Mindfulness training to reduce elder abuse in long-term care

Elder Abuse in Long-Term Setting

Interventions on Change

Clinical Retraining

Mindfulness Training

How to educate the staff to bring about change in the facility utilizing Lewin\'s theory is the focus of this clinical retraining intervention. Mindfulness training is recognized by researchers as an effective tool for bringing about positive change in the quality of care provided patients by healthcare workers (Baer, 2003). Mindfulness training helps workers to cope with stress, overcome stressful situations, and be more present in the moment and attentive to the needs of patients rather than thinking about what is next on their list and viewing patients as hurdles to getting through the shift.

This intervention corresponds with Lewin\'s theory that \"unfreezing\" and \"unlearning\" has to be achieved before new approaches to better results can be learned and implemented. To this end, mindfulness training is an effective method of promoting \"unfreezing\" and \"unlearning\" -- it helps the worker to break out of stale routines that serve as obstacles to actual growth and more positive interpersonal interaction. According to Now Unlimited (2015), a Mindfulness-Based Development Service, \"the practice of mindfulness helps people to develop their attention so that they can recognize in the moment their habitual ways of thinking, feeling and behaving and the results which flow from these. By so doing, it allows people to understand why they behave as they do, judge the appropriateness of their behavior and to rethink and change it if necessary.\" By utilizing a service such as Now Unlimited, which provides professional developmental and mindfulness-based solutions to healthcare organizations, this training can be implemented at the workplace in a special training seminar for employees. Zeller and Lamb (2011) have also shown that mindfulness meditation at the workplace can improve care quality and quality of life in long-term care settings: \"Mindfulness training, which cultivates a practice of being present in the moment, recognizing stressful situations when they arise, and responding to stress in an adaptive manner, holds promise as a simple, inexpensive approach to reduce nursing stress and improve quality of care and quality of life for residents in long-term care settings. Formal and informal mindfulness practices can readily be incorporated into nursing educational programs\" (p. 114). Because mindfulness is a simple, inexpressive training exercise, staff members can be trained within one day-long session.

These sessions will be outsourced to a local provider of mindfulness training. The provider will be hired to give training to the staff at LTC on how to utilize mindfulness in their work. The workplace culture at LTC will also undergo a \"mindfulness\" vitalization in which mindfulness is promoted throughout the workspace, helping to orient nurses to the practices that they will learn in training.

The training session will take place over one day when the maximum number of staff members can be available. This will be a mandatory training session and all employees who are not regularly scheduled for work that day will be paid for their time, as they will be scheduled like an ordinary work day, but the time will be spent in training. Obviously, not all employees will be able to attend because some will be needed to administer to patients like any normal day. The most senior and proficient staff members who are already attentive to \"mindfulness\" will be tasked with administering to patients on this day so that more junior staff members and employees who could benefit most from \"mindfulness\" training will be available for the training session. The \"mindfulness\" trainers will leave behind some reading materials for the senior staff members unable to attend that day so that they can at least read up on what they missed and receive some form of education in this regard. The same will apply for any staff members who \"miss\" their training session for whatever reason. Follow-up questions will be relayed to the \"mindfulness\" trainers who will provide staff with any answers to follow-up questions regarding \"mindfulness\" tools and strategies. The tools and strategies that the \"mindfulness\" trainers recommend will be implemented by staff members and management as part of a regular policy following the training session. During regular staff meetings, these procedures will be discussed and staff will be required to show how well they are implementing these strategies by turning in a tally sheet of the times and times of day in which they utilized \"mindfulness\" techniques. This data will be compiled as part of the measurement exercise and will be used in conjunction with the interview of residents and the staff surveys and competency tests.

Cultural Sensitivity Training

The second type of clinical training that the staff of LTC will receive is based on Lewin\'s theory as well -- this is cultural sensitivity training. This intervention will begin with education on why cultural sensitivity is helpful for improving the quality of care that healthcare providers give to elderly patients at LTC.

This education training will take place over the course of one month and will consist of all staff utilizing downloadable materials to educate themselves on cultural sensitivity. The time required for this will be scheduled into their hours per week and every staff member will be allotted on full hour per shift for viewing the materials while at work. Their normal work duties for that hour will be covered by the other staff members for that hour. This education training will be able to be finished within one month, as the number of employees at LTC and the management of time will require that these sessions proceed at this pace. Management will be responsible for deciding at which time of the shift the worker may view the materials. If shifts are busy and do not permit a straight hour\'s worth of time, the viewing may be paused and returned to at a more appropriate time. This is the benefit of using downloadable materials: they are more user-friendly in terms of time scheduling.

The materials utilized will come from website sources that offer free training in cultural sensitivity. These include Atlantic Training.com (http://www.atlantictraining.com/blog/cultural-sensitivity-powerpoints/), Training Resources offered by the Office of Diversity and Inclusion available at the Diversity.va.gov -- the website for the U.S. Department of Veterans Affairs (http://www.diversity.va.gov/training/), Culturewise.net (http://www.culturewise.net/intercultural-training-downloads/), which offers downloadable training solutions for cultural sensitivity programs. These materials will be compiled into an educative training manual that may be completed over a 4-hours long viewing session. To accommodate the needed time for this session, management will need to allow workers enough time over the course of a month to view the entire session. The aim is for all workers to have received education on cultural sensitivity by the month\'s end.

Critical Systems Thinking

In order to comply with Lewin\'s theory, once the \"unfreezing\" of the mind has taken place, it is necessary to apply a new method of thinking. This is where critical systems thinking can be implemented. As Dolansky and Moore (2013) note, \"to teach systems thinking it is important to enhance the learner\'s awareness of the interdependencies in people, processes, and services and to view problems as occurring as part of a chain of events of a larger system, rather than as independent events.\" Dolansky and Moore (2013) observe that the \"clinical environment is an ideal place to teach systems thinking in staff development education.\" The strategy here is for the learner to have his or her problem identification skills broadened \"from a focus on personal effort in a single situation to a focus on sequences of events with possible multiple causes for both individuals and populations\" (Dolansky, Moore, 2013). Learners can practice envisioning this relationship by creating grids that demonstrate the interconnectedness of workers, patients and actions. This helps the nurse to see how the whole is impacted by the parts and vice versa.

Figure 1. Systems Thinking Continuums

The continuums shown in Figure 1 will be used as examples of how to develop systems thinking skills during this portion of the training. Systems Thinking training will be implemented by management following \"mindfulness\" training and cultural sensitivity training. This portion of the education of the staff will take place, therefore, during the 2nd month and management will divided staff into four groups so that all staff members may receive training from management. The four groups will meet successively one day out of the week for four weeks straight -- the first group meeting the first week for training, the second group for the second week, and so on. This will allow management to comfortably apply the lessons regarding systems thinking while the home can be assured of being properly staffed. A competency course will also be given with this systems thinking class and a competency test will be administered for all groups at the conclusion of the course. This test will not weigh as a factor on the merits of the staff or whether or not they will remain employed but rather will serve as a measuring tool for gauging the effectiveness of the learning implementation portion of this intervention.

Management will obtain materials for teaching systems thinking from Saybrook Graduate School and Research Center and the Italian Association for Research on Systems (http://www.arnecollen.com/wp-content/uploads/2012/07/Seven-Activities_AC_GM_99.pdf). The researchers Collen and Minati (2015) have provided seven activities to engage systems thinking for learners that management will employ during the training session. This material is free to download from the website link provided above. An explanation of systems thinking can be obtained from Dolansky and Moore (2013), obtainable from http://www.medscape.com/viewarticle/822706_3. These materials will be sufficient for helping management to training employees in systems thinking in accordance with Lewin\'s theory of following up the \"unfreezing\" of the mind with a new method of approaching one\'s environment. More materials may be downloaded from valid sources online if management would like a larger store of materials for training. This will be up to the sole discretion of the manager placed in charge of administering the lesson.

Cost

The costs of these interventions will be minimal to LTC. The \"mindfulness\" training session is a one-off session that is well within LTC\'s budget for educational/training expenses. Likewise the cultural sensitivity training is free to download from the websites provided in this project. The systems thinking training is also free as it will be conducted by management and provided to employees during normal working hours (a shift that is specifically scheduled like a normal working day but will be used to administer the training). The variety of methods employed for each training is also helpful for allowing learners a diverse approach to learning, which can assist in better improving skills.

Measuring the Intervention

Staff Competence Test

The staff competence test can be obtained from Nursecompetency.com (http://nursecompetency.com/Longtermcarenursingexams.aspx) which offers a variety of assessment tools. The staff competency test can be administered at the end of each training session as well as on a quarterly basis. This data will provide management with a quantitative set of data that can indicate whether or not the training has been successfully imbibed by the workers.

Interview Residents and Resident Assessment

The resident assessment can be obtained from the Health Care Financing Administration which provides as a public document The Long-Term Care Facility Resident Assessment Instrument User\'s Manual which \"may be copied freely\" and disseminated among long-term care providers (Morris, Murphy, Nonemaker, 1995). This assessment can be utilized in conjunction with the interviewing of residents so as to determine whether or not their perception of the quality of care they are receiving has improved. The resident assessment will provide an objective reading of the patient\'s status that can be correlated with the individual perception so as to produce an optimal assessment of the resident\'s quality of care. The interviews and assessment will be conducted one month after the completion of the implementation of the interventions described above. The interviews and assessment will be conducted again four months following the implementation and again at nine months and 12 months. This will allow management to see a progression or regression in the status of individual residents\' quality of care that they are receiving. Any issues can be resolved at these times, with solutions implemented; this will be discussed in the next section.

Staff Interviews/Surveys

A staff survey and staff interviews will also be conducted, which will provide additional data of both qualitative and quantitative data sets. The interviews and surveys will be randomized with a dozen interviews and surveys being conducted following the first month of implementation of interventions. These surveys and interviews will assess the perception of staff members on the effectiveness of the interventions (mindfulness training, cultural sensitivity, and systems thinking). The surveys and interviews will ask questions regarding the awareness of staff members using the three techniques taught for the intervention, the average number of times they use them during the day, any experiences they can describe in which the techniques helped them to improve the quality of care, whether or not they feel the interventions to be improving the overall quality of care of the facility, and other closed-questions that can be assessed using the Likert scale of measurement for quantitative analysis.

Review and Resolve Issues

Organizations can put up resistance to change for any number of reasons. Fatigue, stress, and a lack of adequate leadership can all be factors in why change is resisted (Schyns, Schilling, 2013; Lovas, Holloway, 2009; Anand et al., 2005). To help workers overcome these obstacles, management will utilize the change management-change thyself approach recommended by Boaz and Fox (2014). This approach is helpful for resolving issues related to change resistance. The idea is that in order to embrace changes, the entire workplace community focuses on how as individuals they all play a role in making the organization into the ideal structure. This strategy helps management to exercise good leadership during the change management implementation so that resistance and obstacles can be mitigated.

During the review phase, issues and obstacles that are revealed via survey, interview and assessment will be discussed by management and proper responses formulated so as to address these issues. As it is impossible to identify such issues ahead of time without having data to go on, it is difficult to identify proper strategies for overcoming obstacles. One method of preparation that can employed ahead of time, however, is the knowledge that resistance factors may stem from fatigue, stress or lack of proper leadership and that these factors are not necessarily indicators that the intervention has been unsuccessful but rather that other variables are impacting the outcomes. These variables and factors can be mitigated by supporting the workplace culture with the ideas described herein -- those that promote mindfulness, cultural sensitivity and systems thinking, while managers utilize the Boaz, Fox (2014) suggestion for effecting a change management solution.