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.
Full-Text
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.
