinger Director: Social Care Consultants, Positive About Care and Crescent Groups Carolyn Barber Consultant in Social Care: Wayfinder Associates, The Good Mental Health Cooperative, The Talk Network Joy Kelly Consultant in Social Care: Coaching with Care Phil Collis Community Development Manager with extensive experience in Stroke care Dr Taleb Durgahee Director: DFB Care Ltd Amir Durgahee Development Manager: DFB Care Ltd Katie Bartlett RadcliffesLeBrasseur Solicitors

Designed by The Graphic Design House Printed by Bishops

Leadership and Management

Coaching as a leadership style: the power of collaborative and facilitative approaches Abstract Coaching is a practice which both describes the interventions and processes a professional coach might use to develop and grow the performance or capabilities of another, as well as, a style of behaving or leading in the workplace. This article discusses a research project within a large private healthcare organisation, aimed at predicting the potential return on investment to leaders and the organisation, of a training programme encouraging leaders to adopt a coaching style within their leadership behaviours. Author: Tracy Hide, Head of Leadership, Coaching and Mentoring, Barchester Business School

A coaching culture As a leadership style, a coaching approach aims to facilitate the growth and development of individuals and teams. It is the inverse of a directive, autocratic approach to leadership behaviours. It enables leaders to ensure the engagement of their teams with business goals through a shift from a ‘telling’ to an ‘asking’ approach. In other words, the leader instructs the team less on what needs to be done and how; and increases the incidences of ‘sharing the vision’, offering feedback on performance and asking questions to elicit ideas and creativity. This encourages engagement and ensures staff feel valued and able to make a positive contribution to the organisation. I view a coaching approach as a powerful way of ensuring ‘adult’ relationships in the workplace, where all individuals are treated with respect and equality. Offering feedback, followed by the asking of questions, enables all staff to acknowledge their performance and respond with personal control over how their performance might develop thereafter. Leaders, who resist giving advice or telling their teams how to solve a problem or approach an issue, encourage problem solving skills and a sense of personal responsibility at work. It is an approach which recognises that staff function as independent, functional adults outside of the workplace, and are; therefore, fully capable of these behaviours at work also. The development of leaders to use a coaching approach would; therefore, seem essential in creating a working culture of growing and developing the organisation through the growth and development of its people. Most leaders I speak to in my organisation would agree and profess to lead, the majority of the time, with a collaborative and facilitative style of leading, such as this. Anecdotally, however, most leaders

say their own line managers lead with grossly autocratic and directive styles of leadership. One explanation of this is the temptation to manage with ever more increasing control and direction when the economic climate is difficult and uncertain. As ‘bottom lines’ are scrutinised closely, resources controlled more meticulously, and margins become tighter, leaders feel the need to control the environment, the resources and the people with greater discipline. Therefore, my aim through this project has been to shift the culture of leading in the organisation to maximise the performance of the teams and individuals, through leading, using coaching skills. I embarked on a project designed to educate and train leaders in the organisation to consider more collaborative and facilitative styles of leadership, through a coaching approach.

Developing a coaching culture in the organisation Through the development of a ‘leading by coaching’ culture, the aim was to reduce incidences of poor performance, and to maximise the development and capabilities of teams and individuals. I hoped that through adopting such a culture, leaders would provide regular, timely feedback in their daily support of staff. This would support the developing awareness of the behaviours required to support business efficacy and excellence in the quality of services provided. It would also significantly reduce the incidences of poor performance that potentially prove costly in terms of the time, resources, staff turnover and reputation to the business. I hoped that the interventions would minimise associated costs of staff leaving, through ensuring job satisfaction, staff commitment and involvement in day to day decision making and problem solving.

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Leadership and Management In adopting a coaching culture, I anticipated that leaders would grow to recognise their role in building a sustainable, profitable, high quality business for the future. Using these skills, leaders could feedback appropriate and inappropriate behaviours to staff in a timely way and facilitate learning from this feedback ‘in the moment.’ This could ensure that leaders manage the performance of their staff constantly and consistently, thereby reducing the incidence of major performance issues.

The coaching for leadership project The training project initially looked to develop skills over time and to encompass learning from experience and the sharing in groups of that experience. The resulting programme spans a year of learning, which included several workshop training days interspersed with group learning sessions. It was called the Certificate in Coaching for Leadership. Workbooks were developed to record key learning from each workshop. Learning and competence development was measured through leaders’ participation in workshop practice sessions, group supervision sessions and the completion of guided reflections of coaching experiences in the workplace.

The move to an introduction to coaching for leadership Whilst most leaders acknowledge that development is a key component in maintaining competence and ensuring business growth, the demands in business environments are currently great. Leaders have been reluctant to commit to engage with lengthy courses which take them away from the core business. Senior leaders have been reluctant to encourage them to do so. In order to continue the move towards a coaching culture in the organisation, we needed to make the training more accessible. With this in mind, the programme was restructured, to be completed in two sections. Section one would consist of one full day workshop, followed by a half day of group learning, some 4 – 6 weeks afterwards. This component is called the ‘Introduction to Coaching for Leadership’ and is designed to be easily accessible to all General Managers across the organisation. It offers the opportunity to learn key coaching skills, practice those skills in a ‘classroom’ environment, and then to move forward in using the learned skills in the workplace, using the guided reflection processes. The reflections and experiences are then shared in the group learning session. Section one is accessed as a ‘standalone’ learning opportunity, which can then be followed by continuing with the remainder of the programme – section two – if the leader so desired.


Researching the project Leaders were already expressing anecdotal evidence of personal successes and benefits of leading through a coaching approach at the second, half-day group support sessions following the full workshop day. They were able to recall events, actions and outcomes of those actions in their day to day leadership of their teams. However, to capture specifically the impact on the business, a more formal method of enquiry was necessary.

Method In order to capture the diversity of change and development taking place from the training, a qualitative approach to gathering data was chosen. A set of broad questions was devised to provide a semi-structured way of collecting the experiences and thoughts of the trained leaders as to the impact on themselves, their staff and their businesses. Two focus groups were arranged, and the set of questions was then reformulated as a survey-based questionnaire for leaders who had attended the training, but who were not able to participate in the focus groups.

Focus group outcomes A total of 11 leaders attended the focus groups. One leader identified how noticeable it was when her line manager had attended the training. She had noticed a significant shift in her interactions, from a directive stance to a more supportive and facilitative stance. This resulted in the leader reconsidering her future and turning down a firm job offer with another organisation. Other leaders were able to identify the development in their line managers and appreciated that the shift had improved relationships and facilitated increased problem solving and control. Another attendee described how easily he was able to identify when peers and other managers had attended the training. He was able to notice the shift in style from a ‘telling’ approach to an ‘asking’ approach and recognised the skill development in himself and others. He described how he was able to work more “easily” with colleagues who had also received the training, because they were more willing to listen to one another, ask questions and move to an agreement. He stated that work between colleagues who had received the training, happened quickly and more supportively with a higher degree of effective outcomes. Another leader described how since the training, she had been able to facilitate her staff to take appropriate responsibility within their roles, which she had never felt able to do before. However, this had prompted the departure of some team members who had felt unwilling or unable to take on their assigned responsibilities and accountabilities.

The Modern Registered Manager – Vol 1 No 5 Sep/Oct 2013

Leadership and Management The leader acknowledged that this was a positive thing for the team, as these staff had neglected their responsibilities previously, had a negative impact on morale in the team and were unwilling to engage in personal development. Another identified that having been in her role for approximately a year, she had enjoyed her first evenings and weekend without phone calls from staff in the home, requesting guidance and advice. She identified that her new skills had facilitated a greater level of thinking, problem solving and confidence in her team members, who were subsequently referring less problems and decisions for her guidance and approval.

Survey outcomes The outcomes documented here are salient points recorded by leaders on the returned survey forms. • Leaders have developed an awareness of their own practice and not taking on problems which should be dealt with by other team members • Leaders were able to find their own answers to problems and facilitate others to find their answers • Staff were performing more effectively • They found increased autonomy in staff • There had been some resignations as some staff had realised they were not suited to a leadership role – this was viewed as a positive outcome • There were swift resolutions to problems which may have previously developed into HR issues • There was greater ownership and understanding within teams which had increased occupancy in one home • There was improved understanding so work was being achieved faster • Problems were solved quicker and more effectively • There were improved standards of practice • New skills were developing teams and individuals constructively and positively • There was improved satisfaction in teams • Managers felt as if they had more time • Leaders noticed happier and more autonomous staff • There was a noticeable reduction of calls to managers out of hours • Managers were able to focus more on business related issues than HR issues • Leaders felt they had more confidence to manage and show leadership • There was improved morale • There was more networking between General Managers

• A more professional image was observed within teams • A more honest and open culture was noticed • Leaders identified reduced stress and reduced workload • The training enabled better delegation with accountability • There were enhanced team relationships Six of the surveys returned (9%) identified that the leader had experienced reduced complaints, and were solving ‘grievance’ problems more easily. Many managers who had not observed a specific improvement in complaints, grievances, HR and retention issues predicted that they would see such an improvement, but only over time.

Survey outcomes one year on Data was collected from General Managers who had answered the original survey and who were at least one year on from the training intervention. The data was collected by a researcher independent of the original research, and who was not an employee of the organisation. The researcher recorded the answers given in the form of verbal quotes as follows: • I’m such a ‘doer’ and had not realised that my style was actually holding the staff back from their own development. I now sit back and think, ask open questions. This new me has been incorporated slowly ‘so as not to shock!’ but is very successful. I now have much more time to do my job, am much calmer. I do help out, but I do not ‘push in and take over’ • I think some of the change depends upon where each manager is on her personal journey, the time has to be right, and the style of training and development suited to us all • To sum up my style now is more collegiate • I sit back and think • Am slower to react • Ask open questions and opinions; assume that they can do their job • Realise that time is needed to learn new things • Coaching seems to be the way of getting the best out of people and creating a ‘can do’ style of working • I think we are much more relaxed, but very much more effective • There are reduced staff grievances; suspect there was a lot of frustration, because I interfered too much • Coaching has long term benefits in terms of staff retention, job satisfaction • There are reduced complaints and they don’t always escalate into huge problems as they used to

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Leadership and Management one area of the organisation, the General Manager indicated a reduction in staff turnover of 17% over a six month period, indicating a saving of £18,450 to the business. A less tangible aspect for financial return is that of a reduction in grievance, and disciplinary issues in the company and the associated costs.

• The coaching model has been used with much success • Not sure about the effect on staff retention as some staff have left, because their confidence has increased, and they are now working at a higher level • It’s such a good method for problem solving, I ask the staff ‘if I wasn’t here, what would you do’ and they usually have a good answer; just sometimes need encouragement to realise their own capabilities. I now have a way of being able to do this which is absolutely sincere

Despite the potential for considerable financial impact, this study has also proven invaluable in establishing quality returns for the organisation. Quality of life in the form of less stress for managers, an opportunity to alleviate heavy workloads, and to work with teams in a more professional and accountable manner, have provided managers with a welcome change.

• This programme should be available for all staff • Staff have grown in confidence and trust, courage and belief • They are more willing to do something, not always worried about how, but willing to take a chance


• I had not realised how parental my style was, not adult to adult • I’m not perfect, and we sometimes need to ‘brain storm’ as colleagues. Staff needed to hear this • It’s now ‘tell me, show me’ not ‘do this’ • The trainer’s words ‘These people manage all sorts of things at home, children, money, etc. why do you think they don’t bring their skills to work with them?’ Those words made me realise that I was ‘spoon feeding’ my staff and not valuing their skills • I have to stop, think and take things slowly. This style does not come naturally to me, but the impact has been so positive that I am persevering

This research has provided a tangible set of positive indicators that the shift to a coaching style of leading has benefitted the organisation through the improvements identified by leaders within it. The return on investment calculation further reinforces such value and provides the organisation with ‘hard’ data on which to base decision making about further training. The study provides a real indication of the power of using coaching skills in the everyday leadership of others, to ensure an improved quality of service, financial functioning and experience for leaders and their teams.

• I have fewer calls during the weekends and when I am off duty • The staff are knocking at my office a lot less than they used to – just making their own decisions • Overall, just smoother


Assumptions and interpretations of the survey data The principal aims of this training were to maximise the performance of teams, and individuals within the organisation through the development of a facilitative and collaborative style of leadership, as a culture shift within the organisation. Despite the brief nature of this training intervention, there are clear indications that the managers have observed significant positive impacts on their business performance. The further survey results support the view that the training intervention continues to offer benefits to attendees, their teams and the organisation as a whole.

A calculation of return on investment Indications are that managers believe there is the potential for future cost savings through improved retention of staff. In


The Modern Registered Manager – Vol 1 No 5 Sep/Oct 2013

Coaching with Care is a specialist coaching service run by Joy Kelly Joy has previously worked in a variety of social care settings including residential work, field social work, family centre management, complaints, management and regulation. She is a registered social worker.

Please contact Coaching with Care on: 07590 661781 or 01722 506727

dementia care

Implementing person centred communication within dementia care settings: the registered manager’s role Abstract Dementia is a disorder that affects a person’s ability to communicate with care workers and the world around them. Therefore, registered managers have a unique role in supporting care workers to maintain the quality of life for people with dementia. Care workers require relevant knowledge and skills to meet the needs of people with dementia, and understand the implications the disorder can have on communication. This article will focus on issues in relation to communication and how registered managers within care settings can assist their care workers in implementing person centred communication. Author: Pat Hobson - Consultant Editor, Independent Nurse Consultant, Dementia Specialist and Lecturer in Nursing

The person centred theory was first identified by Kitwood (1997) in which he identified dementia as a disability, a complex interaction of five defining attributes which have implications for people with dementia. These are personality, biography, neurological impairment, social psychology and physical status. The relationship between each of these is significant when supporting people with dementia. The person’s personality will influence how they interact and communicate with care workers. Some people may have an outgoing personality, where they find initiating conversation and communicating with others not an issue, whilst others may be reserved and find it difficult to engage with people around them. The biography will be a key factor as long term memory becomes evident; therefore, the person may start to communicate with care workers in a manner that relates to their own reality, based on unique significant memories. The social psychology focuses on the environment and the interactions care workers have with people with dementia. Equally so, dementia (neurological impairment) also affects the person’s ability to relate and interprets the world around them. Therefore, communication becomes a challenge, and distress evident, as the person struggles to make sense of what is happening to them. Whilst, the physical abilities of the person can also influence how they may communicate with care workers. Registered managers need to ensure that care workers have the relevant knowledge and skills to enable them to meet the needs of people with dementia. How they achieve this requires an understanding of the complexities associated with communication and how dementia affects this

aspect of the person. This will enable registered managers to work alongside their teams, demonstrating key skills required to communicate with people with dementia.

Issues in relation to communication Communication is an essential aspect of human interaction, and a necessity that enables individuals to express how they feel, their thoughts and desires. When people communicate with each other, they may expect some form of response from the other person, which can either be verbal or non- verbal. Statistically, the majority of communication is attributed to body language, with a quarter being the tone of voice, and the rest involves the use of words. Dementia affects the areas of the brain that enable individuals to verbalise or identify the right words, receive information and understand what is being said. The person might have problems expressing language, known as expressive aphasia, when the person knows what they want to say, but fail to do so, or receptive aphasia, where the person is unable to take in the information that is being said to them. This can prove frustrating for the person with dementia, and when care workers attempt to rush them during communication, this can lead to agitation and distress. Dementia also affects short term memory, with some interference with long term memory (Lehr, 2006). This can result in the person asking the same question over and over, and some care workers may find the repetitive behaviour of asking the same question a challenge and frustrating. The key issue here, is for care workers to remember that, it is them

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dementia care that need to adapt the way they speak to the person with dementia, rather than expect the person with dementia to do so. Dementia also affects the person’s ability to reason; therefore, as the dementia progresses, attempting to reason or argue with the person will be of no benefit, and can result in frustration and anger. Care workers may also attempt to bring the person back to reality, which no longer has any significance for them, and will result in distress. In addition to this, dementia also affects the person’s ability to relate to their environment, which can evoke feelings of fear, anxiety and loss. As the verbal skills deteriorate; other forms of communication become significant.

Behaviour as a form of communication The use of body language is a key factor in individuals’ ability to convey how they feel. Body language becomes significant, as verbal abilities deteriorate. Therefore, behaviours that challenge may be indicative of how the person is feeling. Sloane et al (1998) identified agitation as indicative of a desire to communicate needs and associated with a loss of control and discomfort, such as pain. Manfredi et al (2003) supports this by stating that people with dementia will use body language as a way of communicating needs, particularly within the advanced stages of dementia. Similarly, Kovach et al (1999) identified body language as indicative of a desire to communicate unmet needs, and found behaviours, such as facial expressions and verbal outburst were major communication indicators. Dementia can evoke feelings of fear, anxiety and uncertainty, which can result in the person constantly searching and seeking comfort and solace from care workers. The need to fulfil the emotional needs of people with dementia to alleviate these negative symptoms becomes significant.

Meeting the emotional needs of people with dementia Registered managers may observe that their teams can meet the physical needs of people with dementia well. However, the everyday emotional needs are what many care workers struggle to fulfil for people with dementia due to a number of key factors, such as organisational cultures, time and the environment (McCormick, 2004). The key issue for registered managers is to enable their teams to focus, not only on meeting the physical needs, but most importantly, the emotional needs of people with dementia.

The importance of focusing on the emotional needs of the person Theories relating to meeting the emotional needs of people with dementia are now used with a key emphasis on ‘feelings’ based approaches (Sheard, 2007). As the dementia progresses, people with dementia may struggle to find the right words to express their needs; therefore, feelings become significant as the person attempts to convey how they feel (Kitwood, 1997, Brooker, 2007, Sheard, 2007, Verity, 2009). Emotional need “centers on such basic feelings as love, fear, anger, sorrow, anxiety, frustration, and depression and involves the understanding, empathy, and support of one person for another. Such needs normally occur in everyone but usually increase during periods of excessive stress or physical and mental illness and during various stages of life, such as infancy, early childhood, and old age” (The Free Dictionary, 2012). Verity (2006) summarises the importance of emotional needs, and identifies five key universal emotional needs. These are significant at each stage of the person’s life. Summary of the five universal emotional needs are in Table 1 below:

Table 1 The Five Universal Emotional Needs 1. The need to feel love and be loved 2. The need to have our self-esteem boosted 3. The need to have the opportunity to care 4. The need to feel useful and needed 5. The need to have choice Verity, 2006, Verity, 2009

Emotional needs and significant memories People with dementia will use words that relate more to significant memories, which may be indicative of deeper emotional needs, as outlined in Table 2. The most significant memories people relate to, which can fulfil emotional needs are: Mum, dad, children, wife, husband, pets, grandparents, grandchildren, siblings, home, work and even places.

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dementia care

Table 2: Significant memory

The emotional need and how this would be fulfilled


The need to feel useful and needed, to love and be loved, opportunity to care, boost self esteem, feeling valued, inclusion, self worth, acceptance, acknowledgement, admiration, appreciation, being believed in, competence, confidence, being in control, listened to, reassurance, recognition, being respected, feeling safe and secure, support, trust, understanding. Children give people a sense of purpose. Many people with dementia were and are still parents and grandparents.


A place of comfort, opportunity to care, love, privacy, belonging, feeling useful and needed, alleviate fear, feel valued, safe and secure, supported, trust.

Mother and wife

The opportunity to care, to love and be loved, feel useful and needed, boost self esteem, control. Belonging, intimacy, provider of physical needs, such as food, alleviate physical discomfort, such as pain, fear, feeling valued, inclusion, self worth, acceptance, acknowledgement, admiration, appreciation, being believed in, competence , confidence, listened to, reassurance, recognition, being respected, feeling safe and secure, support, trust, understanding.


The opportunity to care, to love and be loved, useful and needed, boost self esteem, and control. Pets are also a significant source of comfort for many people with dementia. If someone had a pet for a long time, they may relate to this at times when they need to fulfil an emotional need.


The opportunity to care, feel useful and needed, boost self esteem, control. A sense of purpose and belonging, feeling valued, inclusion, self worth, acceptance, acknowledgement, admiration, appreciation, being believed in, competence, confidence, listened to, reassurance, recognition, being respected, feeling safe and secure, support, trust, understanding.

Father and husband

The opportunity to care, to love and be loved, feel useful and needed, boost self esteem, control. Comfort, love, security, stability, protector, provider for physical needs, such as food, alleviate physical pain and discomfort, feeling valued, inclusion, self worth, acceptance, acknowledgement, admiration, appreciation, being believed in, competence, confidence, being in control, listened to, reassurance, recognition, being respected, feeling safe and secure, support, trust, understanding.


Taken directly from Hobson, 2012

People with dementia may relate to these significant memories identified above, and when they feel frightened and lost, will search for what is familiar to them. Listening to the words people with dementia may say will enable registered managers and their teams to communicate and interact with people with dementia based on their unique significant memories. The example in Table 3 is based on one registered manager’s experience, and how she was able to response to the unmet needs of the person with dementia.

Table 3 Example ‘Mary’ is a registered manager in a dementia care unit. She observes one of the service users, called ‘Joan’ walking around the care home. Joan had been walking around for most of the morning. What drew Mary to Joan was the fact that her eyes were tearful and red, and she appeared visibly upset. Mary approached Joan and asked her how she was. The following account is exactly how the conversation progressed.

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dementia care

Mary: Hello Joan Joan: Hello dear Mary: Are you okay? Joan: No dear, I’m not. I’m looking for my mother. Mary: You are looking for your mother. What would mother bring you, Joan? Joan: Everything (Joan bursts into tears). I don’t know who I am, where I am going, where I have come from. I feel lost; nobody has spoken to me at all; you are the only person who has spoken to me today, and no one talks to me here, dear. Mary: And mother is the only person that will take away those feelings. Joan: Yes dear, thank you for talking to me (Joan smiles) Mary and Joan walk around the care home together for a while.

The response of many care workers Mary may have responded by focusing more on the word ‘mother’; therefore, may state ‘She is not here’ or may even tell the person that ‘she will be coming later’, or even worse may attempt to bring the person back to reality, which will distress the person even more. These responses will not address the unmet emotional needs which the person is attempting to convey to the care workers (Hobson, 2012).

Enabling care workers to respond using communication which focuses on feelings and emotions By focusing on the feelings and emotions the person with dementia may be expressing, their tone of voice and body language, care workers may begin to realise that the person in their care is asking for something other than literally their ‘mother.’ As the dementia progresses, the person may struggle to find the right words to say how they feel; therefore, the use of significant memories becomes a way in which the person can express their needs and desires. So it could be argued that Joan in this case may not be literally asking for her ‘mother’ but the significance of ‘mother,’ which indicates a more complex and deeper emotional or physical need, such as they are hungry, upset, need the toilet, need to be loved or someone has upset them, and they are looking to care workers for comfort and reassurance (Hobson, 2008, Hobson, 2012). By developing the ability to focus

on the tone of voice and body language, care workers can become skilled in identifying the complex needs of people with dementia through the words said, and the significance of these in relation to fulfilling emotional or physical needs. For Mary, asking ‘what would mother bring you’ is a way of enabling her to explore feelings and emotions behind the word ’mother,’ thus empowering Joan to state what it is that would take away those feelings of fear, loss, emptiness and sadness. Joan’s emotional needs are what she would like fulfilled; the need to feel useful and needed, to love and be loved, to have self-esteem boosted and to have choice. These enable individuals to feel a sense of purpose and to belong. In addition to this, when people with dementia are asking care workers to go home, it is important to think of the significance of home, observe the person’s body language. Ninety three percentage of communication, which is body language and tone of voice will be telling care workers how the person with dementia is feeling. They may be distressed, upset, appear lost, and standing by the main door or attempting to open this, which may be indicating a desire to leave, particularly if the person appears distressed. The person may feel trapped and lost; therefore, responding by telling them that they now live in the care home, may exacerbate the feelings of anxiety and distress, as the person is no longer able to relate to this, or respond to reasoning. Wanting children, partners, or even significant places and pets are all key communication factors, that people with dementia will use to communicate emotional needs (Hobson, 2012). Unfamiliar places can evoke negative feelings of loss all the time, and if these continue, service users may display behaviours that challenge. Therefore, registered managers and their care workers will need to identify ways in which they can meet the emotional needs of people with dementia.

Conclusion As the person with dementia attempts to make sense of the world around, communication becomes central in an attempt to understand what is happening to them. The article above attempts to provide some insight into the implications of dementia on communication. The need for care workers to adapt their approach becomes an important factor in communicating with people with dementia. One key factor to remember is that people with dementia may forget what has been said to them by care workers, but they will not forget how care workers have made them feel. Therefore, both negative and positive interactions may be forgotten by the person, but the feelings that have been evoked by such interactions will linger for hours. This is what will have an impact on the person. Registered managers and their teams need to ensure that each interaction they have with people with dementia, is one that will evoke positive, and not

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dementia care negative feelings. This will enable care workers to promote quality care, which advocates person centred care, reduces distress, and above all promotes the person’s individualised communication abilities, preserve their uniqueness, because that is what they are, unique (Hobson, 2008). Registered managers can be a driving force in enabling care workers to achieve this. [Accessed 19 September 2013].


Sheard, D. (2007) Being: An approach to life and dementia, London: Alzheimer’s Society.

Brooker, D. (2007). Person-centred dementia care: Making services better. London: Jessica Kingsley. Hobson, P (2008) Understanding dementia: developing person-centred communication. British Journal of Healthcare Assistants. 2(4):162-164. Hobson, P (2012) Communication: Making sense of what people with dementia say. British Journal of Healthcare Assistants. 6(7): 334-337. James, O (2008) My mother was back. The lights were on. Guardian. Available at: ( lifeandstyle/2008/aug/02/oliver.james.dementia. [Accessed 19 September 2013]. Kitwood, T (1997) Person centred care: The Person Comes First: Taylor & Frances: University of Bradford, UK. Kovach, C.G., Weissman, et al (1999): Assessment and treatment of discomfort for people with late stage dementia: Journal of Pain and Symptom Management: 18(6): 412-9.

Marfredi, P.L., Breuer, B. et al (2003) Pain assessment in elderly patients with severe dementia. Journal of Pain and Symptoms Management: 25(1), 48-52. McCormack, B. (2004). Person-centeredness in gerontological nursing: An overview of the literature. International Journal of Older People Nursing, 13(13a), 31-38.

Sloane, P.D., Mitchell, C. M. et al (1998) Environmental correlates of residents agitation in Alzheimer’s’ disease special units. Journal of the American Geriatric Society, 46(7): 862-9. The Free Dictionary (2012)’Emotional Need: Available at: emotional+need [Accessed on 19 September 2013). Verity, P (2009) ‘An Introduction to person centred care and the Spark of Life’ Available at: http://asiaforum. Bo1B/Jane/Breakout%20session%20singapore.pdf [Accessed 19 September 2013]. Verity, P (2006) Truth or Lies – The Great Reality Divide’. Available at php/library/truth-or-lies-the-great-reality-divide.html [Accessed 19 September 2013].

Lehr, R, P (2006) The Brain Map: Available at:

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nursing older people

Maintaining nutrition for service users with diabetes: what to eat and not to eat Abstract Managers and their staff must support residents with diabetes with a well-balanced individualised dietary plan that is nutritionally sound, and enables them to maintain a healthy body weight. “There can often be a lack of understanding by both care and nursing staff of modern dietary principles” and this is often compounded by characteristic problems in residents with diabetes. For example, anorexic symptoms and reduced energy “intake may lead to nutritional deficiency and inappropriate weight loss. This increases the likelihood of hypoglycaemia in those residents on sulphonylurea or insulin therapy,” and makes achieving satisfactory glycaemic control very difficult (Sinclair, 2011). Increased reliance on others to provide meals, poor understanding of dietary needs by care staff, and rigidity of meal times can also contribute to diabetes management difficulties. This article summarises key issues and information taken directly from ‘Good clinical practice guidelines for care home residents with diabetes’ by a Task and Finish Group of Diabetes UK and the Diabetes UK.(Sinclair, 2011) Author: Jackie Watts, Clinical Advisor, Diabetes UK

Dietary requirements for residents with diabetes in care homes Under nutrition remains common in care homes and diabetes is known to increase this nutritional risk because residents may be unnecessarily restricted in their food choices. The National Institute of Clinical Excellence(NICE) (2006) recommends that all adults entering a residential or nursing home are screened for malnutrition. All residents require an individualised nutritional plan and should have access to a registered dietician. Food and nutrition, alongside medication and activity, is the cornerstone to diabetes management. Residents with diabetes should be able to continue to enjoy a wide variety of foods. In the long run, it is better to make small changes that the person with diabetes feels able to stick to rather than completely altering the diet, and the person with diabetes not sticking to it. It is important to note that, in some cases dietary recommendations for the older person with diabetes, can differ to the general recommendations for people with diabetes. Older people in care homes are likely to be underweight rather than overweight, and prevalence of

malnutrition and under nutrition is high. It may; therefore, not be appropriate to reduce fat, sugar and salt in the diet for every older person with diabetes, as it may compromise their nutritional status if, as a consequence, they eat less. Care home staff should have training in recognising malnutrition or a poor nutritional status, and need to work with professionals in planning a nutritional approach. Residents with diabetes may have numerous underlying risk factors for poor nutritional status including multiple medications affecting gastro-intestinal function, and appetite, medical co-morbidities, disabilities affecting the ability to eat and drink safely (eg cerebrovascular disease), low mood states, and poor cognition. The Malnutrition Universal Screening Tool (MUST) is considered a valid and reproducible nutritional assessment tool for residents of care homes. These assessments should take place at admission to a care home, at annual reviews, and whenever there is a history of a serious acute illness or readmission following hospital inpatient stay. They should be reinforced by regular review of medications, oral health, behaviour at mealtimes, and investigating reasons for refusal of food.

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nursing older people

Practical dietary guidelines Plan for three regular meals a day and try to help residents to avoid skipping meals by ensuring breakfast, lunch and the evening meal are spaced widely enough over the day. This will not only help control appetite, but also help in controlling blood glucose levels. Include starchy carbohydrate foods, such as bread, pasta, chapattis, potatoes, yam, noodles, rice and cereals. The amount of carbohydrate eaten is important to control blood glucose levels (a registered dietitian can provide more information on quantities specific to individual needs). All varieties are fine, but try to include those that are more slowly absorbed (have a lower glycaemic index) as these can help maintain steady blood glucose levels. Better choices include: pasta, basmati or easy cook rice, grainy breads, such as granary, pumpernickel and rye, new potatoes, sweet potato and yam, porridge oats and natural muesli. The high fibre varieties of starchy foods will also help to maintain the health of the digestive system and prevent problems, such as constipation. Cutting down on fat can help with weight management, but this is only a consideration for those people who are overweight. All fats contain calories. Fat is the greatest source of calories, so eating less fat and fatty foods will help with weight management. Tips for cutting back on fat: • Use less saturated fat by having less butter, margarine and cheese • Choose lean meat and fish, as low fat alternatives to fatty meats • Choose lower fat dairy foods, such as skimmed or semiskimmed milk, low fat or diet yogurts, reduced fat cheese and lower fat spreads • Grill steam or oven bake instead of frying or cooking with oil or other fats • Watch out for creamy sauces and dressings and swap for tomato based sauces instead. Aim for at least five portions a day of fruit and vegetables. This will provide residents with vitamins, minerals and fibre, as well as to help the balance of the overall diet. One portion is, for example, a banana or apple, a handful of grapes, a tablespoon of dried fruit, a small glass of fruit juice or fruit smoothie, three heaped tablespoons of vegetables or a cereal bowl of salad. Fresh fruit is not always easy for the older person to manage so remember that dried, tinned or frozen fruits, fruit desserts and fruit juice, all count towards the portions.

Also aim to include more beans and lentils, such as kidney beans, butter beans, chickpeas, red and green lentils, as these have less effect on blood glucose and may help to control blood fats. Provide at least two portions of oily fish a week, such as mackerel, sardines, salmon and pilchards, which can be tinned, frozen or fresh. Oily fish contains a type of polyunsaturated fat called Omega 3, which helps protect against heart disease. Limit sugar and sugary foods. This does not mean that residents with diabetes need to eat a sugar-free diet. Sugar can be used in foods and in baking as part of a healthy diet. Using sugar-free, no added sugar or diet squashes/fizzy drinks, instead of sugary versions can also be an easy way to reduce sugar in the diet. It is also a good idea to limit the amount of processed foods in the person’s diet as these foods tend to have lots of salt. Alcohol should be consumed in moderation only. It should be limited to two units a day for a woman and three for a man. For example, a single pub measure (25ml) of spirit is about one unit, while half a pint of lager, ale, bitter or cider has about 1 to 1.5 units. Over the years, the alcohol content of most drinks has gone up. A drink can now contain more units than you think – a small glass of wine (175ml) could contain as much as 2 units. Remember alcohol contains empty calories, so cutting back is helpful if a resident with diabetes is trying to lose weight. Alcohol can make hypoglycaemia (low blood glucose levels) more likely when taking certain diabetes medication, so people with diabetes are advised to never drink on an empty stomach. Do not use diabetic foods or drinks. They offer no benefit to people with diabetes. They will still affect blood glucose levels, contain just as much fat and calories as the ordinary versions, can have a laxative effect and are expensive.

Additional nutritional concerns for residents with diabetes Weight management Weight management is a significant factor in the development and management of Type 2 diabetes. For residents who are overweight or obese, a reduction in weight of between five and 10 per cent may be beneficial, but in some cases weight loss will not be the priority. Specific goals should be identified and negotiated as part of the care planning process. Remember that reducing the fat and sugar content of recipes for most of the residents is not appropriate.

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nursing older people

Underweight and malnutrition A registered dietician can advise on specific individual requirements. Where high blood glucose levels are noted in a person receiving nutritional support, it may be necessary to adjust diabetes medication to achieve blood glucose levels as near as possible to the recommended level.

Oral health It is estimated that people with diabetes can be up to three times more likely to develop gum disease than people without diabetes. Residents with diabetes and gum disease should be identified, and dietary adjustment made according to a specific need.

Dehydration A resident with diabetes and uncontrolled diabetes may be at additional risk of dehydration as a result of polyuria. Particular attention should be made to the monitoring and provision of fluid for this resident, and treatment modified accordingly, so as to limit symptoms of hyperglycaemia.

Information and education The nutritional recommendations for diabetes reflect current research and evidence. It is inevitable that many myths and misconceptions have developed, especially what people with diabetes should be eating. For example, myths exist, such as people with diabetes need to eat a sugar-free diet and people with diabetes should not eat bananas and grapes. These are wrong. Up–to-date and reliable information is available from a number of sources.

Conclusion Under nutrition remains a common finding in care homes, and diabetes is known to increase this nutritional risk, because residents may be unnecessarily restricted in their food choices. Additional nutritional specific considerations should be made for residents with diabetes in care homes. All residents require an individualised nutritional plan and should have access to a registered dietician. Information and education are key to ensuring that nutritional myths and misconceptions do not persist.

Diabetes UK produces a wealth of information, including the Eating Well magazines (there are separate publications for Type 1 diabetes and Type 2 diabetes). They are free and can be accessed at the charity’s online shop at uk . A registered dietician will be able to provide information and may also be able to arrange education for care home staff on the dietary management of people with diabetes. Diabetes UK has also developed a one day course, ‘Diabetes Awareness Training’, to provide people working with diabetes, the knowledge and confidence required to have a positive impact on the lives of people with diabetes. The course is accredited by the Royal College of Nursing (RCN).

References: National Institute of Clinical Excellence (2006). CG 32: Nutrition Support in Adults. Available at: http://www.nice. [Accessed on 19 September 2013]. Sincliar, A.J (2011) Diabetes UK Position Statements and Care Recommendations. Good clinical practice guidelines for care home residents with diabetes: an executive summary. Diabetes Medicine. 28, 772–777.

Dignity in Care Meal times and nutrition “Good nutrition and hydration and enjoyable mealtimes can dramatically improve the health and well-being of older people. Mealtimes should therefore be considered a priority in terms of importance and dedication of staff time; systems within organisations should support this to uphold dignity.” The National Dignity Council (2012)

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Learning Disabilities

Service user involvement in care planning: key issues to consider Abstract Service user involvement is not a new concept; indeed its roots can be traced back many years, and partly came about due to widespread dissatisfaction amongst service users themselves that service provision tended to ignore their views and/or not allow any involvement in service provision itself. In 2001, the Department of Health introduced the White Paper ‘Valuing for People’ which highlighted the need to ensure person centred care planning was central to key philosophies within organisations. In 2009, following a consultation, ‘Valuing People Now’ was released and saw services for people with learning disabilities transformed over the next few years. Central to this was person centred planning (Department of Health, 2009). In part, this document can now be placed within a wider policy context with increased emphasis upon those who use services as being the ones who should have an influence on shaping those services. For example, the move toward personalised budgets, carer assessments and self assessment, could be seen as evidence of this. Author: Mark Hobson - Independent Consultant Social Worker

Definition of service user involvement Phillips (2004) defines service user involvement as “the involvement of service users in the management, design and delivery of services.” This would seem to be a fairly wide definition. However, it goes to the heart of the issue, and as such the question for the registered manager is one of, what are they trying to achieve, and how are they going to achieve it? As regards care planning, it is about taking into account the individual needs, wishes and preferences of the person in order to tailor services to meet their own individual needs.

Issues involved in service user involvement in care planning There are a number of issues to consider here. The registered manager, or their staff may be working with an individual, who could have little or no experience of any involvement in this kind of decision making process. The person may choose to decline to participate, they have a right to say no. The registered manager will need to reflect upon the reasons for any refusal, but be aware, it may be unrealistic in

some cases to expect people (who very often do not really know them to give information) that may be of a sensitive or private nature. It is here that the registered manager will need skills in getting alongside the person, and gaining their trust and understanding. Also consider the need to provide information and to empower the person. Information and empowerment are fundamental to this process. Involvement is of no practical use if a person does not know what it is they are to be involved in, and the reasons why, or what the aim of the exercise is. In these circumstances, there will need to be a process of information sharing, answering questions to empower the person to participate in the process effectively. The registered manager must also be able to provide the time needed, do not expect to complete the exercise in one session, be flexible in their approach, and if necessary agree time needed over several sessions to complete the work. Effective care planning is about the person’s needs, not the registered manager or their team. Another key issue to take into account, is the need to provide an appropriate environment that promotes privacy, and is free from distractions, especially if, for example, the assessment is being undertaken in a care home setting.

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Learning Disabilities The registered manager also needs to adopt a nonjudgemental approach, be able and willing to not just accept, but also work with choices they may not agree with themselves. The ability to do this will ensure that service users’ needs are at the centre of their practice. Here the issue of risk assessment is paramount, and there will need to be a balance maintained between the right to make choices, and the safety of the person. Some work as regards care planning may be needed within the context of the Mental Capacity Act for those people, where there may be reasons to believe they lack capacity to make certain decisions.

References Department of Health (2001): Valuing People: Available at: [Accessed 18 September 2013]. Department of Health (2009); Valuing People: Now: Available at [Accessed 18 September 2013]. Philips, J (2004) Service user involvement in homelessness. Glasgow Homelessness Network for Changing Homelessness in Practice (ChiP). Shelter. Available at: http://www.shelter. [Accessed 19 September 2013].

The individual’s needs and communication will need to be taken into account. Does someone who is hard of hearing require aids or even an interpreter? Would questions be better written down? Are visual aids needed for those with visual needs? Does a family member or friend need to be present? Alternatively, is consideration needed as regards providing an independent advocate? It is important to understand that consideration of all these issues will enable a more effective process to take place; therefore, result in a thorough care plan. Also, where appropriate, the involvement of family members or friends will enable the registered manager to gain an understanding of the history of the person. For example, on admission to a care home environment, where staff are likely to be unfamiliar with the person. Understanding a person’s life history is fundamental in being able to understand the person they are now. Finally, put in place measures that will allow care plans to be subject to review and adaptable, people have a right to change their minds. Also care plans will need to be flexible, and able to accommodate a person’s changing needs or circumstances.

Conclusion In conclusion, it can be argued that involvement in care planning is a complex issue that will require consideration of a whole variety of issues. The registered manager will need to be aware that the process needs to be adapted to the individual needs of each person they are working with, so as to make the process effective and meaningful. Care planning is not a form filling, paper exercise, it is about understanding the needs of the person, and placing them at the centre of what they do. The key themes here, are that of involvement, empowerment, self determination and the skill of the registered manager to enable all of these factors to take place throughout their contact with the person.

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Mental Health

Typical and atypical medication: a brief registered manager’s guide to managing side effects Abstract The terms typical and atypical are used in relation to antipsychotic medications, which are one of the main treatment options for people with enduring mental health problems. The issue of how these medications work and side effects will be discussed. Although there are many side effects that can be associated with these medications, for the purpose of this article, two of the major side effects will be discussed, namely weight gain and diabetes, and some general guidance provided on how these side effects can be monitored to support service users. The reasons for focusing on these two main side effects is attributed to evidence based information, which cites these as more associated with comorbidities and long term implications on health (Ucok and Gabeal, 2008, De Hert et al, 2007, Barnett et al, 2007). This article is intended to provide a general overview and information only, direct guidance and support with regards to medical issues should always be sought from a qualified medical practitioner. Author: Mark Hobson - Independent Consultant Social Worker and Pat Hobson - Consultant Editor, Independent Nurse Consultant, Dementia Specialist and Lecturer in Nursing

Background and definition

Newer or atypical antipsychotics

Antipsychotic medication is usually divided into two groups, namely typical and atypical. They define a range of medications used to treat different forms of mental distress or illness and associated symptoms. These medications are mainly used to treat so called positive and negative symptoms, associated with mental health disorders. The positive symptoms include hallucinations, delusions, ideas or thoughts that may distress a person, and difficulties with thinking clearly, known as thought disorder. And the negative symptoms, such as depression and loss of interest in everyday life, feelings of hopelessness and poor motivation. Treatment with these medications can also include extreme agitation or restlessness that can sometimes be associated with people’s experiences of psychiatric distress, and it can also be prescribed for bipolar disorder.

The newer second generation antipsychotics or atypical have been developed and produced over the last 15 to 20 years ago, partly as a response to the concerns with regards to distressing side effects, but also due to medical advances. As a result, it is believed that they could target a range of symptoms more effectively, and this also includes so called negative symptoms. These include: Olanzapine (Zyprexia), Respiradone, (Risperdal), Quetiapine (Seroquel), Amisulpride (Solian), Clozapine (Clozaril).

Older typical well established antipsychotics Typical are the older antipsychotics, which first appeared in the mid 1950s. These are also referred to as ‘first generation’ antipsychotics and include medications such as; Chlorpromazine, Haloperidol, Fluphenazine and Trifluoperazine.

How do these medications work? When adopting a medical model to explain how these medications work, they all target a range of chemicals in the brain, known as neurotransmitters. These chemicals allow the brain to communicate and control a number of actions. Dopamine is one of the main neurotransmitters affected by these medications. It is believed that if parts of the dopamine system become overactive, this can result in producing symptoms, such as hallucinations, delusions and thought disorder. Therefore, these medications attempt to control and or block the transmission of these chemicals, so as to control symptoms associated with psychiatric distress. It is important to note that these medications do not provide a

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Mental Health cure, very often some residual symptoms remain. Medication usually provides management of symptoms and relief from the worst effects of them. Furthermore, a key point here is that this explanation is reliant upon accepting a disease model of explaining mental ill health where the brain is seen as being overactive and in need of treatment. A social model would argue that causes can be explained by social stress and/or negative life events, and this would explain incidents of depression and psychiatric illness as a result of traumatic events (National Institute for Health and Care Excellence (NICE), 2009).

Difference between typical antipsychotics and atypical antipsychotics 1. The side effects of atypical antipsychotics are less than the typical antipsychotics. 2. The effectiveness of atypical antipsychotics is greater than the typical antipsychotics in the treatment of psychosis.

The main side effects

3: Atypical antipsychotics are less likely to cause problems with physical movement such as tardive dyskinesia when compared to typical antipsychotics.

As these drugs work by blocking the dopamine receptors, most of the side effects associated with these include:

5. Atypical antipsychotics are easier to discontinue and are less addictive than the typical antipsychotics.

• Stiffness and shaking, producing symptoms similar to those seen in people with Parkinson’s disease • Lack of motivation/sluggishness • Restlessness, people unable to relax and sit still, or what is termed as akathisia • Tardive dyskinesia or TD associated with continual movements of the mouth, tongue and jaw • Salivating, dry mouth, tremors, stiffness of limbs (NICE, 2009). However, it would be a mistake to think that the newer medications or atypical do not have side effects because evidence indicates that they do. Research suggests that they are less likely to cause Parkinsonian side effects and tardive dyskinesia, but can result in sedation, dry mouth, constipation, blurred vision, dizziness and postural hypertension, weight gain, and the development of diabetes, for example. Also, in high doses, over a long period, some have the same Parkinsonian side effects as the older medications and can lead to tardive dyskinesia (Royal College of Psychiatrists, 2013). Of the newer antipsychotic medications, Clozapine requires close monitoring due to the most severe side effects it can cause. This should only be used as a last resort if two different antipsychotic medications have been prescribed and failed to control the symptoms (NICE, 2009). Clozapine is cited as having an impact on the bone narrow, which then leads to the depletion of white blood cells. This makes the person more susceptible to infection. Therefore, as part of the monitoring process, the person will require regular blood tests. For the first 3-6 months of the medication being prescribed, the person will require weekly blood tests, then every two weeks thereafter (NICE, 2009).

6. Atypical antipsychotics drugs are recommended over typical antipsychotics drugs. 7 Withdrawal symptoms are less likely with atypical antipsychotics drugs as the physical dependency of this drug is less when compared to typical antipsychotics. (Taken from Coleman, 2011)

Monitoring and supporting with side effects Although the extrapyramidal side effects are troublesome for many service users on antipsychotic medications, the main effects are physical. These can affect the person’s ability to walk, particularly if they have Parkinson type side effects, which include shuffling gait and tremors. The physiological effects of these medications cannot be underestimated, as there is evidence to suggest that they can have implications on the life expectancy of service users. Research indicates that the life expectancy for people with schizophrenia can be reduced by 20%, and 60% of people with this disorder die due to some form of physical illness. Subsequently, there is documentary evidence to suggest that people with a mental health diagnosis have much higher rates of poor health compared to the general population (Ucok and Gaebel, 2008). This includes higher rates of physical and multiple medical problems. In addition, certain groups of people with a particular diagnosis, such as schizophrenia die younger than the general population. Lifestyle changes (which includes high incidences of smoking, lack of exercise and poor diet) have a significant impact on the person’s health. There is a higher prevalence of smoking among people with

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Mental Health mental health problems (Ucok and Gabeal, 2008, De Hert et al, 2007, Barnett et al, 2007). The use of antipsychotic medications predisposes the person to developing disorders, such as diabetes. This is due to the fact that the medications have a direct effect on insulin function (De Hert et al, 2007, Barnett et al, 2007). Furthermore, due to issues, such as a lack of motivation, some people have issues with their diet, and a lack of exercise can result in weight gain. Weight gain predisposes the person to other disorders, such as cardiovascular disease and diabetes.

Weight gain Ucok and Gaebel (2008), suggest that between 40 to 60% of people with schizophrenia are overweight or could be described as obese. As they point out, treatment with both first and second generation medications can be at least partly responsible for this weight gain, as people taking these medications will report an increase in their appetite. The issues for registered managers with regards to obesity are clear in that it increases a person’s risk of cardiovascular problems/disease and mortality. Furthermore, excessive weight can have a detrimental effect on an individual’s self image and their motivation with regards to self care and maintaining a healthy balanced diet (Thakamore et al, 2002, Ryan et al, 2004). In this respect, registered managers will need to be aware of a person’s Body Mass Index or BMI. Ucok and Gaebel (2008) suggest that this should be recorded before medication is started and/or changed, with regular monitoring of weight and recording taking place, so that early and appropriate intervention and support can be identified, due to the significant risks identified in any weight gain. They add to this by suggesting a range of differing interventions, such as liaising with the patient’s GP or psychiatrist as regards medical review of medication currently prescribed, whether this remains appropriate and also advice on healthy nutrition, diet and exercise from the relevant health department. Clearly any interventions will require consent of the person, but the duty of registered managers should be to consider this within their remit, and offer the appropriate help or seek guidance.

Diabetes The prevalence of Type 2 diabetes in people with schizophrenia is more than twice than that of the general population. Ucok and Gaebel (2008) suggest studies indicate that some second generation atypicals, such as Clozapine and Olanzapine are associated with increased risk of diabetes. However, the prevalence of increased weight gain and obesity is a factor that complicates this issue as these are

increased risk factors associated with diabetes. The risks; however, are clear, such as the increased risk of strokes. However, registered managers should be “diabetes aware” and keep in mind that diabetes is not always associated with weight gain. Therefore, monitoring weight alone may not be an accurate way of testing for this. The methods that can be used to assess for this would include random glucose testing, for example (De Hert et al, 2007, Barnett et al, 2007). Registered managers can again seek the support of their GP. For instance, some GP surgeries will have a specialist diabetes nurse linked to the surgery who can provide on going support and monitoring. This can also include advice and guidance on diet and healthy living.

Conclusion Medication use in mental health has been prevalent for many years, at times seen as controversial, and used at the expense of other forms of care and support. Alternatively, it has also been seen as allowing people to live more independent lives away from institutions. However, due to the wide range of medications that are prescribed in this area, there are many issues that registered managers need to be aware of with regards to how they support and monitor their use in care settings. Side effects differ from person to person, and some people experience side effects less than others. However, people in mental health settings can have difficulties in asking and/or gaining access to appropriate support themselves, and maybe unaware of the side effects of the medications they have been prescribed. Therefore, registered managers need to be aware of the physical health issues and effects of their use to provide appropriate support, and know how to seek advice when needed.

References Barnett, AH, Mackin, P, Chaudhry,I et al (2007). Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia. Journal of Psychopharmacology ; 21: 357 -73. Coleman, O (2011) Difference between Typical and Atypical Antipsychotics. Available at: http:// www. [Accessed 20 September 2013]. De Hert, M, Hanssens, L, Van Winkel, R (2007). A case series: evaluation of the metabolic safety of aripiprazole. Schizophrenia Bulletin; 33: 823-30. National Institute for Health and Care Excellence (2009) Schizophrenia: Core interventions in the treatment and management of schizophrenia in primary and secondary care. Available at: [Accessed 30 September 2013].

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Mental Health Royal College of Psychiatrists (2013), Antipsychotic Medication. Available at: [Accessed 20 September 2013].

Ucok, A and Gaebel, W (2008) Side effects of atypical antipsychotics: a brief overview. Official Journal of the World Psychiatry Association. 7(1): 58–62.

Ryan, MC, Flanagan, S, Kinsella, U et al (2004) The effects of atypical antipsychotics on visceral fat distribution in first episode, drug-naive patients with schizophrenia. Life Science ; 74: 1999 -2008. Thakore, JH, Mann, JN, Vlahos,I et al (2002). Increased visceral fat distribution in drug-naive and drug-free patients with schizophrenia. International Journal of Obesity; 26: 137-41.

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The purpose of the evidence based section is to explore research in care settings, the implications for service users and staff and how registered managers can utilize this in

maintaining high standards of care through implementation of evidence based care.

As a Registered manager, you are the key in inspiring, transforming, leading and managing the care sector CONTACT: EDITOR@PHEDUCATIONPUBLISHING. CO.UK FOR FURTHER INFORMATION WWW.PHEDUCATIONPUBLISHING. CO.UK

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Evidence Based Forum Demystifying Research

Mental Health

legal issues

Making decisions under the Mental Capacity Act Abstract The Mental Capacity Act 2005 (MCA) provides a framework to empower and protect people who may lack capacity to make some decisions for themselves. It contains provision for assessing whether people have the mental capacity to make decisions, procedures for making decisions on behalf of people who lack mental capacity and safeguards. The aim of the MCA is to strike a balance between respect for individual autonomy and the need to protect the vulnerable. Author: Katie Bartlett, RadcliffesLeBrasseur

The MCA makes it clear who can take decisions on behalf of others in which situations, and how they should go about this. Anyone who works with or cares for an adult who lacks capacity must comply with the MCA when making decisions or acting for that person. This applies whether decisions are life changing events, or more everyday matters and are relevant to adults of any age, regardless of when they lost capacity. The underlying philosophy of the MCA is to ensure that those who lack capacity are empowered to make as many decisions for themselves as possible and that any decision made, or action taken, on their behalf is made in their best interests.

3. A  person is not to be treated as unable to make a decision merely because he makes an unwise decision. 4. A  n act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests. 5. B  efore the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action. Section 2 of the MCA explains what is meant by lack of capacity. A person lacks capacity if:

The MCA Code of Practice supports the MCA, and provides guidance to all those who care for and/or make decisions on behalf of adults who lack capacity. The Code includes case studies and clearly explains in more detail the key features of the MCA.

• they have an impairment or disturbance (for example, a disability, condition or trauma, such as dementia or conditions associated with some forms of mental illness) that affects the way their mind or brain works, and

Key features of the MCA

• the impairment or disturbance means that they are unable to make a specific decision at the time it needs to be made.

Section 1 of the MCA sets out the five ‘statutory principles’ – the values that underpin the legal requirements in the Act. The MCA aims to protect people who lack capacity to make particular decisions, but also to maximise their ability to make decisions, or to participate in decision-making, as far as they are able to do so. The five statutory principles are as follows: 1. A  person must be assumed to have capacity unless it is established that they lack capacity. 2. A  person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success.

An assessment of a person’s capacity must be based on their ability to make a specific decision at the time it needs to be made, and not their ability to make decisions in general. It is very important to remember that capacity is time and issue specific. Section 2 of the MCA also makes it clear that an assessment that a person lacks capacity to make a decision must never be based simply on: • their age • their appearance • assumptions about their condition, or • any aspect of their behaviour.

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legal issues Section 3 of the MCA explains what is meant by an inability to make a decision. A person is unable to make a decision if they cannot: a) understand the information relevant to the decision, b) retain that information, c) use or weigh that information as part of the process of making the decision, or d) communicate his decision (whether by talking, using sign language or any other means). (“Relevant information” includes the nature of the decision, the reason why the decision is needed, and the likely effects of deciding one way or another, or making no decision at all.) If a person cannot do any one of these four things, they will be treated as being unable to make the decision. Section 4 of the MCA deals with “best interests.” The MCA says that if a person lacks capacity, then any act done for, or any decision made on behalf of, that person must be done, or made, in that person’s best interests. Working out what is in someone else’s best interests may be difficult, and the Act requires people to follow certain steps to help them work out whether a particular act or decision is in a person’s best interests. The following factors are things that should be considered when trying to work out what is in someone’s best interests: • Is the person is likely to regain capacity (e.g. after receiving medical treatment)? If so, can the decision wait until then? • Has the person been permitted and encouraged to take part in making the decision? You should do whatever is possible to permit and encourage the person to take part, or to improve their ability to take part, in making the decision. • Have attempts been made to ascertain the person’s views? You should try to find out the views of the person who lacks capacity, including the person’s past and present wishes and feelings (which may have been expressed verbally, in writing or through behaviour or habits), any beliefs and values (e.g. religious, cultural, moral or political) that would be likely to influence the decision in question and any other factors the person themselves would be likely to consider if they were making the decision or acting for themselves. • Have others been consulted? If it is practical and appropriate to do so, other people should be consulted for their views about the person’s best interests. In particular, you should try to consult anyone previously named by the person as someone to be consulted on either the decision in question or on similar issues, anyone engaged in caring for the person, close relatives, friends or others who take an interest in the person’s welfare, any attorney appointed under a Lasting

Power of Attorney or Enduring Power of Attorney made by the person or any deputy appointed by the Court of Protection to make decisions for the person.

When should capacity assessments be carried out? It is important to carry out an assessment when a person’s capacity is in doubt. However, when assessing capacity, the starting assumption must be that the person has capacity to make the specific decision. It is also important that the person who does an assessment can justify their conclusions. It is important to assess people when they are in the best state to make the decision, if possible. Whether this is possible will depend on the nature and urgency of the decision to be made. To help put someone at ease and so improve their ability to make a decision, careful consideration should be given to both location and timing of the assessment. For example, if there is a particular place where a person feels more at ease, then the capacity assessment should ideally be conducted there. Or if a person is more alert in the morning, the capacity assessment should be undertaken at that time. These factors are particularly important to bear in mind for people who may have fluctuating capacity – i.e. people who have a problem or condition that gets worse occasionally and affects their ability to make decisions. It is important to review capacity from time to time, as people can improve their decision-making capabilities. Some people (for example, people with learning disabilities) will learn new skills throughout their life, improving their capacity to make certain decisions. So assessments should be reviewed from time to time. Capacity should always be reviewed: • whenever a care plan is being developed or reviewed • at other relevant stages of the care planning process, and • as particular decisions need to be made. The person who assesses an individual’s capacity to make a decision will usually be the person who is directly concerned with the individual at the time the decision needs to be made. This means that different people will be involved in assessing someone’s capacity to make different decisions at different times. For most day-to-day decisions, this will be the person caring for them at the time a decision must be made. More complex decisions are likely to need more formal assessments. A professional opinion on the person’s capacity might be necessary. This could be, for example, from a psychiatrist, psychologist, a speech and language therapist, occupational therapist or social worker. But the final decision about a person’s capacity must be made by the person intending to make the decision or carry out the action on behalf of the person who lacks capacity – not the professional, who is there to advise.

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legal issues

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training and development

The Code of Conduct for social care workers and healthcare support workers: implications for practice Abstract This article will examine the 2013 Code of Conduct for health and social care workers. It will provide a background to its introduction and then provide an overview of the framework of the Code and corresponding National Minimum Standards. Some of the key themes and issues that arise from its introduction will then be analysed in relation to its potential effects with regards to workers and managers/employers in terms of its possible strengths and weaknesses. Author: Mark Hobson - Independent Consultant Social Worker

Definition The Code of Conduct for healthcare support workers and adult social care workers was issued in April 2013 and published by Skills for Care and Skills for Health; following a period of consultation with both employers and health and social care workers, and some representative bodies, such as the Royal College of Nursing (RCN). The Code is defined as: “the standards of conduct, behaviour and attitudes that the public and the people who need healthcare, care and support should expect of workers providing this care and support” (Skills for Care, 2013). Its remit applies to all healthcare and adult social care workers in England in either the public, private or independent sectors. Scotland and Wales have their own separate Codes of Practice and systems in place.

Background The Code was commissioned in 2011 by the then Health Secretary Andrew Lansley, with the intention of developing “a code of conduct and minimum training standards for health and social care workers” in England in order to help clarify expectations of staff, and to ensure that conduct and training did not “fall below the standards detailed in the code.” Also to ensure that the Code promotes best practice; therefore, will act to protect users of services. The Code of Practice replaces the General Social Care Council’s (GSCC’s) Codes of Practice, which was in use since 2004.

Principles of the Code of Conduct The guiding principles of the Code are clear in that Healthcare Support Workers and Adult Social Care Workers in England must: • Be accountable by making sure they can answer for actions or omissions. This requires honesty about limitations. Workers need to be able to justify what they do but equally what they do not do and also why they did or did not do something and the actions they took. It requires the ability to maintain professional boundaries and behave appropriately at all times. Finally, this refers to the duty to report or blow the whistle on any malpractice or potential abuse • Promote and uphold the privacy, dignity, rights health and wellbeing of people who use health and care services and their carers at all times. This requires the ability of workers to always act in the best interest of service users, treating them with respect and maintaining their dignity. • Promote independence wherever possible and challenge and report any dangerous, abusive, discriminatory or exploitative behaviour. • Work in collaboration with colleagues to ensure the delivery of high quality, safe and compassionate

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training and development

healthcare, care and support. Is about the ability to be able to work as part of a team. The ability to respect colleagues but also be honest and open with them. • Communicate in an open and effective way to promote the health, safety and wellbeing of people who use health and care services and their carers. The ability to communicate effectively with service users and colleagues and the ability to maintain accurate records and respect confidentiality wherever relevant to do so. • Respect people’s right to confidentiality. All information about service users is confidential and workers must respect, understand and practice this at all times, if not seek guidance from seniors, especially if any disclosure issues arise. • Strive to improve the quality of healthcare, care and support through continuing professional development. • Undertake training and education in line with the competencies that are required for the job. Maintain up-to-date records of training and, if appropriate, contribute to the learning and development of others. • Uphold and promote equality, diversity and inclusion. • Respect individuals and seek to promote equal opportunities at all times and do not discriminate against anyone. Taken directly from Community Care (2013)

In addition to the Code, there is also a set of National Minimum Training Standards which it is intended will be used with the Code to further underpin practice. The Standards set out the minimum knowledge workers must have, and what should be covered within the first weeks of employment, and this would include an induction program. Therefore, there are ten areas intended to cover the knowledge health and social care workers are expected to have.

National Minimum Training Standards These are as follows: • Personal development • Effective communication

• Equality, diversity and inclusion • Duty of care • Safeguarding • Person centred care and support • Health and safety • Handling information • Infection prevention and control Taken from Skills for Care (2013)

Potential benefits of a Code of Practice Payne (2013) suggests that the Code of Practice and National Minimum Training Standards will be useful for care workers setting out a clear framework that workers are expected to meet. It allows care workers to review and develop their practice and update relevant training where needed by identifying areas for Continuing Professional Development (CPD). The framework will also be useful to managers, who could use it, to assess the conduct and practice of staff, to ensure that they comply with the 2013 Code, and have achieved the minimum competencies listed. Managers could also use the standards to ensure they have corresponding procedures and policies which are in place, and also in line with the Code and Standards so as to ensure best practice. Finally, Payne (2013) adds that the Code of Practice and Standards can also act as reassurance to people who use services, and to the public in general, by providing a framework that care workers are expected to conduct themselves against, and to practise in line with agreed standards. This could allow service users, their carers and families to hold workers, their employers and managers to account if these standards are not adhered to. On the other hand, both Payne (2013) and the RCN, Royal College of Midwives (RCM) and UNISION, (2012),who represent health and social care workers have raised their concerns about the Code of Conduct and Standards as regards its effectiveness. They argue that, in the absence of compulsory registration of health and social care workers, it will be impossible to implement the Code and the Standards universally. They point out that part one of the reasons attributed to this, is that the definition of what constitutes a health or social care worker covered by the Code is problematic. They conclude that certain workers employed in other areas of care are excluded from the Code. This will include people working in Advocacy, Brokerage and some people in assessments who are independent from

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training and development professionals. Furthermore, it will also exclude “personal assistants.” There is an increase in the numbers of employers of care workers likely to be individuals responsible for making their own care provision through direct payments and individual budgets. It is argued that excluding such groups from the Code and Standards and a fully registered workforce, creates clear safeguarding risks. These parties all highlight how in Scotland and Wales registration exists for all health and social care workers and this functions alongside a Code of Practice. This leads Payne (2013) to conclude, “The lack of a registration framework then raises the question of what purpose this 2013 Code serves, together with the National Minimum Training Standards. In addition, what purpose are the two frameworks likely to serve in the future if there are no plans to link them to a registration scheme?” Furthermore, Payne (2013), RCN, RCM and UNISION all question the lack of a corresponding Code of Practice for managers, arguing that, in all other UK countries such a Code exists, for both managers and workers, together with compulsory registration for managers. This is used to underpin the respective Codes of Practice for both health and social care workers and managers alike. This leads the RCN, RCM and UNISION to conclude, “It is imperative that there is a corresponding Code for employers that sets out their responsibilities. Failure by employers to give appropriate support to workers will make it impossible for workers to comply with the Code of Practice and National Minimum Training Standards.” In other words, a Code of Practice for employers and managers could mean that this would provide standards for them to ensure that a Code of Practice was fully implemented by themselves and adhered to by their staff.

Conclusion The introduction of the Code of Practice and National Minimum Training Standards can be seen as an attempt to drive up standards, and in so doing create more consistent practice across the care sector by which workers and managers can be judged. This could be beneficial in providing care workers and their managers with a clear practice and training framework that they can work from, build training around, and also allow managers to incorporate this into their policies and procedures. Furthermore, it could also allow users of services and their carers to have a framework by which they can assess the competence of care staff and the settings in which they work, and hold those settings and their employees to account, should the Code and Standards not be adhered to. However, the potential short comings are evident in that the lack of registration for care workers and the definition of who comes into the remit of the Code and Standards continue to

be the missing link in care practice. Leaving out considerable sections of the care workforce raises questions with regards to the ability of the Code and Standards to create consistency of practice across the sector, and raises concerns around safeguarding. In addition, the lack of a corresponding Code and Standards for managers is difficult to understand, when such a Code could further strengthen practice by implementing this alongside the Code for care workers.

References Community Care (2013) At-a-glance guide to the code of conduct for social care workers. Available at: http://www. [Accessed 19 September 2013]. Payne C, (2013) The Code of Conduct for Healthcare Support Workers and the National Minimum Training Standards: part one. Available at Royal College of Nursing (2012) Skills for Health and Skills for Care Consultation. Available at: [Accessed 19 September 2013]. Skills for Care (2013) Code of Conduct for Social Care Workers and Health Care Support Workers. Available at: http:// [Accessed 19 September 2013].

“The Code of Conduct describes the standards of conduct, behaviour and attitudes that the public and the people who need healthcare, care and support should expect of workers providing this care and support.” “The National Minimum Training Standards define the minimum knowledge workers must have, irrespective of individual job role. Both the Code and the Standards were created after extensive consultation with employers and workers across both sectors to make sure they were fit for purpose.” Taken directly from Skills for Care, 2013

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networking IN CARE

Monitoring and managing hypoglycaemic episodes in care homes Abstract Time spent in care homes is associated with diminished glucose tolerance and increased diabetes prevalence (Grobin, 1970). An early review of dosage and frequency of oral hypoglycaemic medication shortly after admission to a care home may prevent unwanted ‘over-treatment’ effects since adherence may improve as mealtimes and administration of medication potentially become more regular. This article is a summary of the relevant section in ‘Good clinical practice guidelines for care home residents with diabetes’ prepared by a Task and Finish Group of Diabetes UK. Author: Jackie Watts, Clinical Advisor Diabetes UK

Many care home residents are likely to require alterations to their therapy to help ensure compliance and good outcomes. Their medicines should be reviewed on an ongoing basis, with choice of agent depending on glycaemic targets, drug adherence and tolerance, co-prescribed medicines and any co-morbidities. Diabetes medication also needs to be closely monitored due to issues with side effects.

Insulin therapy “The most common reason for initiating insulin therapy in older residents will be for improving glucose control in those with Type 2 diabetes on oral agents”(Sinclair, 2011). All people with Type 1 diabetes absolutely need insulin. The most appropriate insulin regimen will vary between residents but those who can self inject can receive insulin in most care home settings. In many cases, a once daily regimen of long-acting analogue insulin or a twice daily regimen of isophane (eg insulatard or Humulin 1) may be “associated with a relatively low risk” of hypoglycaemia. “Long-acting analogue insulins, such as glargine and detemir have been shown to” result in a significantly lower rate of hypoglycaemia (but not severe hypoglycaemia) compared with NPH insulin, which may be very relevant in this frail group. (Sinclair, 2011). Where self injection is not possible, residents in residential homes (but usually not those in nursing homes) will need community nursing support to administer insulin.

For residents with erratic dietary intakes, bolus injections of analogue short-acting insulin may be very useful, as they can be given at the same time as, or immediately after, the resident eats their meal, decreasing the risk of hypoglycaemia. A local diabetes specialist nurse can play an important role in the education of the resident and care staff, including catering staff. In addition, the advice and support of a community dietician when insulin therapy begins is essential.

Blood glucose monitoring in a care home setting “Glycaemic goals will vary with each resident but should be sufficient to avoid recurrent hypoglycaemia (a fasting blood glucose level” of >7-8.5 mmol/l), a random glucose <9 mmol/l, to avoid osmotic symptoms and lethargy, and is likely to minimise longer term vascular complications (Sinclair, 2011). Setting targets to optimise wellbeing “is essential; a target HbA1c range should be 53-64 mmol/mol” (Sinclair, 2011). It should be remembered that the average stay in many nursing homes of elderly residents is around two years, with some residents staying much longer, making the development of visual loss, neuropathy and macrovascular disease possible where a policy allows for a gross relaxation of glycaemic control. Each care home should define who is

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networking IN CARE responsible for blood glucose monitoring. Blood glucose monitoring should only be done by unregistered care staff, where this agreement has been reached by the home manager, and the care staff have demonstrated competence. The format of training and documentation used will be dependent on locally agreed protocols and policies already in place.

Recognition and management of hypoglycaemia within care homes There is a high prevalence of risk factors for hypoglycaemia in residents with diabetes (Chelliah and Burge, 2004). Risk factors include advanced age, multiple co-morbidities, polypharmacy (five or more medications), chronic renal or hepatic impairment, recent hospital admission, history of hypoglycaemia, poor nutrition, use of sulphonylurea or insulin, acute illness, hypoglycaemic unawareness and diminished counter regulatory responses. Prevention of hypoglycaemia has the potential to improve older people’s quality of life, confidence and compliance with their treatment, and reduce unnecessary hospital admission. There is insufficient data about the incidence of hypoglycaemia among older people with Type 2 diabetes, particularly those living in care homes. In a survey among US Medicare diabetic population aged 65 years and over, hypoglycaemia was the most common metabolic complication, with a rate of 28.3 events per 1,000 person-years (Bertoni et al, 2002). However, accurate measures of the frequency of hypoglycaemia are probably underestimated in older people (McAuley and Frier, 2009). The experience of an episode of hypoglycaemia can range from it being unrecognised by the subject to extreme discomfort and can be frightening to patients, family, friends and carers. Hypoglycaemia can cause serious morbidity, provoking major vascular events, such as stroke, myocardial infarction, acute cardiac failure, and ventricular arrhythmias. The morbidities associated with hypoglycaemia, such as impaired consciousness and convulsions, can be particularly debilitating in the elderly, who are at increased risk of injury and bone fractures because of general frailty and osteoporosis. Sweating, palpitations, tremulousness, feeling anxious or nervous are all potential symptoms. Residents with a ‘hypo’ may feel faint or very tired, have difficulties concentrating and exhibit blurred vision. For practical purposes, a level of glucose below 3.0mmol/l will activate a symptomatic response and a level below 2.8mmol/l will cause cognitive impairment (McAuley and Frier, 2009). Partial impaired awareness of hypoglycaemia may be a particular problem

in care homes residents with diabetes. Symptoms may be present but masked by other conditions or residents may be unable to accurately communicate their symptoms to staff. In some cases, the expected classic pattern of hypos may not occur. In general every effort must be made to tailor treatment with sulphonylureas or insulin that significantly minimises the risk of hypoglycaemia and fasting levels should not fall below 6.0mmol/l. Approaches that can be taken to help prevent hypoglycaemia within care home settings include: • Regular review of medication (including doses, frequency of administration, timing of meals) and minimising adverse interactions: ensure similar process occurs after recent re-admission to care home from hospital • A full history should be taken about eating habits, especially erratic and inconsistent eating behaviour: the involvement of a registered dietician is needed for cases of recurrent hypoglycaemia • Glycaemic goals of treatment should be individualised to residents needs • Use of the newer class of long-acting insulin analogues which have the potential to limit the risk of hypoglycaemia and can be conveniently injected once daily • Administration of fast-acting insulin analogues after meals on an as required basis may be needed if calorie intake is variable and unpredictable • Switch patients taking longer acting sulphonylureas onto shorter-acting agents with less hypoglycaemic complications. Identifying residents at ‘high-risk’ of hypoglycaemia (e.g. those on sulphonylureas or insulin, undernourished, cognitively impaired) is worthwhile as interventions can then be targeted. Provision of education about diabetes and hypoglycaemia to care home staff remains the best way to improve hypoglycaemic prevention and treatment.

Conclusion Inadequately treated hypoglycaemia may result in hospital admission. To help minimise the risk of this, agreed “glycaemic target ranges for residents (depending on their functional status/level of frailty) should be documented in their individual care plan” (Sinclair, 2011). Carers should be aware that while a wide range of oral glucose-lowering therapies are available for use in care home settings, extra vigilance, including frequent assessments of renal and hepatic function, is needed to reduce the risk of adverse events and enhance residents’ safety. The threshold for prescribing insulin to residents in care

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networking IN CARE homes has fallen but unless the clinical need is recognised, the regimen is appropriate, and sufficient supervision is present, treatment may fail. Blood glucose monitoring can be an effective part of diabetes management for care home residents and may be of additional value for those on insulin therapy.

References 1. Grobin W (1970). Diabetes in the aged: underdiagnosis and overtreatment. CMA Journal 103 (9); 915 923 2. Chelliah A and Burge MR (2004). Hypoglycaemia in elderly patients with diabetes mellitus: causes and strategies

for prevention. Drugs & Ageing 21 (8); 511-30 3. Bertoni AG, Krop JS, Anderson GF et al (2002). Diabetesrelated morbidity and mortality in a national sample of US elders. Diabetes Care 25; 471-5 4. McAulay V and Frier BM (2009). Hypoglycaemia. In: Sinclair AJ (ed), Diabetes in Old Age, Third Edition. John Wiley and Sons; Chichester; pp287-305 5. Sincliar, A.J (2011) Diabetes UK Position Statements and Care Recommendations. Good clinical practice guidelines for care home residents with diabetes: an executive summary. Diabetes Medicine. 28, 772â&#x20AC;&#x201C;777.

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Evidence based forum

Managing behaviours that challenge in dementia care: exploring research based evidence A review of literature on the main issues, treatment and management options in relation to supporting older people with dementia within care settings. Abstract Dementia is a disorder that affects over 750 000 people in the UK and 60% are said to display behaviours that challenge. The main behaviours identified focus on aggression, apathy, depression, psychomotor agitation or psychosis. A summary of relevant research in relation to behaviours that challenge specifically aggression will be highlighted in this article, and the implications this has for registered managers, their teams and service users. Author: Pat Hobson - Consultant Editor, Independent Nurse Consultant, Dementia Specialist and Lecturer in Nursing

Trigger factors of aggression in dementia

as the most common behavioural symptom associated with the severity of the dementia.

Triggers of behaviours that challenge, especially aggression among people with dementia have been attributed to a combination of key factors, which include physical, physiological, psychological and environmental factors. In this review, communication, physiological and environmental factors will be explored. The reasons for exploring these three main factors are attributed to the fact that they were the most consistently cited contributory factors within research examined, particularly with reference to aggression.

Manfredi et al (2003) supports this by stating that people with dementia will use body language as a way of communicating needs particularly within the advanced stages of dementia, when verbal skills are limited. Dementia affects speech areas of the brain that enable individuals to express their needs verbally (expressive aphasia) or understand what is being said to them (receptive aphasia). This can result in frustration, as a person may struggle to communicate their needs or understand what is being said to them.

Physical factors - communication

Kovach et al (1999) also identified body language as indicative of a desire to communicate unmet needs. The study involved 104 residents and found that behaviours, such as facial expressions and verbal outbursts, were key communication indicators.

Dementia has an impact on the person with dementia’s ability to communicate their needs. As the dementia progresses, the challenges faced by people with dementia in relation to communication can lead to frustration and distress. Behaviour is a form of communication, cited within the literature as a key factor, which enables individuals to express how they feel, when verbal skills are limited. Talerico et al (2002) identified a correlation between verbal and physical aggression and difficulties in communicating needs on 405 nursing home residents with dementia. The person’s inability to communicate needs resulted in behaviour, such as verbal and physical aggression. The study also found a correlation between physical aggression and the use of both physical and chemical restraints as treatment options considered in an attempt to deal with the behaviour. A review by Brodaty et al (2002) cited aggression

Physiological factors Changes in a person’s behaviour can be attributed to a combination of physiological factors. This can be in the form of physical illness, which can exacerbate the behaviour, leading to physical or verbal aggression. Other examples include; pain, constipation, chest infection and urinary tract infection, which have been cited as contributory factors to changes in behaviour. According to Gromley et al (2001), physical illness can result in aggression, and this includes discomfort and pain as key indicators to behaviour changes.

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Evidence based forum

Environmental factors Sloane et al (1998) found physical environment, disorientation, problems with others residents or staff, discomfort, noise, sounds and invasion of personal space as significant contributory factors in behaviour changes, in people with dementia. There was also a correlation between environment and agitation. A study by Cohen Mansfield (1997) focused on the correlation between aggression and nursing intervention, and the frequency of aggression appeared to occur more during care giving episodes. Staff approaches and inconsistencies in the way in which service users were supported was also cited as key contributory factors to changes in behaviours among people with dementia.

Treatment options Pharmacological approaches Research indicates that nearly a third of people with dementia in care homes are prescribed antipsychotic medications to manage behaviours that challenge (Liperoti, 2003, Briesacher, 2005, Rochon, 2007). The most common medications prescribed are haloperidol, olanzapine, quetiapine and risperidone. A study by Lonergan et al (2002) on 856 patients found haloperidol had no effect on agitated behaviour, but indicated moderate results in reducing some aggression. The use of newer atypical antipsychotic medications, such as risperidone, olanzapine and quetiapine, did yield some positive outcomes as pointed out by research undertaken (Katz et al, 1999, De Deyn et al, 1999). However, the use of antipsychotic medications in the treatment of aggression is not without controversy in people with dementia, and concerns raised in relation to their effectiveness and therapeutic properties (Huybrechts et al, 2011). Research examined found some evidence to suggest the effectiveness of antipsychotic medications in the treatment of aggression among people with dementia (Huybrechts et al, 2011, Schneeweiss, 2005, Wang et al, 2007). However, there is significant research cited in relation to the side effects these medications have, which contributed to physical and psychological decline in people with dementia (Huybrechts et al, 2011). Haloperidol was cited as contributing to a rapid decline in people with dementia due to the side effects, even in very low doses, with a significant risk of premature death (Huybrechts et al, 2011, Schneeweiss, 2005, Wang et al, 2007). Other side effects included; parkinsonian symptoms (common in high doses), postural hypotension, sedation, dry mouth, blurred vision, falls and fractures. Long term use of antipsychotics also lead to tardive dyskinesia (Huybrechts et al, 2011, Schneeweiss, 2005, Wang et al, 2007). Therefore, the use of these medications is not recommended in people with dementia. It is interesting to note that withdrawal of antipsychotics medications has little impact on the behaviour as highlighted by some research undertaken

(Cohen Mansfield, 2000, Cohen Mansfield, 1997, Ballard et al, 1999, Brodaty et al, 2003).

Non pharmacological approaches The need to focus on non pharmacological approaches in relation to managing behaviours that challenge is now more favourable (Cohen Mansfield, 2001). The introduction of person centred theories focuses on the need to view dementia as a disability, an interaction of complex attributes, which can have an impact on the person. Therefore, the emphasis should be on the person, and why the behaviour is happening. Kitwood (1997) focused on the need to undertake a comprehensive assessment of the person’s needs. Therefore, the non pharmacological theories focus more on the underlying problems and seeks to address these using various person centred strategies. The main areas explored in this review were person centred feelings based approaches, behavioural approaches and reality orientation.

Person centred approaches accepting the person’s reality The issue of fulfilling emotional needs is one that is gaining more credibility in dementia care and the need to focus more on feelings and emotions of the person (Sheard, 2007). Many theorists and experts in dementia care focus on this approach and the importance of how this needs to be central when working with people with dementia (Kitwood, 1997, Brooker, 2007, Sheard, 2007, Verity, 2006). As the dementia progresses, people with dementia will relate to their unique experiences and memories, which are significant to them (Verity, 2006). People with dementia will attempt to communicate their needs based on these significant memories and their own reality, whilst staff may attempt to bring the person back to reality, which no longer has any significance to them. This will result in a clash of realities, which can lead to frustration and anger (Verity, 2006, James, 2008). Therefore, care workers will need to adapt their approach to enable them, to ‘enter’ the world of the person with dementia and make sense of their reality (James, 2008, Brooker, 2007, Sheard, 2007). Care workers need to validate the feelings and emotions of people with dementia, by becoming more skilled in listening to what they say, thus acknowledge the importance of addressing their emotional needs (Davis, 2004). There is evidence that advocates that as dementia progress, people with dementia will seek what is familiar to them in an attempt to make sense of what is happening to them. Feelings of loss, fear and uncertainty can be communicated more in other forms of communication, such as frustration, agitation and aggression (McCormack, 2004). The ‘feelings based’ approaches seek to fulfil the emotional

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Evidence based forum

needs of people with dementia, thus alleviate these negative feelings experienced. Meeting the emotional needs of people with dementia can be achieved by creating environments and staff interactions that will fulfil their unmet needs (Sheard, 2007, Brooker, 2007, Bryden, 2002.

Behavioural therapy Behavioural therapy aims to use an approach that focuses on the principals of conditioning and the use of learning theory. The key factor is to utilise the strategies, which aim to eliminate the behaviour identified as a challenge. Data collection of the key behaviours over a period of time can enable the team to undertake a detailed behavioural analysis and identify the appropriate form of therapeutic intervention (Moniz-Cook, 1998). Behavioural approaches focus on the process, which uses the antecedent, behaviour and consequences approach, and advocates the person centred theory in relation to undertaking a detailed assessment of the person’s needs (Moniz-Cook, 1998). There appears to be little evidence in reducing agitation and aggression, using behavioural approaches, as they are not effective when used in isolation (Beck et al, 2002, Allen-Burgo, 1999, Bottino, 2005). However, when used in conjunction with person centred approaches, they can enable care workers to assess the behaviour identified first, then implement person centred strategies to help support the person with dementia, and also provide staff with a consistent approach to manage the behaviour.

Reality orientation Another non pharmacological approach used widely within dementia care is known as reality orientation. Reality orientation refers to the term used to support people with dementia by reminding them of where they are, or who they are. Devices can be used to assist in orientation (Spector et al, 2001, Spector et al, 2002). There is little research in this field, which relates to the effectiveness of this approach in managing aggression. There is evidence to suggest the use of reality orientation may be effective in the very early stages of dementia. However, as the dementia progresses, the use of this approach can exacerbate the behaviour, as the person is no longer able to reason, and relate to our reality. Therefore, this should be avoided when working with people with moderate to advance stage dementia.

Implications for practice The implications of the issues explored in the review focus on the need to manage behaviour that challenge, such as aggression, by using more person centred approaches. The review has highlighted key issues in relation to the ineffectiveness of medications in the treatment of aggression, and highlighted evidence to suggest that antipsychotic medications are still widely used to treat behaviours, despite

the lack of robust evidence. Registered managers and their teams need to undertake a comprehensive assessment of the specific behaviour, why this occurs, and then liaise with relevant professionals to identify the best strategies available. When these strategies are identified, it is essential to ensure that care workers maintain the same consistent approach to support service users. Registered managers also need to have the relevant knowledge and understanding of any guidelines available to support staff in the management of aggression. These guidelines should be based on the best evidence available and implemented to support staff and service users. A comprehensive assessment should be carried out to ensure that key issues that could contribute to change in the behaviour are eliminated, and these include; physiological, social, environmental, physical and psychological factors.

Conclusions The review identified some important areas of research in relation to the management of behaviours that challenge in dementia, particularly aggression. The registered manager‘s role is to enable staff to maximise people with dementia’s abilities. Working alongside their teams will enable registered managers to identify ways in which they can promote the uniqueness of each person with dementia, and led by example in demonstrating evidence based practice in the management of behaviours that challenge.

References Allen-Burge, R., Stevens, A. and Burgio, L. (1999) Effective behavioural interventions for decreasing dementia-related challenging behaviour in nursing homes. International Journal of Geriatric Psychiatry, 14, 213–228. Ballard, C. G. and O’Brien, J. T. (1999) Pharmacological treatment of behavioural and psychological signs in Alzheimer’s disease: how good is the evidence for current pharmacological treatments? British Medical Journal, 319, 138–139. Briesacher, BA., Limcangco. MR., Simoni-Wastila, L et al (2005). The quality of antipsychotic drug prescribing in nursing homes. Archives International of Medicine, 165:1280-5. Beck, CK., Vogelpohl, TS., Rasin, JH et al (2002) Effects of behavioural interventions on disruptive behaviour and affect in demented nursing home residents. Nursing Research, 51:219-28. Bottino, CM., Carvalho, IA., Alvarez, AM et al (2005). Cognitive rehabilitation combined with drug treatment in Alzheimer’s disease patients: a pilot study. Clinical Rehabilitation 19 (8): 861–9. Brodaty, H., Ames, D., Snowdon, J., et al (2003) A randomized placebo-controlled trial of risperidone for the treatment of agitation, aggression and psychosis of dementia. Journal of Clinical Psychiatry, 64, 134–143.

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Evidence based forum Brooker, D. (2007). Person-centred dementia care: Making services better. London: Jessica Kingsley. Bryden, C. (2002). A person-centred approach to counselling, psychotherapy and rehabilitation of people diagnosed with dementia in the early stages. Dementia, 1(2), 141-156. Cohen Mansfield, J. (2000) Use of patient characteristics to determine non-pharmacologic interventions for behavioural and psychological symptoms of dementia. International Psychogeriatrics, 12 (suppl. 1), 373–380. Cohen Mansfield, J. and Werner, P. (1997) Management of verbally disruptive behaviours in nursing home residents. Journals of Gerontology Series A – Biological Sciences and Medical Sciences, 52, 369–377. Cohen Mansfield J (2001). Nonpharmacologic interventions for inappropriate behaviours in dementia: a review, summary, critique. American Journal for Geriatric Psychiatry, 9:361-81. Davis, D. (2004). Dementia: Sociological and philosophical constructions. Social Science and Medicine, 58, 369-378. De Deyn, P. P., Rabheru, K., Rasmussen, A et al (1999) A (1999) randomized trial of risperidone, placebo and haloperidol for behavioural symptoms of dementia. Neurology, 53, 946–955. Gromley, N., Lyoon, D and Howard, R (2001) Behavioural management of aggression in dementia: a randomized controlled trial. Age Ageing, 30(2):141-5. Huybrechts, K., Brookhart, A., Rothman, K et al (2005). Comparison of different approaches to confounding adjustment in a study on the effect of antipsychotic medication on mortality in older nursing home patients. America Journal of Epidemiology; 174:1089-99. James, O (2008) My mother was back. The lights were on. Guardian. Available at: ( lifeandstyle/2008/aug/02/oliver.james.dementia. [Accessed 19 September 2013]. Katz, IR., Jeste, DV.,Mintzer, JE et al (1999) Comparison of risperidone and placebo for psychosis and behavioral disturbances associated with dementia: a randomized, doubleblind trial. Risperidone Study Group. Journal of Clinical Psychiatry. Feb; 60(2):107-15. Kitwood, T. (1997) Dementia Reconsidered: The Person Comes First. Buckingham: Open University Press. Kovach, C.G., Weissman, et al (1999): Assessment and treatment of discomfort for people with late stage dementia: Journal of Pain and Symptom Management: 18(6): 412-9.

Psychiatry; 64:1106-12. Lonergan, E., Luxenberg, J and Colford, JM (2002). Haloperidol for agitation in dementia. Cochrane Database of Systematic Reviews, (2):CD002852. Marfredi, P.L., Breuer, B. et al (2003) Pain assessment in elderly patients with severe dementia. Journal of Pain and Symptoms Management: 25(1), 48-52. McCormack, B. (2004). Person-centredness in gerontological nursing: An overview of the literature. International Journal of Older People Nursing, 13(13a), 31-38. Moniz-Cook, E., Agar, S., Silver, M., et al (1998) Can staff training reduce behavioural problems in residential care for the elderly mentally ill? International Journal of Geriatric Psychiatry, 13, 149–158. Rochon, PA., Stukel, TA., Bronskill, SE et al (2007). Variation in nursing home antipsychotic prescribing rates. Archives International Journal of Medicine; 167: 676-83. Schneeweiss, S., Setoguchi, S., Brookhart (2007), A et al. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. Canadian Medical Association Journal; 176:627-32. Sheard, D. (2007) Being: An approach to life and dementia, London: Alzheimer’s Society. Sloane, P.D., Mitchell, C. M. et al (1998) Environmental correlates of residents agitation in Alzheimer’s’ disease special units. Journal of the American Geriatrics Society, 46(7): 862-9. Spector, A., Orrell, M., Davies, S., et al (2001) Can reality orientation be rehabilitated? Development and piloting of an evidence-based programme of cognition-based therapies for people with dementia. Neuropsychological Rehabilitation, 11, 377–397. Spector, A., Orrell, M., Davies, S., et al (2002) Reality orientation for dementia. Cochrane Library, issue 3. Oxford. Talerico, AK., Evans, LK and Strumpf, NE (2002) Mental Health Correlates of Aggression in Nursing Home Residents With Dementia. The Gerontologist 42(2), 169–177. Verity, P (2006) Truth or Lies – The Great Reality Divide’. Available at ruth-or-lies-the-great-reality-divide.html [Accessed 19 September 2013]. Wang, P., Brookhart, M., Setoguchi, S et al (2006). Psychotropic medication use for behavioral symptoms of dementia. Current Neurology and Neuroscience Reports; 6:490-5.

Liperoti, R., Mor, V, Lapane, KL., Pedone, C et al (2003). The use of atypical antipsychotics in nursing homes. Journal of Clinical

The Modern Registered Manager – Vol 1 No 5 Sep/Oct 2013 37

reflective corner

Fatal freedom Abstract This reflective account explores the experience of how a registered manager working within a mental health care settings may feel, following the suicide of a service user. Author: Nigel Leaney: Registered Manager

One of the worst experiences that can happen is a suicide on your watch. It does not get much worse than a policeman knocking at the door of your establishment with the news that someone in your care has thrown themselves off the local shopping mall. Someone whom you spoke to less than two hours ago, and yet none of your thirty years of certificated expertise, had been enough to prepare you for this. The incident catches you on many levels, and each level has a vanishing point that you cannot see beyond. Nothing is enough; no statement, no feeling. The personal tragedy of a young man who felt life was so worthless, and that the only option was to end it. Sitting opposite the grieving parents, bearing witness to a pain no parent should bear, and watch them shrink under that awful weight. Having to tell my staff and the other residents the awful news. Fill the gap that is left by a young person and having to fully describe it, understand it and file it away. In the profession of mental health, where suicide can sometimes be inevitable; what do you do with what is left, the aftermath? There is you, the registered manager, and the private individual. The two overlap, intermingle, yet have separate duties and responsibilities. You muddle through the two handled roles of public and private. Different people come and go, and extra counselling and support are offered to you and your team. Everything is done according to the book, or at least the policies and procedures as stipulated by the organisation. But you do not need to believe in ghosts to experience hauntings. I do not know when my own particular haunting will stop. It is down to me, I know. His mark is still here in the home. Along with all the nagging questions, a registered manager will always ask themselves of such a tragedy. Was there, something, anything I could have done to prevent it? Having gone through it a hundred times, the same answer comes back each time. As registered managers, we have a duty to minimise harm. Risk assessment is our ABC, inscribed into our DNA, and so part of this is suicide prevention. There is the Mental Health Act, where people viewed as a danger to themselves can be involuntary

hospitalised and treated against their will. Thomas Szasz argued that when faced with such preventative measures, the citizen may feel compelled to ‘exercise his existential need of (fatal) freedom.’ This example begs the question, is suicide always a medical matter to be contained under its auspices, or may it be viewed as a moral option? When does the responsibilities of the registered manager, acting out a legal duty of care, transcend the individual’s rights of self-determination and autonomy? Does the latter’s rights simply and always stop by the self-destruct button? Each case is different, and there are many guidelines to support the registered manager through the risk assessment process and recovery plans. All the signed plans, matrices and agreed levels of risk are reduced to a single numerical value. For what it is worth; this is my pledge as a wounded professional, no other person on my watch will jump from any corporate building.

Reference Szaz, T. (2002), ‘Fatal Freedom: the ethics and politics of suicide’, Syracuse University Press: New York.

If you are a registered manager, deputy manager, team leader, and would like to submit a reflective account on your experiences of leadership and management in the care sector. Please email: to subscribe to the journal.

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