Neurophysiology and Rehabilitation (ISSN: 2641-8991)

Research Article :

Investigation of the Preferred Learning Styles of Persons Living with Dementia


Debra Stewart and Andree Swanson

Abstract

The purpose of this investigation was to determine the preferred learning styles of persons living with dementia using the learning styles inventory for persons with dementia. Furthermore, this investigation evaluated unit productivity and job satisfaction of nursing assistants when activities of daily living were designed using the residents preferred learning styles. Revealed through literature review was the concern that nursing assistants in long-term care experience resident resistance to care and resident agitation which is often related to the residents cognitive decline and confusion which reduces unit productivity and makes task completion difficult. Also, through a literature review, the most significant job satisfaction for the nursing assistant was about the relationship that was experienced and shared with the residents in their care. Although a great deal of research exists on preferred learning styles of children and adults, there appear to be limited studies conducted on persons living with dementia. Also, there is limited information surrounding the subject of whether if knowing the preferred learning styles of patients living with dementia helps foster cooperation during activities of daily living and increases unit productivity while maintaining or improving nursing assistant relationships with their residents.

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Introduction


Nursing home facilities are institutional settings designated and designed for long-term care or short-term skilled rehabilitation. The adult population of a nursing facility may consist of any age, morbidity, or socioeconomic class. Dementia is a common condition found in these institutions and may exist in various forms such as Alzheimers disease, Parkinsons disease, or vascular dementia. Activities of Daily Living (ADLs) in the nursing home setting involve eating, bathing, dressing, personal care, medication administration, and toileting. Dementia-related cognitive impairment can make it difficult for caregivers to provide or assist with these functions because caregivers often experience resistance, and combative behaviors from the residents that they are helping.

The investigation of the preferred learning styles of persons living with dementia is the subject to be examined. The study explored whether caregiver productivity and job quality are improved when ADLs are offered based on the preferred learning style of persons with dementia, and the willingness of the resident to cooperate. Caregivers often feel uncertain and hesitate to provide care that takes into consideration the individual differences of the people that they serve. Few attempts at helping a confused resident relearn ADLs and social skills occur because of a reluctance to believe that positive long-term benefits will happen in the cognitively declined population. The reluctance based on myths, fears, outdated information, and cultural or religious beliefs and expectations foster a biased attitude about dementia and cognitive decline and the ability for confused residents to learn and optimally engage in the caregiving process. The literature review based on the underlying assumption that the above-observed social science issue occurs because of a knowledge gap concerning caregivers ability to assess the remaining preferred learning styles of persons with dementia supports the importance of the current study.

Nursing homes and short-term rehabilitation centers are tasked to do more with fewer resources than is needed to meet regulation and to create an environment of relationship-centered care and enhanced quality of life. Cognitive decline associated with dementia can make caregiving difficult and time-consuming. Depending on the level of decline, caregivers of persons living with dementia are often met with resistance or apathy when trying to help residents with the simple tasks of ADLs. According to Pinel, intermediate stages of dementia reveal confusion, irritability, anxiety, and deterioration of speech and later the patient may deteriorate to become a total care patient having difficulty with swallowing and bladder control [1].

Certified nursing aides who work in nursing homes are required to complete a state-approved education program with supervised job-site learning and successful completion of a state-approved competency exam [2].The training to become a certified nursing assistant usually consists of six weeks and requires a high school diploma or equivalent. Essential qualities certified nursing assistants should have as stated by the Bureau of Labor Statistics include communication skills, compassion, patience, and physical stamina [2]. Job responsibilities for nursing assistants vary because of the many settings that utilize nursing assistants to help professional nursing staff. The Centers for Medicare and Medicaid Services (CMSa) govern the regulations for the nursing care in nursing facilities and provide suggestions for standardized care concerning various topics of quality of care [3].

Literature Review

Dementia is an umbrella term for different types of memory loss and cognitive impairment. According to the Alzheimers Association [4], common forms of dementia include Alzheimers disease, vascular dementia, Dementia with Lewy Bodies (DLB), mixed dementia, Parkinsons dementia, frontotemporal dementia, Creutzfeldt-Jakob disease, normal pressure hydrocephalus, Huntingtons disease, and Wernicke-Korsakoff Syndrome. Cognitive losses have been recorded since 2000 BC by Egyptian doctors; however, the term dementia which is Latin for “out of ones mind” was not used until 1797 [5]. In the 1800s dementia was used loosely as a term for the intellectual deficit that occurred in some aging populations and the 1900s resulted in the term dementia used more appropriately for people with cognitive losses [5]. Until better diagnostic tools were available, syphilis was also listed as a common cause of dementia because it affected the brain [5].

Alzheimers disease, a well-known dementia named after Dr. Alois Alzheimer, who in 1906 discovered a specific type of dementia that created plaques and tangles in the brain that interfered with brain cell connectivity and the health and longevity of neurons in the brain [5]. Alzheimers disease is the most common form of dementia; however, it is not a normal part of the aging process [4]. Alzheimers disease causes serious cognitive losses that interfere with tasks and daily life may have an early-onset and is a disease that gradually worsens over time [6].

Alzheimers disease currently has no known cure; however, certain interventions appear to slow the course of the disease and improved quality of life for those suffering from the disease [4]. Medication has been proven to temporarily help with the symptoms of memory loss, confusion, and unwanted behaviors [4]. Behavioral modification programs and alternative therapies such as art, music, aromatherapy, or pet therapy are often short-term interventions for confusion, sleep disturbances, aggression and anxiety [7]. Also listed and used are herbal remedies, diet changes, and supplements as possible alternative ways to reduce the severity of the symptoms of Alzheimers as it advances [8].

Ryd, Nygård, Malinowsky, Öhman, and Kottorp stated that during mild cognitive impairment or early stages of Alzheimers disease ADLs are performed slower, with less efficiency and with errors in judgment, therefore safety is a major concern as the person with Alzheimers disease declines [9]. For example, during art and music therapy, therapists must design the programming based on the level of cognition and safety needed. In later stages of Alzheimers disease, patients may attempt to eat objects that could create choking hazards or become toxic if swallowed. Introducing ADLs based on the preferred learning styles will also need to take into consideration safety and the cognitive level of the patient living with Alzheimers disease, which will also be true for all other dementia types. For example, for bathing, if a patient has a preferred learning style combination of kinesthetic, logical, and music, the program for an early-onset patient with Alzheimers disease might include soft music and a washcloth with scented soaps, also helpful for the learning style combination above would be taking the patients hand and using repetitive geometric movements with the washcloth during the bath. However, in later stages of Alzheimers disease the patient may have limited motor ability and range of motion and may need to sit while listening to music,and the nursing assistant may guide the process with verbal cues without the patients interaction.

Because it is difficult to diagnose dementias while a patient is living, many dementia processes go undiagnosed or are assumed to be a part of the natural aging process. Savva and Arthur commented that assigning a diagnosis of dementia has both positive and negative consequences such as the fear and stigma of the diagnosis and the lack of support and care when the patient goes undiagnosed [10]. In the case of comorbidity, the symptoms of dementia may be assumed to be a part of the primary diagnosis, which also leads to a delay in treatment when dementia is the comorbidity [11]. Dementia diagnosis often depends on the severity of the symptoms, which means mild dementias are not recognized [10]. Mild to moderate cognitive deficits associated with some dementia types can benefit from the approaches and therapies that have developed recently, which have been proven through research to improve mood, cognitive ability, sense of well-being, and quality of life [11].

Understanding the type of dementia as much as it is possible while the patient is alive may be helpful for determining the patients ability and tolerance for learning and relearning simple processes such as ADLs. Also, the literature review suggests that some dementia types cause a rapid decline in patients and others show improvement in function of individuals living with dementia depending on type and treatment response. Frequent assessment of cognitive and physical functions would be essential to develop a plan to help persons living with dementia maintain or improve their cognitive and physical functioning.

 Nursing assistants and persons living with dementia

Nursing Assistants (NAs) are non-licensed nursing staff, who provides direct care and ADLs for those patients needing assistance [2]. Some NAs work long-term in the job classification and some Certified Nursing Assistants (CNAs) are in transition while they acquired the knowledge and certification to become licensed practical nurses or registered nurses and beyond. NAs may work in hospitals, medical facilities, mental health settings, correctional institutions, skilled nursing care, long-term care facilities, home health care, and adult day care [2]. Also, NAs may be of any age, gender, race or cultural ethnicity.

 NAs are required to complete nursing assistant training and then take a standardized competency exam before they are allowed to work as a CNAs in the settings described above [2]. CNAs and NAs have many responsibilities within their job description, and these responsibilities may include collecting patient vital signs, medication administration, specimens, bathing, toileting, dressing, assistance with personal grooming, assisting with setting up and meals, changing linens, assisting with mobility and ambulation as needed [2]. CNAs and NAs are the staff that residents see and interact with the most and often become the residents emotional support. 

Boscart, dAvernas, Brown, and Raasok stated that new graduates of nursing assistant programs are not attracted to nursing homes [12]. Much of the reluctance of working in nursing homes comes from a lack of confidence of working with such a diverse population and the broad range of diseases that must be addressed in the nursing environment that may or may not have been briefly addressed during training [12]. Van der Cingel, Brandsma, van Dam, van Dorst, Verkaart, and van der Velde discussed that person-centered care includes knowledge of specific characteristics of the person in their care and then using the information to deliver more personalized care [13]. For example, some Alzheimers types actually improve when the cause and treatment are known [14]. According to van der Cingel et al. understanding the wishes and preferences of patients helps to establish a caring relationship between the patient and the caregiver [13]. Understanding the wishes and preferences of the patient reveals how the patient interacts and understands their environment [15]. Person-centered care improves productivity and also inspires compassion and value-driven actions concerning trust, equality, and ethical balance and involvement with the patient [13]. 

Norman and Strømseng Sjetne commented that patient relationship is an important part of the commitment of the nursing assistant and job satisfaction [16]. Kusmaul found that NAs are the first to notice mental status changes and physical changes in their residents but may not have the education to assess the situation accurately [17]. Being placed in such complex situations with residents and with so much responsibility, NAs may rely on intuition because of knowledge gaps and make decisions based on inaccurate information and may also underreport certain conditions that may be treatable [17]. According to Kusmaul, NAs are missing important information concerning cognitive and mental health assessment and reporting of resident needs [17]. 

Fasanya and Dada stated that healthcare workers are at risk of experiencing violence in the workplace and the problem include threatening behavior, verbal assaults, and physical assaults from those in their care [18]. Retention for NAs is typically low because of injuries, stress, poor work environments, and burnout and fatigue [19]. Khatutsky, Wiener, Anderson, and Porell stated that there are 8.3 injuries for every 100 NAs that result in absences, work restrictions, and job transfer [20]. Khututsky et al. found through their study that job preparation and training are serious issues and often CNAs and NAs feel unprepared for their job requirements [20]. The type of injuries that CNAs and NAs experience are varied and range from human bites, resident aggression, and lifting and general handling injuries that occur during ADLs [20].

 Preferred learning styles

According to Dr. Howard Gardner learning styles and multiple intelligences are different concepts and should not be confused (personal communication, August 10, 2017). Multiple Intelligence (MI) is an assessment of definable strengths in the way that one learns and understands the world. Dr. Howard Gardner believes that human intellectual capacities range in different categories and reveals specific performance levels depending on the intelligence in that category (personal communication, August 10, 2017). Intelligence in one intellectual capacity does not necessarily predict strength in another domain of intelligence, and that personal cognitive profiles are different among populations and even among twins [20].The difference between MI and preferred learning styles is that a person with a preferred learning style may enjoy something, but be unable to develop a high intellectual capacity in that area (personal communication, August 10, 2017). For example, a person may love music, but be unable to understand the science and composition of music or be able to perform effectively with any high cognitive capacity (personal communication, August 10, 2017). 

The categories of MI are intrapersonal, interpersonal, logical-mathematical, naturalistic, spatial, bodily-kinesthetic, linguistic, and musical [21]. Dr. Howard Gardner states that there are no official MI tests for self-assessment because it is difficult to assess personal strengths and weaknesses without bias and personal insight. Testing using multiple triangulation is essential to differentiate between what a person likes to do, appeals to the person, and true MI capacities [21]. Intellectual capacities are both formed by nature and nurture and education and learning, and according to Dr. Howard Gardner educators should incorporate MI to assist the learning process using multiple ways and methods to deliver a curriculum [21]. 

Recognized throughout academia is the theory that students are different in how they would like learning material presented. According to learningstyles.com [22], students may have a mix of learning styles that they prefer and that preferred learning styles may also depend on the situation. Preferred learning styles can be further developed and may frame how an event becomes internalized, recalled and expressed [22]. Successful use of learning styles may be the result of different learning utilizing different parts of the brain [22].

 Rogowsky, Calhoun, and Tallal stated that there are several approaches to preferred learning styles and assessment using inventory metrics and some inventories focus on perception and ordering while others focus on experiential learning and accommodating [23]. Urick suggested that preferences for learning vary among different age groups and learning may vary depending on how information becomes processed [24]. Urick commented that some of the differences in preferences for learning might evolve from societal events and certain groups may have a “collective conscious” where members have similar preferences in learning styles because they have had similar life course influences [24]. According to Urick, age-based training that suits the preferences of the learning may yield better participation [24].

 Weggelaar-Jansen, van Wijngaarden, and Slaghuis, also commented that the preferred learning styles change over time [25]. Weggelar-Jansen et al. suggested that for optimal learning there are four things to consider (1) relearning and growth concerning abilities, (2) active integration of new ideas and associations, (3) adapting to the situation, and (4) preferred learning styles [25]. For example, examining health care workers, preferred learning styles are better revealed through real-life experiences and social experiences [25]. Interestingly, the authors commented that if the learners know their learning styles, they might be more engaged in designing the learning process.

 Bourgeois et al., shared that although Alzheimers disease and other dementia types are forms of progressive cognitive decline, learning or relearning ADLs may improve quality of life and an enhanced sense of well-being [26]. Bourgeois et al. stated that modeling the action desired of a patient with dementia reduced errors during learning and relearning [26]. Explicit memory declines in a patient experiencing dementia and patients with the diagnosis rely on implicit learning for those functions that are more automatic and without intention [26]. However, with cues and modeling, explicit memory produces fewer errors. The errorless learning model that Bourgeois et al. discussed seeks to emphasize modeling with spaced retrieval, which increases the number of correct responses; however, the memory of certain tasks may decay after a month without prompts, cues, and modeling [26]. 

Hitch, Wright, and Pepin commented that several studies had found evidence that one of the major influential factors of good health is socialization and engaging in an occupation [27]. For older individuals, the occupation could mean volunteering, hobbies, and engaging in meaningful activity [27]. Occupational therapy focuses on key aspects of ADLs and reducing depression in the elderly by encouraging meaningful activity to bring about a heightened sense of health and wellbeing [27]. According to Hitch et al. leisure activity includes the pursuit of interests and self-care; however, older individuals with depression are less likely to pursue leisure activities and interest [27]. Therefore, when patients with memory loss are encouraged to participate in ADLs and leisure interests with cues and prompt in a person-centered manner, better health and well-being are recorded [27].

Complementary Alternative Medicine (CAMs) or Complementary Integrative Medicine (CIM) are approaches to disease prevention and management that focus on non-mainstream health practices that are used alone or integrated into traditional western medicine. According to the National Center for Complementary and Integrative Health (NCCIH) [28], complementary integrative medicine brings together aspects of CAMs and CIM in a systematic way to produce optimal health. Some examples of CAMS and CIM that are relevant to dementia care would be relaxation techniques, movement therapies, music and art therapy, dance therapy, and prayer and meditation. Many organizations are promoting clinical trials to create an evidence-based approach to CAMs and CIM, but informal reports and studies have confirmed that an integrative approach to healthcare can improve mood, reduce pain, and create a better cognitive function, and a greater sense of well-being [28].

Activity professionals have used intellectual, occupational, physical, emotional nutritional, environmental, spiritual, and social therapies with various forms of art, music, meditation, relaxation, movement therapy, pet, and dance therapies since the inception of the Omnibus Reconciliation Act of (OBRA-87) [29]. When patients interact with their preferred activity and methods for socialization and interacting with others, they display less boredom and participate at higher cognitive and physical levels versus being placed in a generic program without respect to being person-centered [30].

 Krupa et al. also suggested that activities can be designed to increase self-care, self-esteem, and self-actualization, and reduce unwanted behaviors such as resident-to-resident abuse and staff-to-resident abuse and wandering behavior and exit seeking [30]. Activity programs are mandated by CMS to maintain and empower resident abilities under the supervision of a qualified activity professional [31]. However, activity programs usually do not include ADLs and the scheduling of programs become conducted during specific time frames of the week and weekends. Knowing the preferred learning styles of patients with dementia can provide NAs with the same success during ADLs because residents usually are drawn to those activities that are still enjoyable and are interesting thus mirroring their preferred learning styles.

 The preferred learning styles are similar to the multiple intelligences defined by Dr. Howard Gardner in a category only (personal communication, August 10, 2017). According to Dr. Howard Gardner, in preferred learning styles the level of intelligence or mastery are not measured; however, observations of resident experiences and responses throughout the day through selection and choice reveal outward signs of contentment and engagement (personal communication, August 10, 2017). The preferred learning styles discussed in the current study are interpersonal, intrapersonal, linguistic, logical-mathematical, musical, kinesthetic, visual or spatial, naturalistic, spiritual or existential, and concrete.

Miao, Yixue, Liqin, and Yi-Lung commented that interpersonal skills such as communication and being able to socialize with peers led to greater cooperation and collaboration [32]. Hill, Tomkinson, Hiley, and Dobson suggested that of the preferred learning styles such as intrapersonal (solitary) and interpersonal (social) the interpersonal or social preferred learning style was preferred by business students who normally work collaboratively [33]. However, the engineering students who tested preferred the logical and intrapersonal or solitary form of learning [33]. According to the Memletic Styles Questionnaire, a preference for the interpersonal learning styles indicates that a person may like to learn in groups [34]. According to the Official Authoritative site for MI, the interpersonal learning style is a social learning style that reveals an ability to interact with others and intuitively respond to others mood, motivation, and temperament [21].

 The intrapersonal or solitary learning style means that the person prefers working or pursuing solitary leisure interests and introspection and reflection. MI Oasis states that persons who referred the intrapersonal learning style were self-intelligent or better at identifying their feelings, goals and personal strengths and weaknesses [21]. Persons who prefer the intrapersonal learning style prefer one-to-one interaction. For example, solitary learning style students were more likely to prefer individual projects than when working in social learning groups [33]. According to Jensen, Rekve, Ulstein, and Skovdahl some patients with a history of preferring to eat alone who develop severe Alzheimers have difficulty with the overstimulation of meal times [35]. However, patients who prefer the intrapersonal learning style may prefer to eat alone and may respond calmer and finish their meals when in settings consisting of fewer stimuli.

 The linguistic preferred learning style involves an interest in speech, words, writing, and the meaning of words [22]. A preference for linguistic learning might also include the order of words, rhythm, sound, or sing-song verses [21]. Miller of California State University Sacramento described the preferred linguistic learner as one who hears words before music or special arrangement. Also, a person with a preferred linguistic style may enjoy making lists, reading, and having social experiences and an environment filled with both oral and written language [36].

 The preferred learning style of logical-mathematical favors the logical relationships among actions or representations or symbols [21]. Miller stated that these learners prefer to think of their world in units that they can place meaning, evaluate, problem-solve, and use mathematical terms to communicate ideas, predictions, and organize their environments [36]. According to Learning Styles [22], those who prefer the logical-mathematical learning styles make lists, agendas, itineraries, favor predictable goal setting, identify flaws in logical during interactions or conversations. Miller stated that the person who prefers the logical-mathematical learning style might enjoy facts, figures, collecting, classifying and organizing activities [36].

 The preferred learning style of music can be seen in a lifelong involvement and love of music and moving rhythmically. A person who prefers music as a learning style uses music to relax or energize ones self to action [36]. MI Oasis listed rhythm, pitch, meter, tone as sensitivities of one who has a preferred learning style of music [21]. For the person with music as a preferred learning style, music may evoke emotions, movement, and sometimes the desire to sing or play musical instruments [22]. The learner who prefers music may also like doing art and dance to music, hum, tap, drum, and write lyrics and music [36].

The kinesthetic preferred learning style involves movement, self-expression using movement, expression of ideas through movement, gaining meaning from movement, and is observant of movement in others [36]. According to Memletics, persons who prefer the kinesthetic learning style use their hands to touch to gain understanding and also to express understanding [34]. According to Learning Styles [22], kinesthetic learners gain satisfaction from manual manipulation, getting the hands dirty, and putting together models and jigsaw puzzles. Also, kinesthetic learners will use movement to problem-solve and to make sense of their environment [21].

The visual or spatial preferred learning style uses pictures, colors, lines, shapes, and landscapes and cityscapes to relax or show emotion [36]. According to MI Oasis, spatial learners can intellectualize and influence complex spatial arrays and picture or visualize difference and movement in the imagination [21]. According to Memletics, learners who prefer using pictures and images may also enjoy the visual arts, painting, and sculpture [34]. Learning Style [22] adds that the visual learning preferences provide learners with a good sense of direction and orientation to their place and surroundings.

The naturalistic preference for learning enjoys and has the unique ability to distinguish and find meaning between natural formations [21]. Also, the urge to classify and organize the environment is said to be a naturalistic tendency for learners who learn from their environments whether they are in urban or rural settings [21]. According to Gardner, naturalistic learners are similar to kinesthetic learners in that they prefer hands-on learning that involves being outside and in nature [21].

The preferred learning style involving spiritual or existential beliefs that help support a persons religious beliefs or questioning and analysis of human existence or a sense of a higher power. According to Clarken, Gardner did not include existential beliefs as a learning style, because he did not find a neurological connection to spiritual or existential learning intelligence [37]. Clarken commented on the difficulty of locating the biological location of a spiritual phenomenon or cosmic inquiry as being a risky venture; however, many have accepted the spiritual, existential learning preference [37]. Also, many psychologists do feel that some individuals center their world around living spiritually, morally and by being seekers of lifes larger questions [37]. Quadagno stated that older individuals manage life transitions by centering their world around religious or existential beliefs because it helps to give meaning to these transitions [38].

The preferred learning style of the concrete or sequential learner involves individuals who prefer order, structured steps, and predictability and looking at the parts rather than the “big picture,” and these individuals tolerate very little ambiguity [39]. The concrete learning style is also a learning preference that is not neurologically based but found within personality models such as the big five personality theory and the trait conscientiousness [40]. Also, the person who experiences memory decline or cognitive decline relies on structure and concrete thinking to make sense of their world [41].

Another system for determining the preferred learning styles is the VARK assessment which is an acronym for visual, aural, read/write, and kinesthetic learning preferences [42]. The VARK is a condensed inventory of learning styles that are useful for student and teaching environments because the modality easily utilizes the resources found in an educational setting [42]. According to Amir, Farzane, Hamidreza, Hossein, and Ali presenting educational information based on the preferred learning styles of patients improved understanding and compliance with treatment protocols and recommendations [43]. Students were placed in groups and depending on their preferred learning style were asked to read aloud, discuss and explain concepts, and audio record and conduct group reviews of the information. In their study of learning groups with diabetes information based on learning styles, significantly improved outcomes were noted for lower fasting blood sugar results and HbA1c levels [43].

Maslows hierarchy of needs for employees

Maslows hierarchy of needs theory was chosen as the theoretical framework for the current study so that the employment position of the nursing assistant would reveal a better understanding of unmet needs regarding basic needs, safety and security, belonging and love, and self-actualization. According to Goodwin, Maslow felt that it was more productive to examine unmet needs as an opportunity to help individuals find self-actualization rather than seeing unmet needs as a barrier [44]. Maslows hierarchy of needs depicted in a pyramid formation lists basic needs such as the basic needs of life, which for the individual also means making a living wage with benefits [45]. Employees should also feel physically safe and free from workplace violence and feel secure in their job status [45]. For employees to feel love and belonging, they also need to be a part of the mission and purpose of the organization with shared goals and recognition [45]. Also, Maslow hierarchy of needs states that individuals seek self-actualization, which is the step that achieved when all other needs become met [40]. Achieving self-actualization is then a step-wise progression toward meeting the needs of the individual to eventually self-actualize which are the basic needs of life, safety and security, love and belonging, and self-esteem and self-actualization [44].

Ivtzan, Gardner, Bernard, Sekhon, and Hart commented that people who are self-actualized have a better sense of well-being and positive interpersonal relationships [46]. It is essential to remember that self-actualization is a very individual life course process where people work toward their highest level of self-fulfillment [40].

Regarding developmental psychology, self-actualization is a process and prioritization of needs as adults can seek higher levels of self-actualization because they have had more time to resolve the lower levels of needs during their normal life course [46]. Older adults in the Ivtzan et al. study were more likely to be self-actualized because they lived in the present, were confident problem solvers problems, and relied on experience and life course knowledge to solve problems [46]. Understanding that nursing assistants may be more involved with resolving lower levels of unmet needs and struggle with building self-esteem and self-efficacy may help with the development and acceptance of new workplace tools and methods to make the workplace safer and more enjoyable.

Maslows hierarchy of needs was used in the study to help categorize NAs unmet needs as found in the current study. Being able to identify and categorizing NAs needs would help identify problem areas in job satisfaction and productivity to help build therapy programs for patients with dementia that are relevant to the caregiver and ordered according to unmet needs for both employee and the patient. Job satisfaction and productivity for CNAs or NAs would be subjective and different for each employee. One of the weaknesses of Maslows hierarchy of needs theory is the difficulty of measuring self-actualization objectively and standardizing interventions across populations [40].

Self-actualization is personal and unique for every individual; however, the lower-order needs on Maslows hierarchy of needs are more basic or considered fundamental and biologically based, which makes these needs easier to resolve and help to create standardized programs to meet those needs. Psychological and safety needs can be great motivators for change especially when the change resolves lower-order unmet needs [40]. CNAs and NAs process of reporting is different across cultures because of the various relationships that develop with the patient and is especially true if the nursing assistant is fearful of job security or patient aggression, hostility and resistance [47].

Many of the unwanted behaviors of the persons living with dementia are a response to pain and discomfort and being unable to express pain symptoms accurately so that staff can intervene with treatment [48]. Hooten suggested that in the case of patient behaviors and chronic pain and mental health disorders it is essential to see a linkage in the comorbidity because of similar neural expressions involved with anxiety, depression and other high-risk behaviors associated with poor pain management [49]. Vaingankar et al. stated that the interdisciplinary team must take into consideration the mental health issues that occur with job stress of nursing assistants and informal caregivers because they are at risk for mental and physical decline [47]. The possibility of mental health issues is especially true for CNAs and NAs with formal relationships with the patient living with dementia and who are difficult to care for because of the behaviors associated with dementia [47].

Also, when chronic pain and dementia issues are comorbid, the fear of pain escalating behaviors or confusion may create hypervigilance for CNAs and NAs and their patients living with dementia. Comorbidity and the fear of pain create antisocial behaviors in the patient and in CNAs and NAs response which add to the burden of meeting lower-order needs for both the patient and the nursing assistant [49]. Hooten suggested an interdisciplinary approach to dementia and pain management which be advantageous and would include pharmacological intervention, emotional support, and other therapies [49]. Vaingankar et al. suggested that caregivers should be screened for mental health issues and stress-related factors commonly associated with caregiving so that support is available on an individual basis [47]. Caregiver attitudes and beliefs about caregiving and dementia that are faulty or outdated create additional stress which may lead to an increased perception of caregiver burden and decrease effective coping strategies [47].

Information throughout the literature review confirms that caregivers have knowledge gaps but are receptive to new information and knowledge. CNAs may benefit from educational intervention regarding caring for persons living with dementia and feel higher job satisfaction. Maslows hierarchy of needs provides the theoretical foundation to explain caregivers unmet needs and how caregivers may not achieve self-actualization in their role as a caregiver when there are knowledge gaps and conflicting information and cultural values regarding caring for patients living with dementia.

Biopsychosocial model of care

The Biopsychosocial Model of Care (BMC) is a way to holistically understand the needs of patients during illness and rehabilitation by addressing several dimensions of wellness during the treatment process [50]. George Engel developed the model to encourage a mind-body-spirit connection to healing and to acknowledge that humans heal better in socially supported environments [50]. According to Gatchel, Howard, and Kishino, it is difficult to manage attitudes about dementia increases fatalistic beliefs, especially helplessness and hopelessness about the disease process [51]. Kent, Rivers, and Wrenn also found that certain positive life-skills may help redirect inappropriate behavior and reduce the psychological burdens of chronic pain [52].

While pain associated with dementia originates from various progressive levels of comorbidity, cultural factors determine the response and source for coping with pain and the symptoms of dementia in an attempt to promote a sense of functioning in ones environment [53]. Sociocultural factors that influence how dementia becomes managed are cultural background, prejudice, and family and community support [53]. Cross-culturally patients experience morbidity differently; however, similar physiological processes for dementia are experienced across cultures [53]. The difference is in how dementia becomes personally tolerated and the sociocultural context that forms CNAs and NAs attitudes and beliefs about dementia [53].

The biological expression of dementia symptoms may be varied and complex and comorbidity may also be present which complicates the clinical understanding of dementia and pain [53]. Another complicating factor is the patients age because early-onset dementia may have a slower rate of decline and patients may understand or be more aware of the decline, which may result in depression and withdrawal [54]. For example, older patients with dementia and comorbidity occurring with pressure ulcers may mask an older patients needs concerning depression, pain, wound and skin care [53].

The biopsychosocial model of care considers the sociocultural context of morbidity as well as the psychological and biological [53]. For example, from a psychological perspective of morbidity, many factors can add to the intensity of the experience of the disease such as lack of sleep, stress, catastrophizing pain and individual attitudes and beliefs about pain [53]. Depression is also common when experiencing dementia and pain, and research has found that other emotions that may make the perception of confusion and pain worse are anger and anxiety [53]. In the Kim et al. study, the intensity of the emotional event or crisis in conjunction with the physical process of pressure ulcers intensified the pain experience. However, using a multidimensional approach that also addresses the psychological and sociocultural context of pain greatly reduces the intensity of the pain experience [53].

Ryan and Carr commented that treating the whole person during an illness can provide a wider therapeutic range of treatment that supports both traditional complementary and alternative treatment protocols [55]. Andreasen, Lund, Aadahl, and Sørensen, stated that the biopsychosocial model also helps to ease the transition between care settings and rehabilitation periods because more professionals are involved with helping the elderly feel supported in their daily decision-making [56]. Also, the biopsychosocial model of care would ease the transition back to home care if needed [30].

Research Methodology

 The research method for the current study was a nonrandom qualitative descriptive single-case study research design and involved ten participants who were both certified and non- certified nursing assistants (N = 10) of varying experience and education working in long-term care. The research questions were designed to gather information about the preferred learning styles of residents with dementia and to determine if knowing the preferred learning styles information would improve unit productivity in areas of dementia patient care. The study examined the following three questions.

RQ1.Is there a signification relationship between knowing the preferred learning styles of patients with dementia and dementia unit productivity?

RQ2. How do nursing assistants describe their attitudes and beliefs about using an inventory that reveals the preferred learning styles of patients living with dementia?

RQ3. To what extent do patients with dementia participate and accept care that is designed based on the patients individual preferred learning styles?

The instruments used to determine the preferred learning styles of persons living with dementia were the learning styles inventory. The learning styles inventory is a scoring method for determining the preferred learning styles of residents living in long-term care with cognitive decline. Based on the literature review, identified were the learning styles and behaviors common to cognitively declined residents in institutional settings. A pilot test further evaluated the practicability of the learning styles inventory in long-term care settings, and the interview questions were field tested by various medical professionals.

The participants of the study were briefed about the study, risks, and volunteer participation and asked to sign a consent form, fill out a demographic study, and were then given a copy of support agencies to assist with any risk associated with caregiver compassion fatigue or burnout. Offered was a brief training unit concerning the preferred learning styles and the learning styles inventory then the participants were asked to evaluate one resident using the preferred learning styles inventory. The scoring of the learning styles inventory was next, and the participants of the study were asked to conduct one ADL based on the top combination of preferred learning styles revealed through assessment. The participants were then asked to complete the structured steps rubric to measure the level of engagement of the resident during the ADL designed around the residents preferred learning styles. The participants were then interviewed using nine questions based on the perceived accuracy of the learning styles inventory. The interview questions were designed to evaluate the attitudes and beliefs about ADLs based on perceived learning styles, the ease of implementation of the preferred learning styles inventory, and the use and transfer of ADLs designed with the residents preferred learning styles across shifts and PRN staff. Also, evaluated through the interviewing process was unit productivity using the preferred learning styles and the potential for maintaining or building upon resident and staff relationships when ADLs are conducted using the preferred learning styles of the patients in their care. For privacy, the participants interview responses and identity were coded for privacy. The data analyzed for themes and patterns using the NVivo12 qualitative software helped to determine if data saturation occurred [57]. 

Results and Discussion

 The purpose of the study was to gather data and to present the data for the research topic of the investigation of preferred learning styles of persons living with dementia and to see if knowing the information could increase unit productivity for nursing assistants when performing ADLs for their residents. The research method used was a nonrandom qualitative single-case study and involved ten participants (N = 10) who were nursing assistants working at Knowles Assisted Living facility in Nashville, Tennessee. The data analysis revealed that the learning styles inventory was consistent in framing then preferred learning styles of patients with dementia and the results also identified the attitudes and beliefs of caregivers concerning the implementation of the learning styles inventory when conducting ADLs with long-term care residents. The themes that emerged from the NVivo12 software queries and resulting nodes and most commonly discussed by the nursing assistants in the current study helped to establish the belief that data saturation occurred:

·          The participants felt that the learning style inventory accurately assessed the resident and that the inventory produced stable results.

·          Residents were cooperative, and the preferred learning styles implemented during the teaching of ADLs would also help with resident understanding during the residents decline.

·          Implementing the learning styles inventory was simple and intuitive and would continue to increase positive resident-staff relationships.

·          PRN staffs were knowledgeable staff members with high retention rates; and therefore, also were knowledgeable of facility protocols and resident preferences.

·          Staff felt that if there were more time in the day staff would use the time to spend quality time with the residents and complete training modules, paperwork, and other duties on the floor.

·          The staff had high regard for relationship-delivered care.

The themes emerged quickly and without hesitation, and the participants of the study revealed a common knowledge-based concerning training and facility protocols. Often, participants would pause during the interview and cite a policy to support their responses. For example, facility protocols for managing agitation and inappropriate behaviors were similar as was giving the resident choices and honoring resident decision-making. Interestingly, the rapport and positive regard for other staff were prevalent as well as staff dedication and loyalty toward the residents, the facility, and its mission and values. 

The staff was open and accepted of trying a new process; however, the staff was a little guarded because of privacy laws and resident confidentiality. The staff used generic terms to describe their resident responses and avoided using the residents name or location of the living area within the facility. The recorded interviews were somewhat brief because of the need for the staff to return to the floor. Noted were informal discussions during the introduction and the training sessions. All introductions and training sessions were conducted individually except for the third shift that was able to assemble as a group of three participants while leaving the door open and with random floor checks during the training.

 Theme 1: The learning style accurately assessed the residents

All ten participants of the study choose the resident that they wanted to assess with the learning styles inventory. The name of the resident was held private by the participant, and only gender references used on occasion during the interview. Once the researcher explained the learning styles inventory scoring, all ten participants completed the learning styles inventory in private and without assistance. Upon scoring and identifying the top strongest learning styles, the participants commented that the learning styles described their resident accurately.

Most of the participants added additional information to confirm their feelings for the results of the survey. For example, participants would often remark that they could see the connection to the learning styles and resident choices throughout the day and particularly when the resident was not feeling well or needed to calm down after becoming agitated.

P10 commented that I would use the preferred learning styles to calm my resident during one-to-one, and P9 stated that during teaching or coaching moments the preferred learning styles would make the process more accepting by the resident. P4 felt that since her resident was intrapersonal in their approach to their preferred learning styles, moving to a quieter area and offering one-to-one interaction would be helpful during times of agitation.

The participants did suggest that new residents should not be assessed immediately after admission because of the adjustment process. Participants of the study stated that after the adjustment period staff would have more knowledge about the resident and time to observe the resident in their environment concerning their preferences, choices, and ways of interacting with others. Most of the staff felt that a two-week period would be sufficient for staff to complete a learning style inventory on a new resident. Interestingly, P8 cautioned that during a significant change, infection or medication change the resident may not be themselves and may deviate from their normal responses and ways of interacting. 

According to QSR International results, the participants of the study commented on how accurate, consistent, and stable the learning styles inventory was in determining their residents preferred learning style 161 times during the interviews [57]. The participants stated that they were surprised that the preferred learning styles of their residents closely mirrored how they interacted with their residents and supported the knowledge that they had gained about their residents through social contact. It is essential for nursing assistants to maintain an accurate assessment of their residents mood and well-being and be consistent and maintain a stable and social presence in the lives of the residents that are in their care [41]. Kim et al. commented that the sociocultural aspect of care could ease confusion and reduce pain because support and social interaction helps to calm anger and anxiety [53].

Theme 2: Activities of daily living and cooperation

The participants of the study related the preferred learning styles to how they learn and interact with their environment or their children and grandchildren prefer to learn. After the learning styles inventory scored for their resident, they were asked to conduct one ADL using the preferred learning styles of their resident. The ADLs and nursing assistant functions selected from the participant populations consisted of a shower, weighing the resident, toileting the resident, medication administration, transfer to bed, orientation, and glucose testing

During training, the participants stated that have been using the current approach to ADLs because of the relationship and knowledge that they have with the resident. Therefore, designing an ADL or nursing assistant function and then measuring the results was fairly easy for the participants. P2 felt that conducting ADLs using the learning style would build more cooperation. In the past, P2 would give the resident a coke to gain cooperation.

P2 also stated that sometimes this resident gets agitated because of the things that he cannot do because of his stroke. Using the learning styles approach, I can use this information to help motivate him to try different activities and games. P9 commented, “I have a lot of experience, and I feel that the learning styles would be a good fit with the facility protocols for agitation.” Additionally, P9 added, “I am involved with teaching and interviewing the resident to encourage the best choices, and I would use the relationship that I have built with the resident and the learning styles to encourage acceptance of suggested behaviors to stabilize glucose readings.”

P3 felt that using the preferred learning styles during ADLs would help to build consistency and trust and because offering the preferred learning styles during ADL design improves understanding and skill, P2 stated that it would also help to build self-esteem. P7 offered a point of caution that while some residents calm easily with the learning styles in the event of a crisis, it would be important to follow facility protocols for dangerous scenarios.

ADLs are a major component of a nursing assistants job, and the caregivers in the study were comfortable with incorporating the preferred learning styles into the design of the ADL. For example, if they knew that the resident in their care was intrapersonal, visual, and linguistic, the ADL would involve a one-to-one interaction, provide choices regarding the items in view of the resident during care, and a dialogue that encourage the resident to express their thoughts and views on the subject at hand or even a topic of community interest. According to QSR International [57], the topic of ADLs, learning, and knowledge about the resident occurred 221 times where the participants emphasized how important it was to build a relationship with the resident through learning and knowledge of the resident.

Theme 3: Learning style inventory implementation 

The researcher provided the participants of the study with the learning styles inventory to discover the preferred learning styles of the resident that they chose to evaluate. The participants completed the inventory in private and then the researcher scored the instrument. Some of the participants had started the scoring process themselves and understood that the higher scores meant that those categories of learning styles were the preferred learning styles for the resident. The learning styles inventory was based on common behaviors relating to the various learning styles; however, the inventory was also based on behaviors and responses commonly found in long-term care settings.

The participants were invited to select an ADL of their choice to compare and contrast the design of the ADL when the preferred learning styles were also incorporated into the process. The participants were encouraged to combine what they know about the residents preferences with the requirements of the ADL so that all standards and protocols are met. The participants of the study stated that it was easy to combine these concepts because they felt that they were already doing the ADL with the learning preferences, they did not have the official terms of the learning process. 

P3 stated that the learning styles would be easy to implement, but it would still be important not to rush the resident or force the resident to complete their ADLs. P7 felt that the learning styles inventory would be easy to teach and also make teaching ADLs to new staff easier.

P10 stated that the learning styles inventory would benefit the resident because the residents like when you honor their likes and dislikes and understand their personality. P6 commented that the learning styles would help to build upon existing relationships with the resident and it would be important to apply this concept across the facility to ensure fairness and impartiality.

Most of the participants cited two concerns with the learning styles inventory. One concern was about new residents and the adjustment period that they go through upon being admitted to the facility, nursing assistants of the current study recommended that the learning styles inventory should be given after a two-week adjustment period to properly reflect how they normally interact and learn from their environment. Also, during a medical event or facility crisis, facility protocols should be followed first. If the event allows for the preferred learning styles used during such an event, then the staff would feel comfortable with managing the crisis while relating to the resident using the preferred learning styles. Some staff stated that the preferred learning styles approach might even calm a resident during an emergency. 

The participants of the study had high regard for the residents comfort and what would make the residents quality of life better. The participants who already are committed to providing the best care possible using a relationship-based person-centered approach were very open and curious about the learning styles inventory. Most of all of the nursing assistants stated that they were providing care based on the residents preferences, but they did not know the science and psychology behind the learning styles and the everyday choices that residents make. 

The participants stated that the survey was easy to complete and the nursing assistants only needed brief training on how to score the inventory. The inventory was designed so that a series of questions could be answered based on behaviors and choices that are common for the learning style being assessed and common for residents with cognitive deficits in long-term care settings. Constructed in brief progress note language, the nursing assistants were familiar with the terms in the survey, and no questions were posed. NVivo12 found 30 references to learning styles with sub nodes that the inventory was easy to share, that the inventory provided increased knowledge about the resident, that the learning styles inventory was intuitive and personal centered. Nursing assistants are required to su

Keywords

Job satisfaction, Nursing Assistants, Productivity, Dementia.

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