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specifically implementation of dementia education, awareness of antipsychotic side-effects and risks, and attention to underlying factors such as pain, constipation and sleep. Another method used was family/alternate decision-maker involvement. Care providers would have discussions with family or decision-makers about risks and reasons for antipsychotic medications, with the opportunity to provide (or refuse) consent. Finally, there is a focus on collecting and sharing resources among the sites, specifically on the Continuing Care Desktop and AHS Seniors Health Strategic Clinical Network external website. The project was not without concerns, though. A 2005 survey 8 of Canadian nurses found 30 per cent of those working in hospitals, and 50 per cent working in long-term care reported they had been physically assaulted by a patient/ resident in the previous year, so increased aggression while off antipsychotic medication was a risk factor. There was also a concern that implementing this project would result in the need for increased staff members or current staff hours; attending to confused, frightened, dependent people is time-consuming. The results The evaluation showed that the 11 early adopter sites are quieter and calmer. Residents are less confused, and communicate their needs instead of screaming. They’re more active and less dependent. They’ve re-engaged socially with families and other residents and participate in activities. It took time up front to figure out more person-centred strategies, but there was no need for increased staffing. Each success empowered front-line providers to look for the reasons behind the behaviours of even the most challenging residents. Here are some examples: • A resident was prescribed antipsychotics to help manage hallucinations associated with delirium caused by a urinary tract infection. After the hallucinations resolved, the antipsychotic wasn’t discontinued. He experienced approximately 45 aggressive episodes per month until the team tapered and discontinued the medication. He’s had no further incidents of aggression. • A resident ‘screamed’ every afternoon around 2 p.m., causing others to be unsettled and call out or scream. Instead of medication, staff assisted her to bed for a nap. Now she’s more settled. • One extremely agitated resident was given a drug holiday. When her 14 medications were removed, the underlying problem became clear: hemorrhoids. She’s now on three medications, knows the other residents by name and helps them to their activities. Antipsychotics are not always the best treatment for dementia. When used inappropriately, they’re chemical restraints. They’re to be used sparingly while better solutions are explored. Not surprisingly, cognitive impairment often improves when we take away a medication that causes confusion, sedation and agitation. In fact, atypical antipsychotics worsen cognitive function at a magnitude consistent with one year’s deterioration compared to placebo. 9 Where do we go from here? The 11 early adopter units are spreading their successes within their sites and organizations, provincially and nationally. The AUA project team is extending support to the remaining 164 long-term care centres in Alberta. Interest is stirring in some acute care hospitals and supportive living facilities. Beyond Alberta, the world is watching. Global attention is focused on the growing prevalence of dementia and the needs of older adults. Alberta LTC nurses are poised to inform dementia care practices nationally and internationally. This is a proud and historical time for gerontological nurses everywhere, and a time to recognize this nursing specialty for what it is: a tremendously rewarding calling and career choice. RN Endnotes 1. Atypical Antipsychotic Drugs and Dementia – Advisories, Warnings and Recalls for Health Professionals, 2005 2. Updated Safety Information for Risperdal (Risperidone) in Elderly Dementia Patients, Announced in Canada by Janssen-Ortho Inco. – For the Public. 2002 http://www.healthycanadians.gc.ca/ recall-alert-rappel-avis/hc-sc/2002/ 14164a-eng.php April 26, 2014. 3. Important Drug Safety Information: Zyprexa (olanzapine) and Cerebrovascular Adverse Eventws in Placebo-Controlled Elderly Dementia Trials 2004. http://www.healthycanadians.gc.ca/ recall-alert-rappel-avis/hc-sc/2004/ 14300a-eng.php April 26, 2014 4. quetiapine: www.nlm.nih.gov/med lineplus/druginfo/meds/a698019.html olanzapine: www.nlm.nih.gov/med lineplus/druginfo/meds/a601213.html risperidone: www.nlm.nih.gov/med lineplus/druginfo/meds/a694015.html 5 ALP ÜÇOK and WOLFGANG GAEBEL, Side effects of atypical antipsychotics: a brief overview World Psychiatry. Feb 2008; 7(1): 58–62 6 Blair DT, Dauner A. Extrapyramidal symptoms of antipsychotic and other drugs. Nurse Pract 1992 Nov;17(11):56, 62-4. 67 7 Atypical Antipsychotic Drugs and Dementia – Advisories, Warnings and Recalls for Health Professionals, 2005 http://www.healthycanadians.gc.ca/ recall-alert-rappel-avis/hc-sc/ 2005/14307a-eng.php April 26, 2014 8 Findings from the 2005 National Survey of the Work and Health of Nurses, Statistics Canada P. 61 https://secure.cihi.ca/free_products/ NHSRep06_ENG.pdf April 26, 2014. 9 Vigen CL1, Mack WJ, Keefe RS, Sano M, Sultzer DL, Stroup TS, Dagerman KS, Hsiao JK, Lebowitz BD, Lyketsos CG, Tariot PN, Zheng L, Schneider LS. Cognitive effects of atypical antipsychotic medications in patients with Alzheimer’s disease: outcomes from CATIE-AD. Am J Psychiatry. 2011 Aug;168(8):831-9 14 Alberta RN Summer 2014 Volume 70 No 2 www.nurses.ab.ca
Assignment of Client Care Guidelines enhanced to focus on leadership of RN role By Pam Mangold, CARNA Policy AND Practice Consultant IN May 2014, Provincial Council approved the CARNA document Assignment of Client Care: Guidelines for Registered Nurses, which replaces Guidelines for Assignment of Client Care, last updated in 2008. The request for feedback on this document was sent to 1,200 randomly selected CARNA members in December 2013. The request for feedback was also included in the <strong>ABRN</strong> enewsletter, the monthly regional enewsletter Take Note and the CARNA website. What we heard from you: • 84 per cent of respondents indicated that the guidelines are useful to their practice setting • 73 per cent stated that all of the key steps around assignment of client care were addressed in the document • 87 per cent responded that nothing should be removed from the document Respondents identified the need for a stronger focus on leadership, teaching and the supervisory role of RNs on the team. You asked for more information about the responsibility and accountability in collaborative practice for the individual health-care provider and for the team. Respondents also identified: • difficulties applying the guidelines • constraints in the practice setting (such as staff shortages or cutbacks) • concern for workloads that include simultaneous client assignments The top revisions Overall, the principles outlined in this document were well-supported as best practices through the literature review, environmental scan and the feedback received. Based on the comments by respondents regarding the need to strengthen the focus on the leadership role of the RN, a section on leadership was added. It includes two subsections: “Role and Responsibilities of the Registered Nurse Assigning Care” and the “Charge Nurse Role.” The intent of adding this section is to clearly articulate the leadership role RNs have in care assignment as a member of the interprofessional team. This section also highlights the communication and organizational skills of RNs. The guidelines were not changed but were moved to the beginning of the document to make them more visible. They are now clearly identified as guidelines, numbered and enclosed in a text box for quick recognition. The five guidelines to be considered in the process of assigning client care are: 1. assess the client and the client’s needs for care 2. assess the practice environment for supports to ensure the safe performance of care 3. assess the health-care providers to appropriately match the required client care to the health-care provider 4. set expectations for ongoing communication and appropriate supervision 5. evaluate and adjust the assignment to maintain acceptable outcomes of care Where can I find this revised document? Download the document at: abrn.ca/assignment-of-client-care The document references the joint position statement of the Canadian Nurses Association, the Canadian Council for Practical Nurse Regulators and Registered Psychiatric Nurses of Canada. Staff Mix Decision-Making Framework for Quality Nursing Care provides guidance in appropriate assignment to specific RNs, licensed practical nurses and registered psychiatric nurses. Each guideline contains a set of questions for you to consider in the assignment of client care. The guidelines now include additional content about informal support systems, such as family, that are considered when assessing the practice environment. We also updated references and definitions throughout the document. The concept of assignment of care being a dynamic process where health-care providers work together to meet the changing needs of clients was enhanced. The section on overall system supports outlines the need for an evidence-informed approach to staffing and skill mix decisions. This includes the need for clear employer policy outlining the roles and the responsibilities of each health-care provider on the team. Importance was added in establishing strong communication processes within management, the team and the client. The section in the document titled “Steps to Take When Safe Staffing, Assignment and Supervision of Care is in Doubt” was repositioned to immediately follow the guidelines. This section outlines steps for the RN to take when there is a concern about the delivery of safe client care. This revised document reinforces that RNs in the charge nurse role can most effectively manage their responsibilities when they do not have a concurrent client care assignment. Increased effectiveness and positive outcomes are achieved when a charge nurse’s primary or sole responsibility is to manage the coordination of client care in the practice setting. Thank you to everyone that participated in providing feedback for the revised CARNA document. RN Questions/Concerns? Please contact one of the CARNA policy and practice consultant at practice@nurses.ab.ca regarding the revised Assignment of Client Care: Guidelines for Registered Nurses document or other CARNA standards, guidelines or position statements. www.nurses.ab.ca Summer 2014 Volume 70 No 2 Alberta RN 15
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