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Care of the Older Person – Unit 2 5N2706

Care of the Older Person

5N2706

Unit Two - Working with the Older

Person

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Care of the Older Person – Unit 2 5N2706

Following this unit, the learner will gain understanding of:

➢ The needs of older people under the following headings:

o Physical

o Social

o Emotional

o Psychological

o Recreational

o Financial

o Environmental

o Spiritual.

➢ The role of the healthcare assistant in providing care for older people.

➢ The importance of communicating effectively with the older person,

his/her family and the multidisciplinary team.

➢ Promoting the following in caring for the older person:

o Empowerment

o Advocacy

o Independence

o Individualised care

o Dignity

o Respect

o Choice

o Self-esteem.

➢ The role of family/carers as partners in care.

➢ Health promotion issues that can be promoted in care settings for older

people.

➢ The provision of therapeutic interventions that will enhance the social

interactions and quality of life of the older person.

Care of the Older Person – Unit 2 5N2706

Contents

NEEDS OF THE OLDER PERSON .............................................................................. 4

Environment .............................................................................................................................. 4

Health ........................................................................................................................................ 5

Nursing the Older Person .......................................................................................................... 5

Hierarchy of Needs .................................................................................................................... 6

Financial Needs .......................................................................................................................... 9

Spiritual Needs ........................................................................................................................ 10

Environmental Needs .............................................................................................................. 11

Activities of Living .................................................................................................................... 11

ROLE OF HEALTHCARE ASSISTANT ....................................................................... 18

EFFECTIVE COMMUNICATION ............................................................................. 23

Methods of Communication ................................................................................................... 23

Golden Rules for Communication: .......................................................................................... 28

Communicating with a person with hearing loss .................................................................... 30

EMPATHY ........................................................................................................... 32

EMPOWERMENT & AUTONOMY ......................................................................... 35

Promoting Education ............................................................................................................... 38

ADVOCACY ......................................................................................................... 39

DIGNITY, PRIVACY & RESPECT ............................................................................. 41

Dignity...................................................................................................................................... 42

INDIVIDUALISED CARE ........................................................................................ 44

HEALTH PROMOTION & EDUCATION ................................................................... 46

Definition Of Health ............................................................................................ 46

‘A state of complete physical, mental and social well-being and not merely the absences of

disease or infirmary.’ WHO {1946} ........................................................................................ 46

Care of the Older Person – Unit 2 5N2706

Objectives of the WHO ............................................................................................................ 46

The Irish Health System ........................................................................................................... 47

Factors That Determine Health: .......................................................................... 47

Factors That Influence Health: ............................................................................. 47

Ageing in Ireland ...................................................................................................................... 49

THERAPEUTIC INTERVENTIONS............................................................................ 53

Reality Orientation .................................................................................................................. 53

Validation Therapy .................................................................................................................. 54

Reminiscence ........................................................................................................................... 54

Sonas {Sonas APC} ................................................................................................................... 54

Music Therapy ......................................................................................................................... 55

Social activities ........................................................................................................................ 55

Physical Activities .................................................................................................................... 56

Which Exercises are Good to Improve Mobility? .................................................................... 58

Complimentary Therapies ....................................................................................................... 61

Aromatherapy ......................................................................................................................... 62

Reflexology .............................................................................................................................. 63

Massage ................................................................................................................................... 64

Reiki ......................................................................................................................................... 64

Tai Chi ...................................................................................................................................... 65

Developing an Activity Within the Care Setting ................................................... 68

Planning the Activity ................................................................................................................ 68

ROLE OF FAMILY/ CARER ..................................................................................... 70

SAFE CARE & THE OLDER PERSON ....................................................................... 74

Maintaining a Safe and Hygienic Environment in a Client’s Home ......................................... 75

Elder Abuse .............................................................................................................................. 77

Restraints ................................................................................................................................. 80

Care of the Older Person – Unit 2 5N2706

NEEDS OF THE OLDER PERSON

An Bord Altranais (2009) published the booklet ‘Professional guidance for nurses

working with older people’. It outlined the guiding principles and beliefs for nursing

older people.

The nurse who cares for the older person supports the belief that:

Each older person is of worth and value.

The older person possesses a broad range of abilities and needs.

Each older person has unique physical, psychological, social and spiritual

needs.

The older person and his/her family/representative are the unit of care.

The older person and family have the right to make informed decisions

about all aspects of their care and the nurse respects the level of

participation desired by the older person and/or family.

Environment

The nurse who cares for the older person supports the belief that:

A flexible, caring environment is established wherever the older person is

cared for, whether in the acute hospital, private or public continuing care

facility or in the community.

Care of the older person refers to a continuum of care that addresses the

physical, psychological, social, and spiritual needs of the older person.

Care is best provided through collaboration and teamwork.

The older person is protected from all forms of abuse (physical,

psychological, social, sexual, and financial, violation of person’s rights,

neglect).

Care of the Older Person – Unit 2 5N2706

Health

The nurse who cares for the older person supports the belief that:

Health includes physical, psychological, social, cultural, developmental,

environmental and spiritual well-being.

Quality of life involves assisting the older person achieve their optimum

state of health and wellbeing.

Each older person and/or family, if appropriate, define their quality of life.

Health for a number of older people is a relative and dynamic process due

to their multifaceted complex needs, special supports and the continuing

care assistance they require.

Nursing the Older Person

The nurse who cares for the older person supports the belief that:

Fundamental to nursing practice is the relationship which is based on trust,

understanding, compassion and support and serves to empower the older

person to make informed choices. Care is provided in a non-ageist and non-

discriminatory manner that is sensitive to the older person and their family.

The goal of each nurse-patient interaction is to establish the conditions that

promote healthy living; compensate for disease-related losses and

impairments; prevent further disease-related losses; promote comfort and

facilitate the diagnosis, palliation and treatment of disease.

Nursing practice involves advocating for, and with, the older person and/or

family to maintain their quality of life and, at the end of their lives, to

experience a peaceful and dignified death.

Nursing practice is person-centred and is based on best available evidence.

Nursing care respects the privacy, dignity and integrity of the older person

and family.

Care of the Older Person – Unit 2 5N2706

The central role that families/friends play in the life of the older person is

acknowledged and actively supported.

The ethical principles of autonomy, beneficence, non-maleficence, justice,

fairness, truth telling and confidentiality are all integrated into the provision

of nursing care.

There is a need to commit to actively participating in updating and

maintaining knowledge through continuous professional development and

on-going education programmes.

As healthcare assistants, you are part of the nursing team and therefore, the above

principles should be held by all staff working with the older person.

Hierarchy of Needs

Many people can meet their needs with little or no outside help. But people who are

ill, injured, or disabled must rely on the help of the healthcare team to make sure

that their needs are met. The needs of the people you care for will change as their

conditions improve or decline. By helping people to meet their most essential needs

first, you will enable them to meet their higher-level needs.

Maslow set up a hierarchy of five levels of basic needs. Beyond these needs, higher

levels of needs exist. These include needs for understanding, aesthetic appreciation

and purely spiritual needs. In the levels of the five basic needs, the person does not

feel the second need until the demands of the first have been satisfied or the third

until the second has been satisfied, and so on. Maslow's basic needs are as follows:

❖ Physiological Needs: These are biological needs. They consist of needs for

oxygen, food, water, and a relatively constant body temperature. They are

the strongest needs because if a person were deprived of all needs, the

physiological ones would come first in the person's search for satisfaction.

Care of the Older Person – Unit 2 5N2706

❖ Safety Needs: When all physiological needs are satisfied and are no longer

controlling thoughts and behaviours, the need for security can become

active.

Adults have little awareness of their security needs except in times of

emergency or periods of disorganisation in the social structure (such as

widespread rioting). Children often display the signs of insecurity and the

need to be safe.

❖ Needs of Love, Affection and Belongingness: When the needs for safety

and for physiological well-being are satisfied, the next class of needs for

love, affection and belongingness can emerge. Maslow states that people

seek to overcome feelings of loneliness and alienation. This involves both

giving and receiving love, affection and the sense of belonging.

❖ Needs for Esteem: When the first three classes of needs are satisfied, the

needs for esteem can become dominant. These involve needs for both self-

esteem and for the esteem a person gets from others. Humans have a need

for a stable, firmly based, high level of self-respect, and respect from others.

When these needs are satisfied, the person feels self-confident and valuable

as a person in the world. When these needs are frustrated, the person feels

inferior, weak, helpless and worthless.

❖ Needs for Self-Actualisation: When all of the foregoing needs are satisfied,

then and only then is the need for self-actualisation activated. Maslow

describes self-actualisation as a person's need to be and do that which the

person was "born to do". "A musician must make music, an artist must

paint, and a poet must write." These needs make themselves felt in signs of

restlessness.

Care of the Older Person – Unit 2 5N2706

The person feels on edge, tense, lacking something, in short, restless. If a

person is hungry, unsafe, not loved or accepted, or lacking self-esteem, it is

very easy to know what the person is restless about. It is not always clear

what a person wants when there is a need for self-actualisation.

The hierarchic theory is often represented as a pyramid, with the larger, lower levels

representing the lower needs, and the upper point representing the need for self-

actualisation. Maslow believes that the only reason that people would not move well

in direction of self-actualisation is because of hindrances placed in their way by

society. He states that education is one of these hindrances and has recommended

ways education can switch from its usual person-stunting tactics to person-growing

approaches!

Maslow states that educators should respond to the potential an individual has for

growing into a self-actualising person of his/her own kind.

Care of the Older Person – Unit 2 5N2706

Financial Needs

The Health Act 2008 brought changes to medical card entitlement for people aged

70 years and over. Under the new legislation, from 1st January 2009 everyone aged

over 70 who apply for a medical card will be subject to a means test. The automatic

entitlement to a medical card for this age group has ended.

In Ireland, the non-contributory pension for a person aged 66 to 80 years is €237, for

those aged 80 or over its €247. Other benefits available to the older person include.

The Household Benefits Package which is made up of three allowances, electricity or

gas allowance, telephone allowance and free television license. These allowances

provide contributions towards your electricity or natural gas or bottled gas refill bill

and telephone bill and cover the cost of your television license each year.

The allowances are applied directly to your bills, where applicable. The package is

available to people aged over 70 who are resident in the State and to people under

age 70 who are also resident in the State in certain circumstances. Only one person

in a household can qualify for the package at any time. Free travel is available to

people aged 66 or over resident in the State, and to people aged under 66 also

resident in the State who are in receipt of certain disability-type social welfare

payments or carer’s allowance.

It allows you to use public transport, and a large number of private bus and ferry

services, free of charge. The older person gets a free travel pass automatically at age

66 if they are resident in the State.

Care of the Older Person – Unit 2 5N2706

Spiritual Needs

The NHS defines spiritual needs as;

‘That care which recognises and responds to the needs of the human spirit when

faced with trauma, ill health or sadness and can include the need for meaning, for

self -worth, to express oneself, for faith support, perhaps for rites or prayer or

sacrament, or simply for a sensitive listener.

Spiritual care begins with encouraging human contact in compassionate

relationships and moves in whatever direction need requires’ (NHS Education for

Scotland, 2009).

It further outlines the following:

The practice of spiritual care is about meeting people at the point of

deepest need.

It is about not just ‘doing to’ but ‘being with’ them.

It is about our attitudes, behaviours and our personal qualities i.e. how we

are with people.

It is about treating spiritual needs with the same level of attention as

physical needs.

Adopting a caring attitude and disposition.

Recognising and responding appropriately to people’s needs.

Using observations to identify clues that may be indicative of underlying

spiritual need e.g. peoples’ disposition (sad/ withdrawn), personal artefacts

photographs, religious/meditational books and symbols).

Giving time to listen and attend to individual need.

Being aware of when it is appropriate to refer to another source of support

e.g. chaplain, counsellor, another staff member, family or friend.

Care of the Older Person – Unit 2 5N2706

Environmental Needs

Standard 25 of the National Quality Standards for Residential Care Settings, places

emphasis on ensuring the environment for the older person enhances their quality

of life by ensuring:

❖ The environment is homely.

❖ The environment is safe, indoors and outdoors.

❖ The environment is clean and hygienic and follows infection control policies.

❖ The client is free to personalise their private room.

❖ The environment is well lighted and ventilated.

❖ Aids for assistance are provided.

Activities of Living

All clients within healthcare facilities require assistance with their activities of daily

living. Roper, Logan & Tierney {1980} identified 12 activities of living that make up a

person’s daily life, regardless of a person’s age, sex or health status.

Activities of living are influenced by a person’s life-span, level of dependence,

biological factors, psychological factors, socio-cultural factors, environmental factors

and politico-economic factors. It is the responsibility of the carer to help the client

achieve/provide assistance with the activities of living.

❖ Maintaining a safe environment.

It is the responsibility of the staff working in the healthcare setting to ensure the

safety and security of the patients and service users in their care. Staff must always

be aware of the possibility that the person is suffering from loss of memory,

diminished sense of smell, failing eyesight, loss of hearing, failing sense of touch,

confusion and agitation.

Care of the Older Person – Unit 2 5N2706

When assessing the patient under the ADL all the above should be given attention

and any action required must be put into place to ensure the patient's safety.

Likewise, in order to maintain the wellbeing of the patient, the staff must adhere to

the infection control policy.

❖ Communicating.

People communicate their thoughts and feelings in speaking, writing, hearing,

seeing, touching, and gesturing in a range of different personal, social and formal

situations. Assessment of older persons needs should involve:

Assessment of their level of communication

Assessment of their ability to hear, see, speak, read and write and use body

language

Assessment of whether personality, I.Q. or mood affects their ability to

communicate

Asking if there is a problem with language or accent.

❖ Breathing.

Breathing is essential for life itself and all other activities are dependent on us being

able to breathe. Breathing ensures that oxygen is taken into the body and carbon

dioxide is removed. Breathing is an effortless activity and it is only when something

happens to alter this that we become aware of it. Lack of oxygen can cause

irreversible damage to groups of cells, e.g. the brain myocardium. Assessment of the

older person should include:

Observation for breathing difficulties i.e. breathlessness, cough, wheeze.

Does the client smoke?

Questioning if anxiety or fear is affecting breathing.

Observing if the client is coughing up sputum.

Care of the Older Person – Unit 2 5N2706

Observing the amount coughed up and whether it is discoloured or

bloodstained as this could indicate a chest infection such as pneumonia.

❖ Eating and drinking.

Eating and drinking, as with breathing, is essential for survival. Food, water and

essential nutrients are necessary to provide energy, growth, repair of body tissue

and to maintain physiological functioning. Eating and drinking are social activities

and influenced by cultural and economic conditions. Adequate hydration is essential

for the correct functioning of the kidneys and for assisting in the elimination of

waste products. Assessment of an older person should include:

Talking to the client about what they like to eat and drink, when they like to

eat and drink, where they like to eat and drink and how they like to eat and

drink.

Observing the condition of their mouth and teeth, and their ability to chew

and swallow.

Asking the client or family to tell you if there are allergies, or problems with

nausea or indigestion.

If there is vomiting, noting the time, the type, whether it happened before

or after food and if pain was relieved by vomiting.

Observing their ability to buy food and prepare it.

Observing for proper storage and cooking facilities.

Checking there is enough money to buy good food.

❖ Elimination.

Elimination is an activity that individuals undertake several times throughout each

day and is necessary to rid the body of the waste products associated with

metabolism. Urinary elimination gets rid of urine from the body (kidney function).

Care of the Older Person – Unit 2 5N2706

Faecal elimination gets rid of faeces (intestine function). The following are important

in assessing an older person's ability to carry out these functions:

Observe for persistent problems with constipation, diarrhoea or

incontinence.

Assess ability to use the toilet independently.

Observe the number of times urine is passed, colour, odour, amount passed

and whether there was any blood, pus or pain.

Checking if the client washed his/her hands.

Noting if the client is embarrassed or worried about privacy.

Questioning if there is a urinary catheter present and how the client and

family copes.

Questioning if the client has a colostomy and does it cause problems.

❖ Personal Cleansing and Dressing.

This includes the activities of personal hygiene, care of the hair, nails, teeth, mouth,

eyes, ears, skin. This activity is very much influenced by cultural and climatic

conditions.

Most people take pride in their appearance; however, illness can result in a client

being dependent on carers to assist them with hygiene and dressing. With this

activity, assess for:

Routine i.e. when, where and how client washes.

The condition of the skin and clothes will help in assessing the client's ability

to be independent in this activity.

The state of their mental health.

Skin problems - observe for bruises, rashes or pressure sores.

An artificial limb or other prosthesis i.e. breast or wig.

Attitude to cleansing and dressing i.e. is client embarrassed or worried

about privacy or modesty?

Care of the Older Person – Unit 2 5N2706

❖ Controlling Body Temperature.

Human beings are able to maintain their internal body temperature at a constant

level due to a heat regulation system. In normal circumstances we are able to

control our environment, e.g. central heating in winter, wearing light clothes or

thermal clothing in the cold. Severe cold and heat can cause hypothermia or

heatstroke. Normal body temperature is 36-37.5 degrees. This is essential for many

of the body’s biological processes and also for personal comfort. It is paramount to

prevent adverse medical problems to assess for the following:

Flushed appearance

Perspiration

Goose bumps

Shivering

Cold hands or feet

It may be necessary to take the temperature with a thermometer

Also observe - room temperature, clothing, ability to adjust heat

Assess knowledge of the importance of keeping warm

Attitude to putting on heating- this can reflect, financial, status or cultural

traditions.

❖ Mobilising.

Mobilisation is essential with the effects of not being able to move having a major

impact on an individual’s lifestyle and social activities. It can have devastating effects

on physical, psychological, economic and social wellbeing. Assess the following:

Dependence/independence in this activity

Stiffness of limbs which may only be obvious when getting up from a chair

or bed

Care of the Older Person – Unit 2 5N2706

Heart or lung conditions which can cause breathlessness and so difficulty in

walking

Observe for pain, posture, attitude to exercise, ability to exercise

The environment for its effects on mobilising i.e. dangerous roads,

pavements, lack of access for wheelchairs

Accommodation which may cause difficulty i.e. high-rise flats

Lack of facilities i.e. garden, park, sports facilities

Financial status which can be assessed by observing lifestyles.

❖ Working and playing.

For the majority of people, work provides an income which pays their bills and

allows them to pursue leisure activities. Work can best be described as meaningful

regular activity for which a person has responsibility, indicating their status, purpose

and/or sense of achievement.

Talking about this activity will help establish client’s interest

Simple observation will show if client is capable of carrying out task

Observe for physical problems

o Pain

o Mobility

Acuity of the senses

Observe for psychological problems

o Such as

o Shyness

Poor social skills

Deterioration in ability to concentrate

Attitude

Mood.

Care of the Older Person – Unit 2 5N2706

❖ Expressing Sexuality.

Expressing sexuality refers to our femininity or masculinity and is reflected in our

dress, make-up and the roles we play in society and our families.

Assess for preference in type and style of clothing, use of cosmetics,

hairstyle, jewellery.

❖ Sleeping.

Sleep is necessary for the preservation of energy and to allow the body time to

restore itself. Growth of body cells are promoted during sleep, a balance between

activity and rest is required. Sleep deprivation results in discomfort, distress and

illness.

Find out about normal routine i.e. how, when, where, what influences sleep

Assess attitude to sleep

Does the client need sleeping tablets?

Observe for pain and discomfort, noise, room temperature, weight of

bedclothes, fear and anxiety.

❖ Dying.

Dying is the final activity of living and is normally preceded by a process. Many

people are affected by the knowledge that death is inevitable, and this can

overshadow their lives. Likewise, they have to come to terms with the deaths of

family and friends. In this activity observe for:

Physical changes in the client's condition

Psychological effects on the client and family

Environment - this can have an influence on this activity

Cultural rituals that need performing/respecting.

Care of the Older Person – Unit 2 5N2706

ROLE OF HEALTHCARE ASSISTANT

The HCA evolved from recommendations made by the Commission on Nursing and

the Hanley Report, in order to support nurses in the delivery of patient care.

Continued development and training of the HCA is necessary and also clarity of job

description and roles is essential. HCAs are accountable for their actions in the

delivery of patient care, for which they have been trained and must not undertake

any duty for which he/she are not trained in. A RESPONSIBLE PRACTITIONER –

MUST BE: -

Competent

Knowledgeable

Skilful

Able to apply judgement

Able to acknowledge limitations of practice

A good communicator

Able to maintain confidentiality

Able to adhere to health and safety requirements

Competent in first aid management

Effective in documentation and reporting skills

Effective in communication {relays, reports, receives and records

information accurately and clearly}

Willing to continue professional education.

Healthcare assistants (HCA) are valued members of multidisciplinary teams and work

under the supervision and direction of a registered nurse. With the introduction of

The Healthcare Act 2007 and The Health Information and Quality Authority, National

Quality Standards for Residential Care for Older People in Ireland, they are now

implemented across the healthcare setting.

Care of the Older Person – Unit 2 5N2706

There are 32 Standards outlining the care expected for older people in all settings,

e.g. hospital, nursing homes, residential homes. Standard 24 - Training and

Supervision, states that all newly recruited care staff and those in post less than one

year, commence training to FETAC level 5 or equivalent within two years of taking up

employment. Long standing care staff must have their competencies and skills

assessed to determine their need for further training.

HIQA also developed standards for disability services and the content of the above

standard also applies to this setting. Patients/clients may require assistance in some

or all activities of daily living and it is the duty of the nurses to assess, plan,

implement and evaluate the care required by the patient. The primary role of the

healthcare assistant is to assist the nurse in the implementation of the care, as

determined by the registered nurse.

Duties assigned to the healthcare assistant will vary depending on the care setting

and include the following functions. This is not an exhaustive list:

❖ To carry out assigned and delegated tasks involving direct care and all

activities of daily living under the supervision of a registered nurse (e.g. to

assist clients to maintain standards of personal hygiene, laundry, dietary

intake, physical and mental health).

❖ Assisting the registered nurse in the provision of a quality nursing service by

promoting and adopting a philosophy of care within the service area.

❖ Assisting the registered nurse in duties associated with the delivery of care

and management of the ward/healthcare environment and other support

duties as appropriate.

❖ To report any incident or potential incident which may compromise the

health and safety of clients, staff or visitors and take appropriate action.

Care of the Older Person – Unit 2 5N2706

Healthcare assistants should conduct themselves in a manner that conveys respect

for the individual and ensures safe patient care. The personal characteristics that

indicate these principles should include:

Confidentiality

Courtesy

Accountability

Communication

Dignity and privacy

Health and safety.

What other interpersonal skills should a HCA have? Interpersonal skills should

include the following:

Empathy

Consideration

Reliability

Professionalism

A caring attitude.

Dependability

Trustworthiness

Courtesy

Respect for others

Honesty

Enthusiasm

Self-awareness.

There are many different healthcare settings within which the HCA can work, once

the person has achieved the appropriate qualification of a FETAC Level 5 Health Care

Award. The different settings include:

Acute hospitals: care for and treat people during acute illness.

District Hospitals that provide short-term care for non-acute conditions.

Care of the Older Person – Unit 2 5N2706

Private nursing homes that provide long-term care for older people. They

may also provide respite beds.

Residential homes for people with physical disabilities, such as the Cheshire

foundation.

Residential homes for people with learning disabilities, run by both state

and voluntary bodies.

Respite care centres providing respite for people with physical and/or

learning disabilities. Administered by state and voluntary organisations.

Group homes run mainly for people with learning disabilities, mainly run by

voluntary organisations.

Hostels that offer accommodation to people with learning disabilities or

mental health problems.

Sheltered housing units that offer accommodation for older people and for

persons with learning disabilities and mental health problems.

Assisted living units for people with physical disabilities, for example, the

Wheelchair Association.

Day care facilities for older people and for people with intellectual

disabilities. Administered by the HSE or voluntary organisations.

Private homes where people live and are cared for by relatives.

The healthcare assistant will ensure the highest possible level of care is maintained

by supporting/assisting clients, when required, with personal hygiene and all other

aspects of daily living encouraging independence at all times. They provide care

under the supervision of a registered nurse and report any problems encountered to

the nurse. An HCA follows instructions/guidelines from care plans from any member

of the multidisciplinary team.

The HCA will assist clients in all aspects of care needs e.g. physical, emotional and

spiritual; will assist clients with limited mobility or physical difficulties, making best

use of aids provided. They closely monitor clients who may have

challenging/behavioural problems and observe care planning needs and complete

any documentation.

Care of the Older Person – Unit 2 5N2706

The HCA will assist with social activities by interacting with clients, helping them to

continue with hobbies and activities. They also liaise with other members of the

healthcare team, including relatives, family and friends.

Care of the Older Person – Unit 2 5N2706

EFFECTIVE COMMUNICATION

Effective interpersonal skills are fundamental in building relationships with clients

and are an essential requirement for working within the context of health and social

care. Effective communication and interpersonal skills assist the carer in building

relationships with those they care for and work with. Good communication skills are

fundamental to the delivery of high-quality care to patients and their carers.

Effective communication provides the means to develop relationships with patients

and their carers, providing a sense of belonging and security (Duke and Bailey, 2008).

Communication is the sending and receiving of a message and happens in many

ways and at different levels. It is a means of exchanging information and feelings.

Aspects of Communication Include:

Sender - the one who conveys the message to another person.

Message - the thought, idea, or emotion conveyed.

Channel - how the message is sent.

Methods of Communication

Communication skills are divided into two categories, verbal and non-verbal

behaviour, with non-verbal communication considered particularly powerful in

blocking or eliciting a response (Wilkinson and Mula, 2003; McCabe and Timmins,

2006).

The effective use of non-verbal behaviours can, however, signal to patients an

interest in their wellbeing and can help to develop rapport, the foundation of a

trusting relationship (McCabe and Timmins, 2006).

Care of the Older Person – Unit 2 5N2706

Useful non-verbal behaviours include being aware of personal space, facial

expression, eye contact, posture, gestures and using touch effectively (Wilkinson and

Mule, 2003).

Listening is an important non-verbal skill and one that is often neglected or under-

valued (Stanton, 2009). Active listening requires focusing with complete

concentration on the patient /client (Chambers and Ryder, 2009), responding

appropriately with minimal non-verbal prompts, e.g. nodding of the head or minimal

verbal interactions such as: ‘mm’, ‘up’ or ‘yes’.

Listening and observing are two of the most valuable skills a carer can have. These

two skills are used to gather the subjective and objective data for the nursing

assessment. Active listening: is the process of hearing spoken words and noting non-

verbal behaviour. Active listening takes energy and concentration.

Listening Skills:

❖ Observe and listen to everything the person is saying and expressing

❖ Use body language that conveys your attention

❖ Make eye contact

❖ Smile at the person you are in communication with

❖ Be relaxed and open

❖ Do not fidget or look around the room

❖ Stop and listen, do not do another task at the same time

❖ Don’t interrupt (encourage)

❖ Empathise

❖ Be respectful and non-judgmental

❖ Give time to the person

❖ Remember what the person has said

❖ Allow silences to occur.

Care of the Older Person – Unit 2 5N2706

In healthcare it is vital that information is understood as misinterpretations can have

serious consequences. Mehrabian (1960) listed this classis statistic for the

effectiveness of spoken communication:

7% of meaning is in the words

38% of meaning is paralinguistic (the way the words are said)

55% of meaning is in facial expression

Influences on Communication:

❖ Age

❖ Education

❖ Emotions

❖ Culture

❖ Language

❖ Attention

❖ Surroundings

Communication Techniques:

❖ Clarifying/validating

❖ Asking open questions

❖ Using indirect statements

❖ Reflecting

❖ Paraphrasing

❖ Summarising

❖ Focusing

❖ Silence

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Barriers to Communication:

Some barriers include:

❖ Closed questions

❖ False reassurance

❖ Judgmental responses

❖ Defensive reflex

❖ Agreeing/disagreeing or approving/ disapproving

❖ Giving advice

❖ Requesting an explanation

❖ Changing the subject

Barriers to communication from a carer’s perspective:

❖ Looking disinterested

❖ Not making eye contact

❖ Looking around the room

❖ Not responding to what the person is saying

❖ Fidgeting

❖ Leaning back

❖ Whistling or humming

❖ Interrupting

❖ Yawning/stretching

❖ Looking at your watch

❖ Sighing

Other barriers to effective communication could include:

❖ The environment i.e. there is too much noise

❖ Hearing or sight loss

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❖ Confusion

❖ Other people

❖ Lack of interest

❖ Lack of time, and interruptions

❖ Picking up and following cues

Open Questions

These are questions used when you are trying to help a person open up about

themselves, to give you some insight into how they are feeling, or how to explore a

situation in more depth. They do not allow a yes or no response but instead, invite

the person to talk about the topic. Examples of open questions:

Can you tell me how this happened?

What did your parents think about...?

Can you tell me in your own words about...?

Why do you think that was?

Not everyone will open up easily and this might take considerable time.

Closed Questions

A closed question invites a straightforward yes or no answer and are necessary when

gathering factual information. For example, did you go to the toilet today? Would

you like a cup of tea? Closed questions can give a message to the other person that

you are in charge, know what you are doing and where you are going, and that they

can put their confidence in you.

Both open and closed questions have a role to play in effective communications. It is

up to the carer to judge which is the most appropriate and effective, taking into

account the person you are working with.

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A client’s communication is affected by:

Social factors

Religion

Family situation

Level of consciousness

Stage of illness

Visual, hearing and speech ability

Language proficiency

Golden Rules for Communication:

Face the person

Control your tone of voice

Speak clearly, slowly and distinctly

Do not use jargon

Repeat information if necessary

Ask one question at a time

Wait for answers

As a HCA, you must be a successful communicator, both as a sender and as a

receiver of information, with both those you care for and your co-workers. For

example, you will use communication skills to comfort, reassure, and teach your

residents. Because the HCA is the member of the healthcare team who typically

spends the most time with a resident, the HCA is one of the strongest links between

the resident and the other healthcare team members.

Remember the value of silence and a comforting touch. Carter and Goldschmidt

(2010), remind us that there will be many times throughout your career as a HCA

when words will not be enough to communicate your care and concern to a resident

or to a resident's family members.

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Silence and a comforting touch will say more than words can. Touch is perhaps the

most universal of all languages but remember to be sensitive to the person's comfort

level. Many residents appreciate affection and will enjoy a hug or sitting and holding

your hands as you talk. Other people may not be as comfortable with affection.

Carter and Goldschmidt point out that as you form relationships with your residents,

they will talk to you, confide in you, listen to you, and trust you.

In addition, by carefully watching your residents for non-verbal communication cues,

you may be the first member of the healthcare team to notice that Mr. Jones' colour

is not quite right, or that Mrs. Smith is having abdominal pain after eating, even

though she is not complaining verbally.

Collins (2009) informs us that each individual that we support will have their own

style of communication. Some will be very good talkers, others not very good at

talking or maybe not able to talk at all. Some will be able to get their message across

by writing notes or letters, others will use sign language, others will point to what

they want. Some will be good at listening, others will not, some will use body

language to communicate, e.g. smiling to show they are happy or folding their arms

or hands on hips to show they are annoyed.

Therapeutic communication is what all carers should be striving to achieve. Ruesch

(1961) defined therapeutic communication as a purposeful form of conversation. It is

the human contact between client and carer allowing them to achieve health related

goals. As carers, we should always see health related goals as encompassing social,

psychological, and spiritual goals. Indeed, Peattie and Walker (1995) stress that

modern nursing theories emphasise the importance of holistic care and that the

person has psychological and social needs.

They inform us that if the carer hopes to meet these needs, he/she must understand

how they communicate.

Care of the Older Person – Unit 2 5N2706

Carter and Goldschmidt gave us some advice on how to communicate effectively

with a shy person:

❖ Never force the person to talk

❖ Ask open ended questions and wait for answers

❖ A shy person may hide behind sunglasses or a cap pulled down over their

forehead.

Communicating with a person with hearing loss

Minimise background noise. Background noise, such as a television set, other people

talking, or the clank of silverware and dishes in the dining room, can make it difficult

for the person to hear you. If a television set or radio is contributing to background

noise, ask the person if you might temporarily turn it down (or off) so that you can

talk to her.

If the person is in an area where there are several other people or lots of activity,

you may need to move with the person to a quieter location.

❖ Face the person when you are speaking to him. Many people who lose their

hearing gradually develop the ability to partially lip-read what people are

saying to them. You should always face the person as you speak so that the

person has a clear view of your mouth. Make sure that you are not standing

in front of a window, or other bright light.

The glare from the light will prevent the person from seeing your face clearly,

and he will not be able to read your lips. Also, avoid chewing gum or speaking

fast. These actions can also make it difficult for the person to lip-read.

Care of the Older Person – Unit 2 5N2706

❖ Make sure that the person fully understands what you said. Some people,

especially if the hearing loss is recent, hesitate to ask other people to repeat

themselves. They may feel embarrassed by their hearing loss. When you are

the “sender”, you need to make sure that the person has gotten the message

you were trying to send. If you are not sure that a person has understood

what you have said to her, simply ask the person to repeat what you said

back to you.

For example, say, “If you could please repeat back to me what I said, I can

make sure I told you everything I needed to”. When the request is phrased in

this way, the person feels as though she is helping you to do your job by

repeating back the information.

This helps to preserve the person's self-esteem and is a much better

approach than just saying, “Now, what did I say?”.

❖ Let the person know if you cannot understand what he is saying to you.

Many people with hearing impairments have difficulty speaking clearly. If you

cannot understand what the person is saying to you, let the person know

this. The person may be trying to tell you something that is vitally important

to his care or health. Tell the person that you did not understand and look for

another way for him to get his message across. For example, you might offer

him a notepad so that he can write down what he needs to tell you.

Care of the Older Person – Unit 2 5N2706

EMPATHY

Is the ability to put oneself in the client/patient's situation, so one can understand

what the client/patient is experiencing. Some experts say it is unrealistic to try and

achieve this, as no two people react in the same way no matter how similar the

experience. Empathic responses by the carer allow clients/patients to feel:

Understood

Respected

They are being listened to.

To be able to respond empathetically one must be an excellent listener and

understand the meaning behind the words. Tone of voice can communicate the

anger, relief, anxiety of the client. The use of open questions allows the client to give

opinion and views, rather than yes/no responses.

Carers should have the ability to empathise: to empathise is to set aside our own

interpretation of things and to attempt to think and feel the way the other person

does. Empathy is not always easy but using imagination and seeing yourself in

another person’s position can help. Empathy is aided by:

Understanding

Courtesy

Sincerity

Positive body language

Ability to listen attentively

Including patient and family in decisions about his/her care

Being alert for feelings of frustration, apprehension and fear

Keeping confidences

Using tact.

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RESPECT: Every client regardless, of class, religion, social status deserves respect.

Respect can be given by addressing the client by the name they would like to be

called. Respect will also be conveyed by good listening skills and allowing the client

time to express themselves.

Ensuring clients' privacy will also convey respect.

CONFIDENTIALITY: MUST be maintained at all times. Information obtained during

the assessment, which is necessary for planning care, must be treated with the

utmost care. The client's records must be stored safely and discussion of clients' care

must not be conducted in public places.

Possible reasons for lack of empathy:

Care staff may be sympathetic rather than empathetic

Care staff may interpret clients' experience incorrectly

Care staff may distort clients' experience because of one’s own similar

experience

Care staff may make assumptions

Care staff may fail to hear the message behind the words

Care staff may not have good listening skills

IMPROVING EMPATHETIC RESPONSES:

Improve listening skills

Observe non-verbal signals

Improve observational skills

Be aware of your own body language

Use open questioning

Develop a warm and genuine attitude towards clients

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Introducing patterns of communication that avoid exerting power and control over

clients is important, i.e. attitude, taking time to listen and providing information.

Clients often develop ‘passivity’ which leads to dependence. This is often the result

of ‘routine’ dominating care. A lack of knowledge or experience on the part of the

carer can result in this approach to care.

Care of the Older Person – Unit 2 5N2706

EMPOWERMENT & AUTONOMY

In relation to older people, Bond and Corner (2004) have identified the following

seven aspects as relevant to their quality of life:

1) Subjective satisfaction (people’s own perception of their satisfaction with

life)

2) Physical environment (including, for example, housing, transport, facilities)

3) Social environment

4) Socio-economic factors

5) Cultural factors

6) Health status

7) Personality and personal autonomy.

Patient empowerment in the healthcare context means to promote autonomous

self-regulation so that the individual’s potential for health and wellness is

maximised.

Patient empowerment begins with information and education and includes seeking

out information about one’s own illness or condition, and actively participating in

treatment decisions. Empowerment requires an individual to take care of themself

and make choices about their care and lives (Funnell et al, 1991). The carer should

ensure that the client is enabled to participate fully in all decision making about their

treatment and care and give authorisation for any changes.

We, as carers, are encouraging clients to do as much as they can for themselves,

rather than us doing it for them. Assistance should only given where and when

required. An elderly person may lose their self-esteem and sense of worth because

of reduced independence.

Care of the Older Person – Unit 2 5N2706

One of the primary aims of geriatric care is the prevention of dependency and

therefore, the individual must be encouraged to remain self-sufficient and mentally

active. The carer can provide psychological support and promote alertness.

Care plans should allow the person to participate in decision making. They should

always be consulted on matters that directly concern their care. Helping the elderly

person to maintain contact with the outside world e.g. by encouraging visitors, by

ensuring that access to a telephone is provided, as well as newspapers, radio and

T.V. Spend time talking to the client. Many elderly people take a keen interest in

current affairs and enjoy discussing them. Carers should welcome the opportunity to

spend time with older people, as they have so much to contribute and we can all

learn a great deal from them.

Addressing a person courteously and correctly, calling them by the name they

prefer, is of great importance. It is wrong to assume that all elderly appreciate being

called by their first name or by a pet name such as ‘pop’ or ‘gran’. Most elderly

people and their relatives find this offensive. Avoid insulting an individual’s

intelligence by treating them as a child. A carer may find themselves doing just that,

particularly if the client is dependent on the carer for most of their needs. Every

elderly person, regardless of their circumstances, must be treated with dignity and

respect.

Demonstrate an interest in the elderly person's activities e.g. any skills learned in the

O.T. department. It is important to encourage an ambulant individual to walk in the

care centre grounds or take a non-ambulant person outside in a wheelchair and

encourage social interaction with other clients. Providing opportunities whereby an

elderly person can continue to pursue their religious practices is important.

Many care homes have a visiting chaplain/clergyman. All denominations must be

respected. It is important to provide a pleasant environment and encourage the

elderly person to have whatever personal possessions they wish to have with them.

Care of the Older Person – Unit 2 5N2706

Elderly people will feel less isolated and less anxious when they are able to keep

some familiar objects with them in their room. Encourage preservation of self-

respect by acknowledging the client’s right to privacy, their freedom to choose and

by encouraging pride in their physical appearance.

The ‘United Nations Principles for Older Persons’ state specifically that:

‘Older persons should be able to pursue opportunities for the full development of

their potential and that older persons should have access to the educational,

cultural, spiritual and recreational resources of society.’

Although these principles are based on human rights, they are not yet legally binding

(Doron and Apter, 2010). In its ‘International Plan of Action on Ageing’, the United

Nations has, however, strongly recommended their implementation in its member

states (United Nations, 2002a). The plan specifically recommends that member

states should encourage the following:

Empowerment of older persons to fully and effectively participate in the

economic, political and social lives of their societies, including through

voluntary work.

Provision of opportunities for individual development, self-fulfilment and

well-being throughout life as well as in late life through, for example, access

to lifelong learning and participation in the community.

Ensuring the enjoyment of economic, social and cultural rights and civil and

political life of persons.

(United Nations, 2002a)

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Promoting Education

'Ageing with Confidence' is a psycho-educational programme for older people in the

community provided locally by local development organisations, VECs, partnership

companies and others.

The aim of 'Ageing with Confidence' is to enhance the development of older people

by providing education for health, by developing life skills and by promoting positive

mental health and self-confidence.

This can be achieved by:

❖ Increasing participants’ self-confidence by: facilitating people to explore

their own ageing; challenging the myths and stereotyping that lead to

ageism; and providing information on the physical, psychological and social

aspects of growing older.

❖ Providing training for facilitators, some of whom are older people, and the

facilitators are engaged by the local partners to deliver the programmes

using programme materials developed by Age & Opportunity.

❖ Providing ongoing support for facilitators by holding bi-annual support days.

This programme is based on an ethos of empowerment and mutual self-help among

older people (United Nations, 2002a, No. 21, Objective 1, Action d, MIPAA). It also

promotes physical and mental health and, thus, has the potential to contribute to

WHO goals regarding healthy ageing and Irish goals and actions in the area of health

promotion.

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ADVOCACY

For most people, making their own decisions and choices, is a matter of some

considerable importance. Being part of decision-making processes is not only a route

where self-identity is expressed, but it is also an important aspect of personal

freedom. However, a number of barriers can prevent people from actively taking

part in decisions which affect their lives and can affect an individual’s ability to speak

up for themselves.

BARRIERS TO ADVOCACY:

Lack of communication skills

Isolation

Lack of knowledge

Lack of education

No network support.

Advocacy is taking action to help people say what they want, securing their rights,

representing their interests and obtaining services they need (Kings Fund, 2008).

Advocacy is about enabling every person to have a voice of their own and ensuring

that they are not excluded because they do not express their views in ways that

people understand (A voice of their own, BILD, 2006).

Advocates and advocacy schemes work in partnership with the people they support

and take their side. It promotes social inclusion and social justice (About advocacy –

Action for Advocacy).

❖ An advocate is: a person who speaks up for, and defends the rights of him

or herself, or of another person.

❖ A self-advocate is: a person who speaks up for him or herself, and defends

his or her own rights.

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❖ A parent-advocate is: a person who speaks up for, and defends the rights of

his or her child, and is willing to work with a school or other service provider

to make sure that their children get the services they need and deserve.

An “advocate” is any person who speaks up for his or her own rights or for the rights

of others.

Where a client cannot give clear instruction, the advocate must:

Take time to get to know them and build a picture of their preferences and

lifestyle including their cultural background.

Seek appropriate alternative forms of communication which enable the

service user to express views and choices and ensuring the person’s

fundamental human rights are respected and upheld at all times.

Challenge service providers and decision makers in order to promote a

person centred approach act as a ‘witness’ or observer in the settings in

which the service user spends time.

An instructed advocate’s role includes:

Establishing an open, trusting relationship with the service user.

Ascertaining what the service user wants from the relationship.

Identifying goals and desired outcomes from the advocacy process.

Gathering information on behalf of the service user.

Representing the person’s views, wishes and concerns to third parties.

Reviewing progress and redefining goals in light of experience.

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DIGNITY, PRIVACY & RESPECT

Privacy, independence, dignity and positive self-image are of paramount importance.

Patients have the right to be treated with respect, dignity, and as an individual. As a

HCA you must ensure that patients/service users are:

❖ Treated equally.

❖ Given equal access to care resources.

❖ Afforded informed consent and the right to refuse treatment and care.

It is vital that you act as an advocate on behalf of those who cannot speak for

themselves and maintain wherever possible, client independence and choice. As a

HCA you will often be the main contact person for the patient/service user. You must

assist the person to maintain and/or develop a positive self-image and preserve the

individual's self-respect. An HCA should encourage clients to express their fears and

wishes and recognise and accept that the patient/service user has the right to make

their own choices and decisions. It is important to support and encourage personal

independence.

Encourage compliance with treatments.

Encourage the person to become involved in appropriate organisations etc.

Assist the patient to maintain good personal hygiene.

Encourage and assist the person to dress in their chosen style.

Encourage and assist the patient to use makeup perfume, aftershaves etc.

as they did prior to admission and of their choice.

Give positive comments and praise to the patients on their appearance.

Power (2008) stresses the importance of maintaining patient privacy and gives us the

following guidelines to protect privacy.

Care of the Older Person – Unit 2 5N2706

Inform the patient of what you are planning to do and get their agreement. This is

called informed consent. Protect the client from any unnecessary exposure of parts

of their body.

Always knock and ask permission before entering the client's room and secure the

client's privacy before carrying out a procedure and facilitate privacy for visitors.

Other key areas to be aware of include:

❖ Never listen to telephone conversations.

❖ Never carry out a procedure against the client’s wishes but remember to

report a refusal to your supervisor.

❖ Always listen and give the client the opportunity to express their

preferences.

Remember that in order for care to be effective it must be based on trust. By

ensuring and fostering privacy, independence, dignity and positive self-image the

trusting relationship between carer and patient will grow.

Dignity

Dignity is derived from the Latin word dignus {worthy}, it is defined as the state or

quality of being worthy of honour and a sense of self-importance {Collins dictionary,

Accordingly, dignity can be understood as a personal attribute that is recognised by

oneself and/or others and commands respect.

Fundamental Rights

In the Charter of Fundamental Rights of the European Union, the first article states

that;

‘The dignity of the human person must be respected and protected. The

understanding of dignity is that it belongs to all persons, it commands respect, but

it also needs protection as it can be violated.’

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Human dignity should be promoted as evidence suggests that within healthcare,

one’s health can actually improve and that one can cope better with illness when

one is valued and treated with respect. Dignity is sometimes associated with

autonomy and having control over one's destiny. However, research suggests that

dignity is not upheld within care of older persons' settings.

Quality & Fairness: The government's health strategy 'Quality & Fairness – A Health

System for You' published in 2001, included dignity as a key element.

‘The vision adopted for the future health system places a high value on treating

people with dignity and respect.’

WHAT DOES IT MEAN TO TREAT SOMEONE WITH DIGNITY? IT MEANS:

Respecting their rights

Giving them freedom of choice

Listening and taking into consideration what they say

Respecting their wishes and decisions, even if one disagrees

Being sensitive to their needs

Involving them in the decision-making process

Respecting their individuality

Promoting their independence

Giving them privacy

Treating them the same as everyone else {not looking at their

illness/disability}

Treating them as an adult not as a child/incompetent

Treating them as part of the community

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INDIVIDUALISED CARE

Individualised care is considered an important indicator of quality nursing care, it

describes a philosophical approach to care. Due to the fact that it places great

emphasis on the needs, wishes and lifestyle choices of the individual client, it also

involves the client's family in the decision making process. It respects the client's

autonomy and their dignity. The individual care plan will hold all relevant

information on the client, likes/dislikes, level of assistances with ALs, independence /

dependence levels and intervention required. Care is planned and changes recorded

in consultation with the client on a regular basis.

Standard 11 of The National Quality Standards for Residential Care Settings for

older People in Ireland states:

Standard 11: The Resident’s Care Plan

The arrangements to meet each resident’s assessed needs are set out in an

individual care plan, developed and agreed with each resident, or in the case of a

resident with cognitive impairment with his/her representative.

Criteria:

❖ 11.1 The resident’s care plan is commenced within 48 hours of admission,

or earlier if indicated by the general risk assessment, from the

comprehensive assessment drawn up with the resident. (See Standard 10:

Assessment)

❖ 11.2 The care plan reflects the assessment findings and sets out in detail the

action to be taken by staff, to ensure that all aspects of the health, personal

and social care needs of the resident are met. Residents, including those

with dementia/cognitive impairment, are actively encouraged to participate

in this process.

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❖ 11.3 The care plan meets clinical guidelines produced by professional bodies

concerned with the care of older people. It is updated regularly to reflect

daily changing needs and best practice.

❖ 11.4 The resident or his/her representative has access to the care plan and

is kept informed of care changes.

❖ 11.5 The care plan is discussed, agreed and drawn up with the involvement

of the resident and/or his/her representative. If the resident is unable or

unwilling to participate, this is documented.

❖ 11.6 The care plan is formally evaluated by staff in consultation with the

resident and/or his/her representative. It is updated as indicated by the

resident’s changing needs and circumstances and current objectives for

health, personal and social care and no less frequently than at three-

monthly intervals.

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HEALTH PROMOTION & EDUCATION

Health was traditionally viewed as the absence of disease. ,It is a complex

phenomenon. It is influenced by a variety of factors. All individuals have their own

views of what being healthy means.

Definition Of Health

‘A state of complete physical, mental and social well-being and not merely the

absences of disease or infirmary.’ WHO {1946}

Health is Therefore:

A resource for everyday life, not the object of living

A positive concept, emphasising social and personal resources as well as

physical capabilities

A fundamental human right

Something which allows a person to carry out daily life in a productive

manner.

Objectives of the WHO

The WHO advocates that we move beyond the biological cause of health and well-

being and view health in a holistic manner. We must address the physical, social,

spiritual, environmental and mental well-being of the person.

The WHO aims to identify strategies for disease prevention and management and

adopt effective health promotion and education strategies, promoting equability and

fairness.

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The Irish Health System

Is guided by the WHO and a number of documents, policies and strategies published.

It advocates for patient-centred care, access is fair and equal, provides support and

allows clients to make informed decisions. It aims to provide high performance,

better health care for all. These aims are set out in the Quality & Fairness document

2001, Framework for Change and includes:

Strengthening primary care

Reform acute services

Funding

Developing human resources

Organisational reform

Developing health education

Factors That Determine Health:

❖ Age/sex/hereditary = we have no control

❖ Socio-economic == education, employment, housing, food , water,

sanitation, work environment

❖ Social & community == availability of local services, information, family

support

❖ Individual lifestyles == responsibility, skills, knowledge, economic means

Factors That Influence Health:

❖ Existing physical and mental status

❖ Physical fitness

❖ Early detection of problems

❖ Medication

❖ Accidents/falls

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❖ Value placed on health

❖ Motivation

❖ Expectations

❖ Culture

❖ Ethnic origin

❖ Family relationships

❖ Work and home environment.

The National Health Promotion Strategy 2000 – 2005 states: With the onset of

middle age, Irish life expectancy figures begin to slip down the EU rankings and by

the age of 65 years, life expectancy for both men and women is the lowest in the EU.

Generally, though, we are living longer and it is projected that there will be a

noticeable increase in the number of people over the age of 65 years by the year

2021. This is expected to pose a significant challenge to our health and social

services. (Department of Health and Children, 2000c:44).

SLAN 2002 data for respondents aged 65 years and over revealed that 38%

perceived their general health to be fair to poor. In relation to extreme/moderate

problems experienced by older people, pain/discomfort and anxiety/depression

rated highly.

A cause for concern is that 36% of older people surveyed reported taking no exercise

and for those aged 75 years plus this rose to 71%. 21% of the 65 – 75 age group were

current smokers and only 14% in the over 75s smoked.

The challenge for health promotion, is to improve longevity so that we live as long as

our European counterparts. This can be achieved by promoting lifestyle changes,

creating supportive environments and providing appropriate services for older

people.

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Ageing in Ireland

In 2007, The Central Statistics office (CSO) produced a document entitled 'Ageing in

Ireland', which outlines some key findings of people aged 65 and over in Ireland:

❖ In line with the overall increasing population, the number of persons aged

65 years and over increased by 54,000 people between 1996 and 2006.

❖ In 2006, Ireland had the lowest proportion of its population aged 65 and

over among EU countries at 11%, this is compared to an EU 27 average of

16.8%.

❖ There is a projected upward trend in the 65 and over dependency ratios for

both Ireland and the EU from 2006 to 2026. This dependency ratio is

expected to increase from 16.4% to 25.1% for Ireland, and increase from

25.2% to 36.6% for the EU 25.

❖ The age specific death rate for males aged 65 and over has decreased from

around 77 per 1000 in 1980 to 51 in 2005. The corresponding decrease for

females was 60 to 44 per 1000 indicating a significant narrowing between

both rates.

❖ In 2006, 29.5% of persons aged 65 and over indicated they had a disability

compared to 9.3% of all persons. The proportion of persons with a disability

increased with age, particularly for the older age groups. The disability rate

varied from 18.7% for the 65-69 age groups to 58.6% for the 85 and over

age group.

❖ The proportion of women aged 65 and over living alone in Ireland (31.7%)

was the eighth lowest of EU countries, but the rate for men at 20.6% was

the fourth highest.

❖ Ireland had the sixth highest employment rate for people aged 65 and over

among EU countries in 2006. Men aged 65 and over in Ireland had a much

higher rate of employment than the EU 27 average in 2006 (14.4%

compared to 6.6%). The difference for women between Ireland (4.2%) and

the EU 27 (2.8%) was less marked.

Care of the Older Person – Unit 2 5N2706

❖ In 2005, around 20% of persons aged 65 and over were at risk of poverty,

which was substantially lower than the 2004 rate of 27.1%. This increase

was due mainly to an increase in the old age pension in 2005.

(CSO 2007:10)

The challenge for the Irish Health Service is to improve life expectancy among this

group and thus, increase the number of illness and disability free years in later life.

The WHO outlines a strategy for achieving this goal which involves promoting

lifestyle changes, creation of supportive environments and the provision of

appropriate support services for older persons.

Many studies have shown that preventive care in later life can improve longevity and

benefit health and quality of life {Eurolink, 1997; WHO, 1995;}. An Irish study on the

prevention of falls among older people in long-term care, found that with the

introduction of appropriate preventive measures the incidence of falls among the

group was considerably reduced {Journal of Health Gain,1997}.

A WHO study 1995, found that there is considerable potential for the prevention of

cardiovascular disease in older people by adopting a healthy diet, changing lifestyle

habits, engaging in moderate activity and controlling weight. The older person may

have a negative attitude to altering their behaviours believing that they are too old

to change and benefit.

Early recognition of illness is essential in order to prevent the onset of psychological

stress, possible withdrawal from society and it allows the older person’s time to

adjust and adapt coping skills. Health promotion programmes must take into

account the care setting of the older person, the psychological, social and economic

changes associated with ageing in order to be effective.

Care of the Older Person – Unit 2 5N2706

The publication ‘Adding years to life and life to years: A Health Promotion Strategy

for Older People’ {1998}, highlights the health promotion needs of the older person,

acknowledging the impact housing, transport, security, attitudes and income have

on quality of life. While health promotion for all ages is about preventing illness, for

older people it is also about lessening the effects of illness or disability. In addition,

equal and early access to geriatric and other services is essential to ensure early

recognition and treatment and, where appropriate, early rehabilitation.

The Department of Health and Children recently published guidelines on physical

activity for Ireland (Department of Health and Children, 2009) which states:

“At least 30 minutes a day of moderate intensity activity on five days a week, or

150 minutes a week. Focus on aerobic activity, muscle strengthening and balance.”

(Department of Health and Children, 2009, p.15)

The aim is to maintain health and function and to promote independence. A major

review of 36 studies of community-dwelling adults found that participating in

physical activity of a moderate intensity was beneficial to the psychological well-

being of older adults in a number of ways (Netz et al, 2005). Such participation

increased:

❖ Emotional well-being

❖ Self-perceptions, including self-esteem (feeling good about themselves)

❖ Self-efficacy (the belief that people have the capacity to exert control over

their own lives)

❖ Sense of mastery (having the ability or skill to use, understand or control a

given activity).

Care of the Older Person – Unit 2 5N2706

WELL INTO OLDER AGE — AGE & OPPORTUNITY AND THE EVIDENCE

{Dr. Áine Ní Léime & Professor Eamon O’Shea 2010}.

Guidelines for health promotion according to Vernon (2008) include:

Health education classes

Keeping active both physically and mentally

Choice of food if possible

Importance of exercise, appropriate diet and calorie intake

Knowing what is the ideal weight and how to maintain it

Keeping in touch with family and friends

Outings and various activities

Support and development of hobbies, interests and pastimes

Health screening and medical check-ups, for example blood pressure,

routine blood tests, vision and dental check-ups, breast screening

Encouraging independence even if it is in a limited way

Promoting good hygiene practices to prevent infection.

Within the care setting, the HCA can promote clients' health and wellbeing by

promoting:

A healthy diet

Participation in physical and cognitive activities

Good skin care

Oral hygiene, to include regular check ups

Lifestyle, such as smoking cessation

Regular GP check-ups

Keeping warm in winter

Uptake of flu vaccine

Foot care

Education on illness

Eye care, to include optician check-ups.

Care of the Older Person – Unit 2 5N2706

THERAPEUTIC INTERVENTIONS

The concept of therapeutic recreation is supported by Lowry, L. and Ryan, A. (1993),

who state that "Recreational therapy is a concept of meeting the patient's

psychological and social needs through meaningful daily activities".

Many residential settings now have activities co-ordinators. These co-ordinators

provide activities based on the interests and choices of the residents. Activation

promotes a sense of wellbeing and satisfaction. Therapeutic interventions that will

enhance the social interactions and quality of life of the older person include the

following:

Reality Orientation

The main aims of reality orientation are to maintain and improve the patient’s

orientation and awareness of their environment through a variety of prompts and

activities. The physical environment is important in facilitating orientation by using

notices and clear signposting of key locations. Buildings should make finding rooms

and directions easy (Kerr, 1997).

Clearly sign-posted toilets will aid continence. Staff and carers are encouraged to

stress information relating to orientation (e.g. by mentioning the time frequently

and referring to an individual by name). Boards above patient’s beds stating name,

ward, etc. also help to orientate them to their environment.

Reality orientation also takes the form of special sessions whereby small groups of

people meet with staff or carers on a regular basis for a fixed duration. Questions

and comments are raised concerning areas such as weather, day, date, month,

history etc.

Care of the Older Person – Unit 2 5N2706

Validation Therapy

Validation therapy focuses on the importance of an individual’s feelings and their

attempts to express them. Instead of correcting factual errors in conversation, one

seeks to find the true meanings behind verbal and non-verbal communication and

attempts to gain a full understanding of a person (Feil, 1993).

Reminiscence

Reminiscence therapy encourages recollections of details or events in an individual’s

life. It has a positive effect on well-being and personhood. Participants are

encouraged to reminisce and discuss the past in the presence of a group facilitator.

This stimulates memory and encourages social interaction.

One-to one work can also be beneficial. Reminiscence is interactive and informative.

Knowing a little about a person’s past, their hobbies and their interests, enables

carers to understand an individual better and therefore, promote person-centred

care.

Sonas {Sonas APC}

It was 1990 when Sister Mary Threadgold developed the Sonas approach. Now,

twenty three years later, more than 5,500 care assistants, nurses, speech and

language therapists, occupational therapists and many other healthcare workers

have been trained in the use of her programmes. The aim of Sonas is:

To activate the potential for communication that has been retained by the

older person with communication impairment.

To encourage the creation of an environment which facilitates

communication.

To have activation of potential for communication recognised and accepted

as an essential part of care planning for older people.

Care of the Older Person – Unit 2 5N2706

Sonas APC has been used successfully in many nursing homes, day centres and

hospitals for people with dementia. It assists the patient to communicate in secure,

safe and familiar surroundings.

Music Therapy

Music therapy is a creative use of musical improvisation by an individual and

practitioner to create an environment in which healing can take place. A review of

music therapy for dementia, showed that it might be beneficial in treating the

symptoms and improving quality of life for patients and their carers (Alzheimer’s

Society, 2003).

Social activities

We all go out from home, we go to school, work, shopping, to the pub, cinema, to

participate in sporting activities. It is normal for us to go out, likewise it should be

normal for those in residential care to go out. Many residents in residential homes

do not go out on a regular basis, the reasons for this include:

Immobility

Disability

Lack of transport

Staffing issues.

Volunteers and relatives should be encouraged to assist with social outings. Outing

to the local community are extremely important as they provide a continuing link

with their familiar past and local community. After such visits they have things to talk

about and comment on, they return with their spirits lifted. Short visits can include:

❖ Shops

❖ Supermarkets

❖ Open markets

Care of the Older Person – Unit 2 5N2706

❖ Post office

❖ Church

❖ Cafe

❖ Library

❖ Musical/theatre shows

❖ Sports centres.

Physical Activities

‘If we could give every individual the right amount of nourishment and exercise,

not too little and not too much, we would have found the safest way to health."

Hippocrates (460 BC -377BC)

Physical activity is of benefit to people of all ages but is especially important in older

adults. 17.6% of people aged between 65 and 69 live with a disability. This rises to

66.9% for those aged 85 years and older. (CSO, 2002)

‘Physical Activity is the single most useful thing that individuals can do to maintain

their health and function and quality of life.” (World Health Organisation, 1997)

As we get older, various physiological changes occur, irrespective of

disease/pathology, which may impact on mobility. These changes include:

A reduction in muscle mass as a result of a degeneration of muscle fibres.

A reduction in the blood flow to the muscle, both of which ultimately result

in some reduction in power of the affected muscles, without necessarily

affecting function.

Poor sensation in the feet.

Poor vision.

Decreased physical endurance.

Debate centres on whether immobility in older age is an inevitable decline or simply

a preventable disability in the older population.

Care of the Older Person – Unit 2 5N2706

Research (Lyndon-Griffith, 1996, Skelton, 2001) has shown that with regular

exercise, older adults can improve their functional ability (for example, the ability to

move from one position to another with less assistance, to walk further with less

assistance) and can, as a result, prolong independent living.

Social acceptance of physical frailty and provision of care and assistance to

dependent persons has now turned to helping frail elderly adults to maintain or

improve functional independence (Brill et al., 1998).

Benefits of Physical Activities & Exercise:

❖ Improves muscle power.

❖ Increases physical endurance.

❖ Increases cardiovascular health.

❖ Has a positive effect on cognition.

❖ Has a positive effect on mood.

❖ Improves quality of life.

❖ Decreases the amount of physical assistance required for everyday tasks

e.g. transfers, gait, activities of daily living.

❖ Can help to improve confidence in mobility.

Reduced muscle strength and power is a major cause of functional dependence in

the elderly, contributing also to the increase in the prevalence of many age-

associated chronic diseases, such as pain, and osteoarthritis.

Some of the conditions associated with ageing that can be improved with exercise

are: impaired gait and balance, arthritis, type II diabetes, coronary artery disease,

hypertension, osteoporosis, obesity, depression, muscle weakness and decreased

flexibility (Rogers & Evans, 1993, cited Lyndon-Griffith, 1996).

Care of the Older Person – Unit 2 5N2706

Which Exercises are Good to Improve Mobility?

For an older person whose mobility may already be limited to some extent, many

types of exercise seem daunting. Older people residing in nursing homes generally

require exercise that will help to maintain a level of independence in mobility and

activities of daily living.

Strengthening Exercises:

❖ Sit to Stand Exercise: Sit in a chair with armrests. Move your bottom

forwards to the edge of the chair and stand up slowly. Stand as tall as

possible before sitting down slowly. Repeat 5 - 10 times.

❖ Stair Climbing: Climbing onto and off the bottom step of the stairs with

appropriate supervision and assistance can help improve power in the legs

and cardiovascular system.

❖ Arm Exercise: While sitting in a well-supported position on a chair, lift a

walking stick/sweeping brush in both hands as high as possible overhead.

Extreme caution should be taken for those who have suffered from a

previous stroke.

Flexibility Exercises:

❖ Knee Rolling: Sit on a bed with both knees bent up and with feet resting on

the bed. Keep the knees together and gently roll them from one side to the

other without letting the upper body follow through. This exercise is

generally prescribed to help improve trunk and pelvic flexibility and ease of

movement in/out of bed and for turning.

❖ Trunk Rotations: Similarly, trunk turning aims to improve turning ability and

posture by increasing flexibility of the trunk. Sitting in a well-supported

position on a chair, fold the arms and turn as far as possible from the waist

to look over your shoulder. Repeat to the other side.

Care of the Older Person – Unit 2 5N2706

Inactivity is more of a threat to health than the natural ageing process. Physical

inactivity is one of the five leading global risks for mortality, and can increase the risk

of chronic diseases, such as heart disease and cancers (World Health Organization

(WHO), 2009).

Care providers have a duty to motivate residents to do physical activities to

promote better health.

Other Activities That Have Proved Successful Include:

Throwing different sizes of ball or balloons to each other, to a leader or over

a dividing line between two groups.

Indoor or outdoor bowls or skittles.

Throwing horseshoes.

Throwing quoits over a numbered posts on the door or the floor or lawn.

Golf using putters and plastic cups.

Crazy golf, make up a course using homemade obstacles.

Swing tennis.

Badminton.

Swimming is one of the best exercises of all as it provides movements that

improve suppleness, strength and stamina while supporting the body and

avoiding weight bearing on joints. It can give a patient with physical

impairments a boost to self confidence in achieving equal performance with

the able bodied. Many pools have hoists in situ to allow access to the pool

for those with physical disabilities.

Walking, depending on the physical ability of the patient, walking is an

excellent exercise. A gentle walk around the garden can be very pleasant,

the patient will enjoy not just the walk, but the environment and if

accompanied by a carer, a friendly chat.

Care of the Older Person – Unit 2 5N2706

Outdoor Activities:

Can assist in the promotion of physical exercise and include the following pursuits:

Gardening

Walking.

Indoor Activities:

Can assist in emotional, cognitive and social wellbeing, activities could include the

following:

Bingo

Group reading

Karaoke/sing a long

Card games

Board games

Movies ‘old films’.

All activities can provide for social interaction and wellbeing, consider the following

cognitive activities:

Crossword puzzles done alone or with a group can be great fun.

Newspapers read alone or in a group. Local newspapers which contain news

from the different areas are very beneficial as they keep the patients

informed of what is going on in their towns land/area.

Discussions. Pick a topic of interest and encourage participation by the

whole group.

Reading for people.

Card games, many elderly people are capable of playing cards and will enjoy

participating in a game.

Consider a newsletter for the residential home.

Quizzes.

Board games.

Care of the Older Person – Unit 2 5N2706

Complimentary Therapies

Complementary medicine involves the use of modalities together to complement

offerings of conventional medicine, with therapies used in conjunction with, rather

than instead of, conventional medicine. Such therapies are increasingly incorporated

into nursing practice. They are considered helpful in enhancing patients’ overall

wellbeing, symptomatic relief and self-help when used as adjuvant therapies to

conventional medical interventions. A complementary therapy has been more

readily accepted in the area of palliative care, where emphasis on quality of life is

paramount.

Complementary therapies are types of healing that have not been traditionally

accepted by practitioners of conventional western medicine until recently. In eastern

cultures, complementary medicine has always been a significant strand of

treatment.

More recently, the rise in the use of complementary therapies and acceptance of

some treatments by some of the medical profession, has made them more

accessible. Complementary therapies can be used to either exclusively treat an

illness, or are used alongside conventional medicine. People often turn to

complementary therapies because they aren’t happy with conventional medicine or

they feel they want to ‘add’ something to the treatment they are receiving. In line

with the palliative care approach within the NHS, complementary therapies are now

increasingly recommended by healthcare professionals to support other treatments.

This is known as integrated medicine.

Complementary Therapies Can:

❖ Often be used alongside conventional treatments without interference.

❖ Improve quality of life both through mental wellbeing and also treating

conditions such as muscle problems, pain and nausea.

❖ Provide natural relaxants to help with tension and anxiety.

Care of the Older Person – Unit 2 5N2706

The term complementary therapy covers a wide range of health related practices,

which are used alongside conventional treatments. They are not given with the aim

of curing disease, but to support physical, psychological, emotional and spiritual

recovery. These therapies may help in a number of ways:

❖ Ease pain and reduce physical tension and stiffness.

❖ Relieve the side effects of treatments and assist with symptom control.

❖ Provide time to relax, talk and share any worries in a safe environment.

❖ Promote relaxation and reduce the emotional stress, which can accompany

a diagnosis.

Types:

Aromatherapy

Reki

Reflexology

Acupuncture

Homeopathy

Massage.

Aromatherapy

Aromatherapy is, like the others, a very ancient practice. The Chinese, Egyptians,

Greek and Roman Empire all have records of use, in some form, of aromatics. The

Chinese burned incense to create balance and harmony and likewise, the Egyptians

would also use incense made from aromatic herbs and spices and used oils to anoint

their bodies to rejuvenate their skin. Essential oils have been used for therapeutic

purposes for nearly 6,000 years. The ancient Chinese, Indians, Egyptians, Greeks, and

Romans used them in cosmetics, perfumes, and drugs.

Care of the Older Person – Unit 2 5N2706

Essential oils were also commonly used for spiritual, therapeutic, hygienic, and

ritualistic purposes. Aroma was infused into the cultures and was found to have not

only medicinal and spiritual benefits, but also as a form of cosmetic use which grew

to become what we now know as perfume.

Essential oils are concentrated extracts taken from the roots, leaves, seeds, or

blossoms of plants. Each contains its own mix of active ingredients, and this mix

determines what the oil is used for. Some oils are used to promote physical healing -

- for example, to treat swelling or fungal infections. Others are used for their

emotional value -- they may enhance relaxation or make a room smell pleasant.

Researchers are not entirely clear how aromatherapy may work. Some experts

believe our sense of smell may play a role. The "smell" receptors in your nose

communicate with parts of your brain. Other researchers think that some molecules

from essential oils may interact in the blood with hormones or enzymes.

Reflexology

Reflexology has its roots in ancient times, where images in the Physicians Tomb at

Saqqara, Egypt are painted upon the wall and point to foot therapy. In the West,

reflexology was developed by Dr William H. Fitzgerald M.D who created Zone

Therapy. He discovered that when he applied pressure to the zones on the feet and

hands, relief of pain and the cause of the pain resulted.

This was further explored and refined by Dr. Shelby Riley M.D who added horizontal

zones to the hands and feet. From here, Eunice D. Ingham, a professional physical

therapist, recognised through extensive treatment of patients that the reflexes on

the feet were an exact mirror image of the organs in the body and mapped these

into reflex points on the foot.

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Massage

Massage is another ancient practice dating back to 3000 BC China where the first

known recorded writings of the practice are to be found in the Cong-Fu of the Toa-

Tse. India, Egypt, Greece and Rome all practiced this form of therapeutic healing and

there is evidence that athletes as far back as 776 BC used massage before

commencing the games. Massage and touch therapies may prove an effective

mechanism for caring for, and communicating with, extremely ill patients.

An unpublished Irish study in a hospice by Hayes and Waldron (2000) on the effects

of touch therapy on patients’ perceptions of their quality of life, found a significant

reduction in patients’ anxiety levels following interventions. Many patients with

cancer now receive both conventional and allopathic treatments such as

chemotherapy and radiotherapy interventions on a daycare basis. Aromatherapy

massage has also been found to have a role in reducing psychological distress and

improving symptom control in patients with cancer.

Reiki

Unlike other forms of therapy, there is no attempt to control or direct how the

healing is used, be it physical, mental, or spiritual; Reiki may (for instance) help the

client with acceptance, reduce pain, and/or reduce depression, depending on the

client's need. Reiki has no religious affiliation, nor is an enhanced religiosity per se an

intended outcome of Reiki, however Reiki practice is commonly associated with

spiritual growth.

Reiki have been associated with improved quality of life in palliative situations. Some

general trends seen with Reiki include: periods of stabilisation in which there is time

to enjoy the last days of one's life; a peaceful and calm passing if death is imminent;

and relief from pain, anxiety, dyspnoea and oedema. Reiki is a valuable complement

in supporting patients in their end-of-life journey, enhancing the quality of their

remaining days.

Care of the Older Person – Unit 2 5N2706

Tai Chi

Tai Chi, a martial arts form that enhances balance and body awareness through slow,

graceful, and precise body movements, can significantly cut the risk of falls among

older people and may be beneficial in maintaining gains made by people age 70 and

older people who undergo other types of balance and strength training.

Researchers found that older people who regularly performed the traditional

Chinese “mind and body” technique, were less likely to suffer high blood pressure

and were physically stronger. Tai Chi, which has grown in popularity throughout the

world, is typified by slow, deliberate repetitive movements and is based on co-

ordination and relaxation rather than muscular tension. It is believed that focusing

the mind solely on the movements helps to bring about a state of mental calm and

clarity.

With the growing interest in complementary therapies around the world, many

therapies are coming under scientific scrutiny to determine whether they are

clinically effective and, if they are, how they actually work. As there are often many

factors making up a complementary therapy treatment, it is sometimes difficult to

determine which part of the treatment is causing a specific effect.

Benefits of leisure and recreation in maintaining health:

❖ Psychological wellbeing and contentment

❖ Less aggression and hostility

❖ Less depression

❖ Less isolation

❖ Life satisfaction

❖ Mental stimulation

❖ Control

❖ Developing relationships

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❖ Network of support

❖ Humour and laughter

❖ Socialisation

❖ Slows down decline in mental ability

❖ Slows down memory loss

❖ Overall better life satisfaction

Physical benefits:

❖ Improved circulation

❖ Improved respiration

❖ Greater flexibility

❖ Greater strength

❖ Greater endurance

❖ More energy

❖ Lower blood pressure

❖ Lower cholesterol

❖ Improved mobility

❖ Greater physical independence

❖ Greater longevity

❖ Improved general health.

Social/psychological/emotional benefits:

❖ Greater psychological wellbeing

❖ Higher quality of life

❖ Higher morale and life satisfaction

❖ Higher self-esteem, self-concept, self-efficacy

❖ Keener mental abilities

❖ Feelings of achievement and accomplishment

❖ Greater optimism

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❖ Greater levels of social interaction

❖ Laughter

❖ Lower anxiety and hostility

❖ Lower incidence of loneliness and depression

❖ Improved perceived health.

Agar {2009} and Leithner and Leitner (1996)

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Developing an Activity Within the Care Setting

When planning to undertake an activity, remember activities should:

❖ Compensate for lost activities

❖ Promote self-esteem

❖ Maintain skills and not involve new learning

❖ Provide an opportunity for enjoyment, pleasure and ocial contact.

Planning the Activity

Communicate with the residents. Bring your forms to prompt you as to what

information you need to gather. You will need to determine the residents' physical,

mental, and emotional capabilities. Go through the activities form. These are usually

generic with lists of activities, hobbies, crafts, and games.

Find out and check off on the form those activities which the resident gives a

positive response to. You will then have to classify the activities to find out if it's

something they used to do, want to do, or would like to learn to do. Consider all that

has made the person unique. This means knowing the person’s former lifestyle, work

history, hobbies, recreational and social interests, travel and significant life events.

A person with dementia may enjoy an outing even if they do not remember where

they have been. What is important is that the moment is enjoyed, even though the

experience may be soon forgotten. Give the time and space necessary to allow the

person to do as much as possible. Focus on one thing at a time. Break down activities

into simple, manageable steps. Communicate one instruction at a time.

People with dementia often have difficulty with visual perception and co-ordination.

Ensure that surfaces are uncluttered with few distractions and noise.

Care of the Older Person – Unit 2 5N2706

Good lighting, without glare, individual seat preferences and correct work heights

are all important. Using plastic containers might help to avoid breakages.

To ensure maximum success when carrying out activities it is best to consider the

times of day when the person is at their best. For instance, sometimes walking is

best done in the morning or the early afternoon. However, for some people who are

particularly restless later in the day, or who have had a particularly long or

meaningless day, a late afternoon walk may be better.

Care of the Older Person – Unit 2 5N2706

ROLE OF FAMILY/ CARER

The National Institute for Clinical Excellence (NICE, 2004) defines carers as follows:

‘Carers, who may or may not be family members, are lay people in a close

supportive role who share in the illness experience of the patient and who

undertake vital care work and emotional management’.

Family care giving is largely hidden work that is often taken for granted, yet it is

crucially important. Carers should be supported in their role and helped to prepare

for the illness and loss of the patient before the death, in addition to being offered

bereavement support afterwards, where required. They are often unprepared for

the many demands they might face and they experience considerable physical,

psychological, social and financial challenges (Hudson & Payne, 2008). For many,

particularly women, it is an inevitable part of life and a cultural expectation of them.

Caring for a family member may be seen as a ‘natural’ element of family

relationships.

Families are often assumed to be readily available and willing to care for dying family

members, although this is not always the case. In many societies, strong social norms

mean that care-giving within family networks are obligations that people fulfil out of

duty.

All carers need to know how to access health and social care services, both for the

patient and for themselves. They need to receive information that prepares them for

supporting their relative (Payne & Hudson, 2009). This includes information about

giving practical care and support to the patient, and hospital discharge planning.

Carers also need to know how to minimise the burden placed on them, how to

survive the experience.

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The Carers Association was established in 1987 in response to the need for

recognition of family carers and their rights and entitlements.

In the following 22 years some advances have taken place, but the development of

improved rights and service provision for family carers still remains the major

challenge facing The Carers Association today. Progress to date has been too slow

due to a failure to recognise the economic and social significance of family carers'

work in the home. Every week 3.7 million hours are worked by 161,000 family carers.

Families are an invaluable source of information and this information will assist the

healthcare team to ensure quality care is delivered. It is important that family

members are invited to be involved in the care of the patient, with the consent of

the patient, this will help both the patient and the family members to adjust to new

circumstances.

Communication is a vital ingredient for shared care in a true partnership model

between the care staff and relatives. Keeping the lines of communication open

requires an effort from both partners. The quality of life for the person receiving

care should be the common focus for all discussion.

Teamwork is the only way to deliver care to improve the quality of life for the

resident. Care staff cannot provide total care without the input from family

members and family members cannot undertake all the care that a skilled caregiver

can provide.

Appropriate interactions with families:

❖ Always be welcoming

❖ Be polite

❖ Listen to what they have to say

❖ Inform them of the grievance procedure if they wish to make a complaint

❖ Acknowledge their input

Care of the Older Person – Unit 2 5N2706

❖ Encourage their participation in caring for their relative

❖ Work with them in order to provide a high standard of care

❖ Be aware of how they are feeling: angry, anxious, guilty, stressed, going

through bereavement.

The effect on the family when a loved one is admitted to residential setting

include:

Feeling of loss/grief

Anger

Fear

Financial issues

Uselessness

Guilt

Sadness.

They may be struggling to accept the change in the resident’s condition that made

admission to the residential setting necessary in the first place. It may be difficult for

them to accept that their loved one is in declining health or is no longer able to be

independent. Finally, family members do not always get along with each other.

When this is the case, it may be hard on the family to agree on a course of action.

They are under stress, and this can lead to conflict within the family.

The care of the family member should be planned using a partnership approach. This

can only be good for the wellbeing of the patient. The family should be involved in all

stages of planning and encouraged to actively play a role in caring for their family

member. This could be assisting the patient to eat their dinner, organising outings or

home visits for the patient. They should be consulted on all aspects of care and their

opinions and views respected.

Care of the Older Person – Unit 2 5N2706

It is important to remember that should family wishes differ from those of the

patient, the patient’s wishes must be adhered to. As carers our first duty is to the

patients in our care. If a patient requests that the family not be involved in any

aspect of care, then that is their right. Involving family in the care of the patient

assists in building a good and trusting relationship between the family and the caring

organisation.

Care of the Older Person – Unit 2 5N2706

SAFE CARE & THE OLDER PERSON

Providing safe care promotes quality and holistic care for clients, it is also the client's

right to have a safe environment and care practices should reflect best practices

which promote the health and wellbeing of clients.

It is the responsibility of all staff to reduce the risk of accidents to clients in the

workplace. Safety and accident prevention should be part of all the staff's daily

routine. The risk of infection to clients is also great and all staff must adhere to

policies and procedures of the facilities to reduce this risk. Some of the steps that

must be taken to ensure a safe and hygienic environment for clients, whether in

home or in a care facility, are:

❖ Medicines should not be left on client’s lockers.

❖ Medicine trolley should not be left unattended.

❖ Be aware of dangers in the environment that may precipitate falls and take

action to prevent them.

❖ Be particularly aware of the dangers of the following situations:

❖ Wet floors.

❖ Loose flexes.

❖ Unsafe equipment or furniture.

❖ Call bells not working.

❖ Brakes on beds not working.

❖ Spills.

❖ Clutter.

❖ Be aware of the importance of good hygiene and encourage all staff to

adhere to good hygiene practices i.e. washing hands, correct disposal of

linen etc.

❖ Ensure that all sharps are correctly disposed of.

Care of the Older Person – Unit 2 5N2706

❖ Be aware of the reasons for adhering to the correct disposal of linen and

soiled material.

❖ Adhere to good food hygiene practices at all time.

❖ Use aids and adaptations to help elderly or disabled persons remain

independent.

❖ Take responsibility for using correct procedures for moving and handling

clients.

❖ Be aware of fire regulations and attend practice as required, so that in the

event of a fire you will know what to do for the safety of clients and staff.

❖ Report any unsafe practices to the person in charge.

Maintaining a Safe and Hygienic Environment in a Client’s Home

Regarding the safety of clients in their own home, it is important to ensure that they

feel secure. This may include checking that windows and doors have working locks

and that the front door is locked to prevent anyone entering who is not invited. It

may also be important to have a security chain on the door or a security spy hole in

the door.

An entry phone or identification system may also allow the client to feel safe.

Security lighting is essential in order to allow the client, and especially elderly clients,

to see who is at their door before they open it. An emergency call system in the

event of a fall can be reassuring for the client. It is important to check household

appliances and equipment regularly for defects, especially gas cookers, electric

blankets, heating and ventilation systems and smoke detectors.

Any household appliances that are found to be defective should be repaired or

replaced, as they may be the cause of a fire if ignored. The installation of a fireguard

for an open fire is essential. Safe storage of medicines is also very necessary to

prevent grandchildren getting access to dangerous substances.

Care of the Older Person – Unit 2 5N2706

As elderly clients are at risk of trips and falls, it is important to try and reduce this

risk as far as reasonably possible. This might include installing aids and adaptations

to help older clients remain independent safely. Ensure that stairs and rooms are

well lit to prevent clients tripping on furniture.

Avoid the use of loose rugs or items of furniture positioned in inappropriate places.

It is important to ensure that chairs and toilet seats are the correct height to make it

easy for clients to get up and down.

Prevention of infection is important in the home situation. Clients should be

encouraged to practice good hygiene such as washing hands after using the toilet

and after playing with pets, or before handling food. Older clients may rely on carers

to assist with personal hygiene and general house cleaning. Older clients may need

information regarding good food hygiene practices to prevent the risk of food

poisoning occurring.

Older clients who are able to get out and about should be encouraged to have a

checklist before leaving the house, to ensure that it is left in a safe condition. Areas

that would be important to check would be the following:

Ensure nothing is left cooking

Put fire guard in place

Check that gas/electric cooker is turned off

Check that windows and doors are secured

Shopping list

Wear hearing aid or glasses to assist in hearing or seeing.

It is necessary that the client is aware of the dangers on the road and that the

necessary precautions are taken to prevent accidents occurring. This would include

crossing at the allocated place and walking on the footpath.

Care of the Older Person – Unit 2 5N2706

To assist clients to remain in their home safely, many things can be done and anyone

involved in working with clients at risk should be aware of these.

Elder Abuse

Can be defined as:

“A single or repeated act or lack of appropriate action occurring within any

relationship where there is an expectation of trust which causes harm or

distress to an older person or violates their human and civil rights.”

{Protecting Our Future Action on Elder Abuse}

Forms of Abuse:

Physical abuse

Sexual abuse

Psychological abuse

Financial abuse

Neglect and acts of omission

Discriminatory abuse.

PHYSICAL ABUSE: includes:

Not providing sufficient food

Neglecting personal care needs

Not requesting medical care

Use of physical restraint or assault

Sexual assault

PSYCHOLOGICAL ABUSE: includes:

Lack of respect

Lack of privacy

Care of the Older Person – Unit 2 5N2706

Lack of dignity

Swearing at a person

Humiliation

Harassment

Verbal threats.

MATERIAL ABUSE: Consists of misuse or theft of property or money. Can take place

within a family setting, their place of residence e.g. institutional settings such as

nursing homes or hospitals.

SOCIOLOGICAL ABUSE: Which consists of:

Loss of social contact

Abandonment

Any suspicion of abuse should be reported and investigated in accordance with local

and professional guidelines and regulations. The HSE dedicated elder abuse service,

established in 2007, receives over 1,800 referrals for alleged cases of elder abuse

each year. In 2009, psychological abuse was the most frequently reported form of

abuse at 28%, followed by self-neglect (21%), financial abuse (18%), neglect (17%)

and physical abuse (12%), sexual abuse (1%) and other/discrimination (3%).

POSSIBLE SIGNS

The "Protecting Our Future" report of the Working Group on Elder Abuse, published

in 2002, outline the following possible indicators of elder abuse:

❖ Psychological: demoralisation; depression; feelings of

hopelessness/helplessness; disrupted appetite/sleeping pattern;

tearfulness; excessive fears; agitation; resignation; confusion; unexplained

paranoia.

Care of the Older Person – Unit 2 5N2706

❖ Neglect: dehydration; malnutrition; inappropriate clothing; poor hygiene;

unkempt appearance; under/over-medicated; unattended medical needs;

exposure to danger/lack of supervision; absence of required aids, including

reading glasses and dentures; pressure sores.

❖ Financial: unexplained or sudden inability to pay bills; unexplained or

sudden withdrawal of money from accounts; funds diverted to someone

else's accounts; funds diverted for someone else's use; being charged for

unsolicited work or significantly overcharged for work done; unexplained

disappearance of possessions; no funds for food, clothes or services; refusal

to spend money; disparity between living conditions and assets;

extraordinary interest by family in person's assets; making dramatic

financial decisions.

❖ Physical: bruises or cuts, particularly to mouth, lips, gums, eyes and ears;

abrasions; scratches; burns (inflicted by cigarettes, matches, rope, iron,

immersion in hot water); sprains; dislocations; fractures; hair loss (possible

hair-pulling); missing teeth; eye injuries (eg black eye).

❖ Sexual: trauma about the genitals, breasts, rectum or mouth; injury to face,

neck, chest, abdomen, thighs, buttocks; presence of sexually transmitted

disease.

Elder abuse is the hidden shame of Ireland's caring industry. The exact incidence and

extent of the phenomenon is unknown and probably unknowable. Many factors

stand in the way of proper reporting of the abuse, as the victims are often unable to

formulate clearly the abuse that they are suffering, or because they fear

estrangement from those who are caring for them.

There is a consensus among experts that a wide range of abuse of older people

exists. Their physical frailty and dependency on others leave them vulnerable to a

number of different forms of abuse. The media often focus on more 'newsworthy'

cases of physical and sexual abuse of older people, but in fact, financial exploitation

and psychological abuse are much more widespread.

Care of the Older Person – Unit 2 5N2706

Vulnerable persons need to feel enabled, empowered and encouraged to have their

voices heard if they are victims of abuse. Professionals have a responsibility and a

duty of care towards vulnerable persons in their care.

It is the right of the older person to be treated with dignity and respect.

Restraints

Restraint may be defined as "any device that limits an individual's freedom for

voluntary movement" (Sullivan-Marx, 1995). It can be described as an intervention

that prevents a person from causing harm to themselves, others or property (Duff et

al, 1996).

The use of restraint can have untoward physical and psychological side effects. The

goal of a restraint free environment is considered the most desirable, but when

restraint is required, it is important that the rights, risks and responsibilities of the

practice are considered carefully. Restraint is often applied because staff members

believe that there is no alternative.

Lee et al, (1999) highlight that nurses/staff perceive the following reasons as

justification for using restraint:

To prevent falls

To protect from injury

To maintain treatment regimens

To control people exhibiting confusion or agitation.

Types of restraint

Restraints can be classified under two categories: physical and chemical:

Cot sides

Harness

Locks (mechanical and electronic)

Care of the Older Person – Unit 2 5N2706

Arranged furniture to impede movement

Specially designed chairs to immobilise

Inappropriate use of nightwear during the day

Putting a person into bed during the day who doesn't need rest

Vests, body harnesses or wrist restraint garments

Controlling language, body language and non-verbal behaviour

Isolation from others

Sedative medication.

Effects of Restraint

In Ireland, apart from the Mental Treatment Act 1945, there is no law authorising

the restraint of an adult and thus depriving them of a fundamental human right. In

addition to this, there is increasing evidence advocating restraint free care. Watson

(2001) suggests that when using restraint, nurses may believe that they are acting in

the best interests of the older person. However, restraint has adverse physical and

psychological consequences.

Physical effects these include:

Muscle atrophy

Loss of bone density

Pressure sores

Infection

Strangulation

Functional decline

Cardiac stress

Incontinence.

Psychological effects include:

Depression

Cognitive decline

Emotional isolation

Confusion and agitation.

(Watson, 2001).

Care of the Older Person – Unit 2 5N2706

The Legal Side of Restraints

In principle, a patient should receive treatment only after consenting to it. Consent is

rooted in the Irish Constitution's guarantee of bodily integrity. To be legally valid,

consent should be made by a competent patient without coercion and upon relevant

information about the treatment's side-effects and alternatives. The use of a

restraint, therefore, runs contrary to the principle of consent.

However, the Irish law also recognises that in many cases restraints are necessary to

ensure a right even higher than the right of consent - the right to life.

In such a way, anyone who uses chemical, physical, or psychological restraints must

ensure that the restraints are necessary to prevent patients from harming

themselves or others. Restraints, however, should not be used as a means to compel

competent patients to receive treatment. The law recognises that competent

patients possess the right to refuse medical treatment even when that treatment

will bring about their deaths.

Although many institutions often ask family members to "consent" to the restraint of

an incompetent or unwilling adult patient, such "consent" has little legal effect. In

law, only the adult individual can give a valid consent. Deciding what type of

restraint to use is based not on law, but on good clinical practice. What the law

requires is that any restraint be the minimum type of restraint necessary to achieve

the result of preventing harm.

As with any other form of care, nurses should document any use of restraint,

including the reason for the restraint. Where a patient is unnecessarily or improperly

restrained ALL STAFF HAVE an ethical duty to complain to the relevant authority

about the restraint.

Care of the Older Person – Unit 2 5N2706

Alternative intervention must be explored: examples:

❖ Moving the patient nearer to the nurse's station. Human contact may calm

him/her. Watching activities may distract him/her.

❖ Chairs should be made more comfortable and assessed as suitable for the

person's requirements.

❖ Wheelchairs should be used for transport purposes only, unless their use is

necessary for the individual needs of the person.

❖ Patients who have to sit for extended periods should be positioned in a

chair that provides adequate support for their back, arms and legs.

❖ Reassess the need for intravenous infusions, feeding tubes and urinary

catheters as part of the restraint assessment.

❖ Comfort measures can reduce need for restraint in some situations. An

example of this is the use of humidification and comfortable tape when

delivering nasal oxygen.

❖ The patient/client's environment should also be considered. The bed should

be placed in a low position. The pathway to the bathroom should be clear of

obstacles and the floor should be checked regularly for spills or

obstructions. Suitable lighting may be necessary to allay anxiety and

increase safety.

Other Approaches That May Reduce the Need For Restraint:

Sonas aPc

Music therapy

Reality orientation

Multi-sensory rooms

Reminiscence therapy

Validation approach

Relaxation

Care of the Older Person – Unit 2 5N2706

Massage

Aromatherapy.

Good practice must be adhered to if restraints are deemed necessary. A restraint

policy should reflect the following ethical principles:

❖ Beneficence: the intention to do good.

❖ Non-maleficence: the intention to do no harm.

❖ Justice: to treat all clients fairly and equally.

❖ Autonomy: to aid and respect the patient/client's right of self-

determination.

If, despite all alternative approaches having failed, restraint is assessed as an

appropriate intervention, an individualised care plan should be made detailing the

outcome of the initial assessment. The decision to use a restraint should be made in

consultation with the multidisciplinary team. The restraint must be a time limited

intervention and should be for the shortest time possible.

The resident must be provided with a means of calling for assistance.

Review times must be specified in advance and it should be documented

that review took place.

Where a patient has been restrained for over a period of two hours, the

restraint must be removed to change the patient/client's position and/or

exercise limbs.

If the patient is restrained for over four hours, the multidisciplinary team

must undertake a full review.

“If we spent as much time on trying to understand behaviour as we spend trying to

manage or control it, we might discover that what lies behind it is a genuine

attempt to communicate.” Goldsmith, M. (1996) Slow down and listen to their

voices, Journal of Dementia Care 4(4) 24-25.

Care of the Older Person – Unit 2 5N2706

HSE National Restraint Policy

The HSE National Policy on the use of Physical Restraints in Designated Care Units

for Older People (2010).

The policy (HSE, 2010) on the use of physical restraints in designated residential care

units for older people, was developed by an interdisciplinary group, led by the HSE

and working in partnership with Nursing Homes Ireland. The development of this

policy was guided by the ‘National Quality Standards for Residential Care Setting

for Older People’ (Health Information and Quality Authority (HIQA) 2009 and the

HSE policy ‘Responding to Allegations of Elder Abuse Policy’ (HSE, 2007).

End of Unit 2

Care of the Older Person – Unit 2 5N2706

NOTES: