State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Florida


Steering Committee's Consensus Document of Core Competencies for Dementia Training of Licensed Practical Nurses (LPNs) in Long-Term Care

As one of the key professionals in LTC, the LPN performs important duties while serving as a mentor/role model for the CNAs and other staff providing direct care to persons with Alzheimer's disease and related disorders, which we designated in this document as dementia. Some less-common dementias may differ in their presentation and clinical course from Alzheimer's disease; we have emphasized as core competencies in dementia those pertaining to recognition and management of persons with advancing Alzheimer's disease.

Under the supervision of the registered nurse, the supervising, teaching, and mentoring roles of the LPN, in concert with their central role in providing direct care to persons with dementia, prompted our initial focus on specifying the competencies for this pivotal position in the care continuum. Acknowledging that core competencies will change as knowledge and skills in dementia care advance, the following listing represents the current consensus of the Steering Committee's workgroup and leadership. Our proposed phases of training for LPN competencies is organized to reflect training that might occur in 1- and 3-hour sessions in compliance with the dementia training mandate of SB1202.

Phase 1 (first hour of training)

Competency 1.1 -- Understanding the characteristics of dementia and the special needs of the person with dementia

Knowledge, skills, attitudes:

  • Defines dementia as decreasing brain function including memory problems, loss of some thinking and communication skills, and changes in personality
  • Contrasts dementia with cognitive changes of normal aging and delirium
  • Describes the early, middle, and late phases of dementia
  • Recognizes and incorporates into the dementia care plan that quality of life is a realistic goal
    • Interprets individual responses, mood, and other feedback as meaningful
    • Seeks to create a homelike and comfortable environment
    • Seeks a wide range of resources, such as community volunteers in daily care, whenever possible
  • Uses individual's preferences and social history in daily practice

Competency 1.2 -- Adapts communication to cognitive/emotional needs of the person with dementia

Knowledge, skills, attitudes:

  • Explains changes in communication skills that occur during progression of dementia
  • Describes the relationship between communication and distress behaviors
  • Demonstrates strategies for effective verbal and nonverbal communication
    • Uses touch to gain person's attention
    • Uses simple sentences
    • Presents one idea at a time
    • Asks one question at a time
    • Avoids negatively worded statements
    • Breaks task down
    • Gives simple choices
  • Identifies nonverbal expressions of physical discomfort and pain
  • Identifies verbal and nonverbal pain and discomfort, reports changes in cognitive function, anticipates individual's needs to prevent pain, fatigue, dehydration, and hunger and assists with plan to address same
  • Demonstrates communication skills/strategies for managing disruptive, aggressive, and other problem behavior
    • Listens and responds to emotional message
    • Uses verbal redirection
    • Uses written and visual cues
    • Allow time to respond
    • Avoids asking "why," arguing, correcting misinformation, confrontation
    • Avoids raising voice
    • Avoids sarcasm with person with dementia
    • Demonstrates desired action
  • Reacts appropriately to negative communication by individual with dementia
  • Avoids responding to negative language by individual with dementia
    • Uses redirection
    • Reinforces own positive self-image using techniques such as positive self-talk
  • Discusses cultural differences in individuals with dementia and how to appropriately adapt communication strategies
  • Includes emotion-focused communication strategies in interactions with individuals
    • Gives recognition
    • Expresses positive regard
    • Uses verbal encouragers
    • Explores incomplete expressions of ideas
  • Adopts an attitude of respect for individuality and dignity of the person with dementia
    • Uses individual's name in communication
    • Approaches individual in a calm, unhurried manner
    • Avoids confrontation and arguments in communication

Phase 2 (hours 2-4 of training)

Competency 2.1 -- Demonstrates a working knowledge of dementia

Knowledge, skills, attitudes:

  • Lists several diseases or conditions that may cause dementia
  • Identifies polypharmacy, depression, and other conditions that may result in symptoms of dementia
  • Describes how the disease progresses, as well as symptoms, behaviors, and challenges associated with each stage.
  • Discusses current research findings, including the research on cause, prevention, cure, and the recommended diagnostic process

Competency 2.2 -- Recognizes, prevents, and manages distress behaviors including agitation, pacing, exit-seeking, combativeness, withdrawal, and repetitive vocalizations

Knowledge, skills, attitudes:

  • Recognizes antecedents and consequences for distress behaviors
  • Monitors, documents, and reports to team the time, place, and circumstances accompanying distress behaviors
  • Looks for patterns that reveal potential causes (correlates vs. triggers) of distress
  • Monitors, documents, and reports to team staff responses to residents' distress behaviors and residents' responses to consequences
  • In collaboration with interdisciplinary team and family, plans prevention or modification strategies and addresses residents' needs
  • Under the direction of a registered nurse, teaches and supervises nursing assistants regarding their responses to dementia-related behaviors
  • Assists in the design and implementation of care plan
    • Cooperates in modification of care plan
    • Teaches and supervises nursing assistants in reporting behaviors
  • Under the direction of a registered nurse, teaches and implements recommended staff stress-relieving strategies such as social support
  • Promotes quality of life and mental health consistent with resident's individual history and preferences through:
    • pet therapy
    • music therapy
    • structured activities
    • family photos and/or tape recordings
    • physical exercise
  • Describes the risks associated with wandering, pacing, and exit seeking
  • Identifies and addresses mental health issues appropriately
  • Identifies and reports symptoms of psychological distress, acute confusion, or depression
  • Describes the effects of pain, illness, limited mobility, and sensory loss on behavior
  • Discusses the use, positive effects as well as side effects, and undesirable effects of medications used in memory loss
  • Discusses the use, positive effects as well as side effects, and undesirable effects of medications used to manage symptoms of dementia
  • Understands the use and misuse of restraints

Competency 2.3 -- Understands special needs of family and friends of persons with dementia

Knowledge, skills, attitudes:

  • Discusses the psychological needs and stress of family members including:
    • Stages of grief, anger, concern, and guilt
    • Cultural differences in expressions of grief, anger, concern, guilt
    • How to respond to family expression of above
  • Identifies and reports family member needs, problems, and concerns to the team
  • Plans with team strategies to address family issues and includes family input
  • Supervises nursing assistants regarding their responses to families' concerns
  • Includes family members in planning care and devising strategies
  • Incorporates resident's philosophy and values in an individualized care plan

Competency 2.4 -- Promotes independence in activities of daily living

Knowledge, skills, attitudes:

  • Incorporates an approach to remaining capabilities and capitalizes on individual's potential for rehabilitation:
    • Breaks tasks down to manageable components
    • Promotes independence in activities of daily living
    • Looks for appropriate process as outcome in chosen activities rather than successful product
    • Encourages direct care staff in a "doing with" rather than "doing for" approach to activities of daily living
    • Allows for personal choices and preferences using past history and other family information

Competency 2.5 -- Promotes an optimal environment that will support resident autonomy and enhance capabilities

Knowledge, skills, attitudes:

  • Maintains safety and security of residents in a supportive environment
  • Monitors and modifies environmental stimuli, such as noise, lighting, reflective surfaces, distractions
  • Provides information as to date, day, season, and weather
  • Ensures residents' access to prostheses and appliances, such as eyeglasses, hearing aids, walkers, canes
  • Encourages socialization through group activities, such as family, friend, and community visits, as well as intergenerational experiences
  • Promotes the use of simple designs/colors to maintain resident orientation
  • Monitors reflective surfaces such as mirrors in hallways or common rooms
  • Initiates appropriate conversation to maintain participation
  • Provides opportunity for productive activity
  • Decreases background noise -- TV, radio
  • Uses written cues as reminders, such as posting signs, labeling photos
  • Promotes constancy and predictability through an established routine, familiar caregivers, and appropriate activities

Competency 2.6 -- Recognizes ethical issues that arise in dementia care and incorporates these into care approaches

Knowledge, skills, attitudes:

  • Articulates an awareness of issues such as privacy, honesty, and autonomy in the daily care of persons with dementia
  • Identifies common ethical conflicts that may arise when caring for residents with dementia
  • Discusses ethical decision-making process using problem-based learning
  • Recognizes varying family and cultural values and their effect on ethical decisions
  • Identifies the resources available for resolving ethical dilemmas

Advanced Competencies (important, but not to be covered in the 1- and 3-hour initial dementia training sessions)

In order to prevent excess disability, incorporates an approach to remaining capabilities and capitalizes on potential for rehabilitation

  • Understands the end-of-life issues facing residents, staff, families, and guardians related to dementing illness
  • Explains the complex and terminal nature of providing care for persons with advanced, progressive dementia
  • Incorporates palliative care principles into planning, supervision, and delivery of care
  • Discusses the concept and implementation of an Advance Directive

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