Implementation of a Stepwise, Multidisciplinary Intervention for Pain and Challenging Behaviour in Dementia (STA OP!): A Process Evaluation

Steps	Description
Start with a ‘Behavioural Change Identification’: define the target behaviour, its expression and when (in what situation) this behaviour is challenging. Check if the behaviour is new or recurrent. If the behaviour is recurrent, check what has been done in the past to treat it. Define for whom the behaviour is challenging: the patient, family, or caregivers? A psychologist can be consulted at this step. If the nurses and the multidisciplinary team of healthcare professionals make a clear description of the targeted behaviour, the nurse moves to the next step (0).
0	Perform a basic care needs assessment, and assess if basic care needs are fulfilled (e.g. hunger, thirst, eyeglasses, hearing aids or toileting). If assessment is positive, a targeted intervention is implemented or the appropriate discipline is consulted to begin treatment. If the assessment is negative, or if treatment fails to decrease symptoms, the nurse moves to the next step (1).
1	Perform a pain and physical needs assessment. In addition to a brief physical nursing assessment (screening for pain) by the nurse (a), nurses fill out an observational pain instrument (PACSLAC-D) as well (b). This form is handed to the nursing home physician (or if available a nurse practitioner), who performs a more comprehensive physical assessment (c) in order to find other probable physical causes associated with discomfort. For those residents already using pain medication or psychotropic drugs, and still have behavioural symptoms possibly related to pain or affective discomfort, the nursing home physician assesses whether the medication given is in accordance with the guidelines of the World Health Organization (WHO) and Verenso (the Dutch Association of Nursing Home Physicians) (also see steps 4 and 5). If assessment is positive, a targeted intervention is implemented or the appropriate discipline is consulted to begin treatment. If the assessment is negative, or if treatment fails to decrease symptoms, the nurse moves to the next step (2).
2	Perform affective needs assessment that focuses on needs of people with dementia: (a) environmental stress threshold not exceeded, (b) balance between sensory-stimulating and sensory-calming activity throughout the day, and (c) receipt of meaningful human interaction each day. The psychologist (or social worker) working in the nursing home can be consulted at this step. If assessment is positive, a targeted intervention is implemented or the appropriate discipline is consulted to begin treatment. If the assessment is negative, or if treatment fails to decrease symptoms, the nurse moves to the next step (3).
3	Administer a trial of non-pharmacological comfort treatment(s). Treatments used are customised to the person and the situation, and are based on a list of psychosocial and environmental treatments that are associated with decreasing agitated behaviours. If a one-time treatment is effective and continued use is desirable, take actions needed to ensure continued treatment (e.g. communicate new treatment to other staff and family, write it down in the patients care plan with prescribed times or administration). If a trial of non-pharmacological comfort treatment(s) does not ameliorate behaviours in a time frame likely to show outcomes, the nurse should move to the next step (4). Stop ineffective treatments.
4	Administer a trial of analgesic agents by either administering the prescribed as-needed analgesic agent or obtaining orders to escalate a current analgesic medication. If treatment is effective and continued use is desirable, take actions needed to ensure continued treatment (e.g. schedule dosing of effective treatments for continued use, write it down in the patients care plan with prescribed times or administration). If there is not a response to a trial course of analgesic medications, consider consultation regarding further escalation or proceed to the next step (5). Stop ineffective treatments.
5	Consult with other disciplines (e.g. psychiatrist) and/or administer a trial of a prescribed as-needed psychotropic drugs in this step if the behaviour continues and alternatives are carefully considered, and potential side effects are weighs against the comfort needs of the resident. Monitor for recurrence and new problems. Conduct regular comprehensive assessments. Establish clear criteria for evaluation of problems and treatment effectiveness, need for treatments, and possible side effects. If treatment is negative, and/or behavioural symptoms continue, repeat consultation or the entire process at the initial ‘behavioural change identification’.

[i] Copyright (2016) Wiley. Used with permission from (Marjoleine J.C. Pieper, Anneke L. Francke, Jenny T. van der Steen, Erik J.A. Scherder, Jos W.R. Twisk, Christine R. Kovach, and Wilco P. Achterberg. Effects of a Stepwise Multidisciplinary Intervention for Challenging Behavior in Advanced Dementia: A Cluster Randomized Controlled Trial. J Am Geriatr Soc., John Wiley & Sons, Inc.).

Table 2

Overview of data sources, sorted by organisational level.

Organisational level	Data source			Time of collection	Number of collections (N)
Organisational level	Qualitative data	Combination qualitative and quantitative data	Quantitative data	Time of collection	Number of collections (N)
Level Organisation/Management (unit/nursing home)	Notes and memos of the coordinator and research assistant			On-going during study
	Questionnaire for managers/management staff; written evaluations regarding organisational changes and factors		T2	12
Level Multidisciplinary team	Semi-structured interviews			T2	6
Level Multidisciplinary team	Written evaluations by trainers/instructors			T1	4
Notes and memos of the coordinator and research assistant			On-going during study
	Questionnaire for healthcare professionals; written evaluations regarding the STA OP! training & training manual		T1	136
Level Individual; Resident/Healthcare professional	Completed forms of STA OP! assessments (residents)			On-going during study	58
		Registrations regarding care (research database)	T0–T1–T2	148

[i] Note: Time of collection, T0 = baseline, T1 = 3 months and T2 = 6 months.

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DOI: https://doi.org/10.5334/ijic.3973 | Journal eISSN: 1568-4156

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Language: English

Submitted on: Feb 1, 2018

Accepted on: Aug 15, 2018

Published on: Sep 7, 2018

Published by: Ubiquity Press

In partnership with: Paradigm Publishing Services

Publication frequency: 4 issues per year

Keywords:

behaviour,

dementia,

Health Plan Implementation,

pain,

© 2018 Marjoleine J.C. Pieper, Wilco P. Achterberg, Jenny T. van der Steen, Anneke L. Francke, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 18 (2018): Issue 3

Implementation of a Stepwise, Multidisciplinary Intervention for Pain and Challenging Behaviour in Dementia (STA OP!): A Process Evaluation

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