Beyond Appearances

Modify Alzheimer’s patients’ behavior by thinking outside the box

by Tim O’Connor

Throughout my 40 years in the healthcare industry, I have always believed quality must be intentional. The only true responsibility of a leader is to create an environment in which staff can choose to be successful. Unfortunately, in healthcare, the center of attention in determining quality is measuring how staff members comply to a rule, regulation, policy or protocol. The emphasis should instead be on an ongoing commitment to provide total quality.

A farmer once told me, "It ain’t just the horse—it’s the oats." Borrowing from that logic, it isn’t just the process; it very well may be the people. If the box we focus on is always the process, there is a very good chance we may be thinking outside the wrong box.

I frequently ask the question "Who is the most important individual in our facility?" The answer I most often hear is the resident. Staff was usually surprised when I suggest it is, rather, the responsible, hands-on staff member. The reasoning is simple and straightforward: If your best quality improvement efforts are directed at establishing commitment of staff, they will, in turn, render superior care. This fact has proven to be true during my entire career in numerous settings.

For the last 35 years, I have created multiple seminars and educational workshops for healthcare staff directed at enhancing the quality of care. In every instance, we first established a shared vision of quality of care. We would ask the question, "Is what we are doing getting us what we want?" If not, then we can either change what we are doing or change what we want.

We can continue to improve and apply the same protocols and care processes over and over again with the expectation of attaining the results we want, but what happens when we fall short of the expectations and results we intended?

Meeting true needs

All behavior is purposeful. This fact holds true for every individual in all circumstances without exception, even for those who suffer from severe Alzheimer’s disease.

In one particular long-term care workshop, I focused on meeting the true needs of the Alzheimer’s resident and understanding his or her behavior. Once the workshop attendees understood and accepted the fact that all behavior is purposeful, they could observe, evaluate and respond appropriately, and manage Alzheimer’s-related behavior quite effectively.

For example, an 82-year-old Alzheimer’s resident lived in one of our facilities, and in the morning, he would wake up and urinate on the radiator under the window in his room. Policies and protocols were immediately put in place to monitor his fluid intake the night before, wake him earlier in the morning and assist him to the bathroom. More often than not, however, he continued his behavior.

All the traditional interventions were deployed to no avail. Policies and protocols were reviewed and new interventions were established. The care process was studied fervently to address the issue, and the resident was constantly approached and verbally encouraged by the staff to change his behavior.

You can imagine the nursing and housekeeping staff’s ongoing frustration. Not only was the odor repulsive and the sanitation situation unacceptable, the time spent cleaning the inside and outside of the radiator was substantial.

As a result of attending the Alzheimer’s behavior workshop, however, a committed resident care aide took her newly acquired Alzheimer’s-behavior knowledge base and decided to step back and think outside the box—not the protocol box, but the resident behavior box. She reflected on the fact that "if it is indeed true that all behavior is purposeful, then why is he doing what he’s doing?" She spent time observing him and investigated his background and history.

A farmer for life

She learned he grew up on a farm and was a farmer his entire life. She thought about what this had to do with his behavior. One morning, she observed his behavior through a new mental lens and noticed the radiator was under the window. Outside the window was a tree the resident gazed at while urinating.

Then it occurred to her: Perhaps he was recalling his times on the farm and seeing himself out in the fields away from the house when a sense of urgency arose. Could it be that simple? That he had to urinate, and in his mind, there was an opportune tree?

Her solution was to purchase a three-foot plastic ornamental tree and place it in the resident’s bathtub. She left the bathroom door open where the resident could see the tree immediately when he got up in the morning. It worked. He saw the tree in the bathroom and urinated in the bathtub, which was a lot easier to clean than the radiator.

It worked phenomenally. The resident retained his dignity, and the staff was amazed at how such a simple solution was so effective. Resident-care protocols and interventions were still in place and improved upon for more appropriate outcomes. In time, the resident was weaned from the tree and eventually used the toilet.

As for the aide, she was so proud and elated that her solution was effective, she could not wait to get to work and address other challenges. There was no need for her to focus on a level of compliance; to her, it was all a matter of commitment.

Understanding the past

There was another elderly gentleman, also afflicted with Alzheimer’s, who would never bathe or shower. The staff initiated every conceivable intervention, but the man still refused to shower.

An aide stepped back, reflected on his behavior and investigated his background. She discovered he was a handyman for 50 years. A light went off, and she purchased a $3 wrench.

She approached the resident and told him the shower head in the bathtub didn’t work. She asked him if he thought he could he fix it. The resident jumped into the bathtub and began, in his mind, to "fix" the broken shower. After a few minutes—and a few scratches on the chrome shower head—the resident proudly exclaimed the shower was fixed. The aide then asked if he would mind testing it out. The aide helped him take off his clothes, and he took a shower to test his work.

The shower was "broken, fixed and tested" every Wednesday morning at 9 a.m. from that day forward.

To say the least, all staff members changed their perspective on human behavior. For them, quality was not an option—it became their mantra.

"It ain’t just the horse—it’s the oats." Smart farmer.

Tim O’Connor is a management consultant in Big Flats, NY. He earned his MBA in healthcare from the State University of New York at Buffalo. He is a member of ASQ.

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