Gentle Persuasive Approaches to
better understand patients
As a lead hand in the security department at the Juravinski Hospital and Cancer Centre in Hamilton Ontario, Jason regularly assists patients with dementia, an age-related disease that affects cognitive ability. Often, individuals with dementia become so confused or frightened that they appear unwilling to cooperate with those around them, posing a risk to the well-being of themselves or others. In these cases, Jason’s job is to decompress the situation, a task that often requires a great deal of patience and care.
Jason recently completed training to become a certified coach in Gentle Persuasive Approaches (GPA), an educational curriculum that helps front line and ancillary hospital staff members better understand how to care for patients with dementia. Through GPA training, Jason learned that sometimes the best approach is to simply stop and listen.
“Patients with dementia or delirium often see a security guard as a person with authority, and they feel safe speaking with us,” says Jason. “That’s why I make sure to give them the time to talk and fully listen to what they have to say. Just lending an open ear can be very reassuring to them.”
Health care workers trained in GPA learn how to use a person-centred, compassionate, and gentle approach when responding to patients who are demonstrating challenging behaviours associated with dementia and/or delirium. The evidence-based curriculum was developed, implemented and evaluated in long term care settings in Central South Ontario in 2004 by a group of clinicians, educators and researchers with funding from the Regional Geriatric Program Central. Since then, it has spread to over 700 long term and complex continuing care facilities across Ontario and Canada. To date, over 63,000 staff members have been trained in Gentle Persuasive Approaches, and 1000 of them have completed training to become certified GPA coaches.
Until 2009, GPA had been accepted practice in long-term and complex care environments, but had not yet been evaluated for its effectiveness in acute care settings. In 2009, a pilot trial of GPA on the Juravinski Hospital’s hip fracture unit, supported by orthopedic manager Heather Pepper and clinical nurse specialist Karen Robinson, demonstrated a reduction in Code Whites (violent situations) and restraint use, as well as patient-related staff occurrences (patient-staff interaction where potential or actual negative outcome for the staff member occurs).
In May 2010, with funding from Hamilton Health Sciences’ Centre for Healthcare Optimization Research and Delivery (CHORD), the program was widely implemented at the Juravinski Hospital (JH) and has since expanded to the Hamilton General Hospital (HGH). The CHORD funding has also supported a research study that examines the effectiveness of GPA in acute care, using the JH as a test site. The study examines data pre- and post-GPA implementation, and has shown a reduction in the number of Code Whites, Code Yellows (missing patients), and the use of patient restraints at the JH. Study results also support that education in GPA provides staff members in the acute care context with the knowledge and confidence to respond effectively to older adults who exhibit challenging behavior.
“GPA has been very effective in supporting staff to use other techniques and strategies versus restraints,” says Leslie Gillies, chief of nursing practice and project lead for GPA at Hamilton Health Sciences (HHS), which includes the Juravinski and Hamilton General hospitals. “It’s made a big impact as far as ensuring a least-restraint environment at HHS.”
Staff members who participate in the one-day GPA education session learn a variety of techniques for responding to patients with dementia and/or delirium who are displaying what is referred to as ‘responsive behaviour’. Anne Pizzacalla, a clinical nurse specialist and certified GPA coach at HHS, says the training encourages staff members to first change the way they think about this type of behaviour, which then influences the way they respond.
“Using the word ‘aggression’ tends to be judgmental,” says Anne. “Aggression implies purpose or intent. Dementia and delirium are diseases of the brain. GPA helps staff to understand that this behaviour isn’t being done on purpose.”
Leslie says that when patients are behaving in an aggressive way, they are likely responding to an unmet need. Gentle Persuasive Approaches teaches staff members to perceive the world from the patient’s point of view.
“They may be feeling fear or hunger or pain, and are not able to express themselves,” she says. “The behaviour is resulting from that, not because they are trying to be aggressive. With GPA, staff members are encouraged to stop and ask: ‘What’s causing this situation? How can we address this unmet need?’”
“GPA training really made me understand the everyday world of a patient who has dementia or delirium,” says Jason. “I have a new sense of empathy when communicating with these individuals.”
As in Jason’s case, GPA can be useful to any hospital employee who has some contact with patients with dementia or delirium.
“We’ve had a great uptake with security, housekeeping, engineering, among other areas,” says Anne. “The education is relevant across many departments and disciplines. All departments are learning together.”
“It is common for non-clinical staff to have contact with patients,” says Jason. “It’s beneficial for staff outside the direct line of patient care to receive GPA training. The training will not only help staff identify patients with dementia or delirium, it also provides confidence when responding to these encounters.”
Maureen Montemuro, a clinical nurse specialist at St. Peter’s Hospital in Hamilton and one of the original developers of GPA, feels one key benefit of the program is that staff members can participate one day, return to work the next and immediately apply what they learned.
Lori Schindel Martin, associate director – Scholarly, Research & Creative Activities at the Daphne Cockwell School of Nursing, Ryerson University, was also an original developer and evaluator of the GPA curriculum. She continues to play a key role as a member of the GPA CHORD Project team at HHS.
“The team approach to the implementation and evaluation of GPA in an acute care setting has resulted in a highly successful research project,” says Lori. “The project was purposefully designed to enhance the transfer of knowledge to the point-of-care. It’s very exciting to be a part of this project.”
For several years, GPA training has been provided to staff at St. Peter’s Hospital as part of their new employee orientation. Beginning in April 2012, as a result of its success in enhancing patient care at HHS, GPA training will be offered through the Clinical Practice and Education department as a continuing education opportunity for all hospital staff, and as a standard component of hospital orientation for new staff members across all sites.