The Best Friends Staff Building a Culture of Care in Alzheimer's Programs By Virginia Bell, M.S.W., and David Troxel, M.P.H.

Excerpted from the Introduction for The Best Friends Staff: Building a Culture of Care in Alzheimer’s Programs.

Copyright © 2001 by Health Professions Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

Introduction

The Best Friends Staff: Building a Culture of Care in Alzheimer’s Programs is directed primarily at professionals working in long-term care settings. The goal of this book is to help program leaders develop a dementia-capable staff, one that is knowledgeable about the disease, is sympathetic to the world of its residents or program participants, has a sense of fun and joy, thinks on its feet; and is dedicated to preserving dignity and enhancing quality of life for persons with dementia. These are the qualities of a Best Friends™ staff.

This book also discusses the challenge of staffing long-term care programs in the competitive and challenging job market for employers: How do you attract good line staff today, train them, and keep them? How do we retain talented leadership when news headlines frequently highlight resident neglect and million-dollar lawsuits? Although the challenges are daunting, Best Friends programs will have the greatest chance at overcoming these obstacles and changing the culture of care.

A 1997 report from a nursing facility advocates meeting in Rochester, New York, defined culture as “an organic, ongoing process that has potential for change, growth and development. There are no culprits — good guys and bad guys. Rather, there is the presence, or not, of vision, energy, and perseverance and a willingness to nurture and support one another in these change efforts.” This statement reflects the philosophy of a group calling themselves “Pioneers”(see Appendix C) that have taken on the mission of changing the culture of care in long-term care. The authors embrace their definition of culture and change: Now is not the time to point fingers and assign blame; now is the time to look for new and creative ideas, to identify common goals, and to be supportive of one another as we search for enhanced job satisfaction and new models of care.

The authors have written this book for a wide audience of individuals working in long-term care settings including in-home services, adult day center care, assisted living, and skilled care. The book also may be helpful for caregivers who want to know more about issues surrounding staff training and development. Specifically:

• Program administrators will learn how the Best Friends model can improve client, family, and staff satisfaction. The model makes the case that training a Best Friends staff is a good investment, improving census, reducing staff turnover, and having a positive impact on “the bottom line.”
  
  
• Staff trainers or developers will discover easy-to-use materials and programs for initial staff orientation, ongoing training, and reinforcement of lessons. Handouts, worksheets, and exercises are provided that can be copied or adapted and used in training programs and classes. The book is not a curriculum, but it does offer a framework for staff to do their work not only with skill but also with purpose and satisfaction.
  
  
• Activities staff will appreciate the book’s philosophy that all staff who come into contact with residents or participants have a role in activities. A Best Friends program not only enriches group activities but it also encourages living between structured activities and suggests ways to make this happen. Also important, the book encourages staff to bring their own interests, hobbies, and avocations into the activity program.
  
  
• Clinical staff who read this book will appreciate the book’s view that learning the basics of the medical and scientific aspects of dementia is important for all staff. The value of a thorough medical assessment and the importance of ongoing medical care are discussed. The book also demonstrates the value of behavioral approaches, which when combined with good medical care, promote optimal health. 
  
  
• Architects and designers, who play such an important role in creating dementia-friendly environments, will find that this book gives them and their clients important tools for a program philosophy on which to build their designs and plans. Best Friends programs partner with these professionals to build and create a winning design. 
  
  
• Volunteer coordinators will find that the Best Friends model helps programs expand their volunteer base. This book champions the role of volunteers in dementia care; any program can develop effective programs in this area. Notably, the book suggests that volunteers can be particularly effective when matched one-to-one with persons with dementia. They also can play a role in group activity programs. Because their work becomes more meaningful, volunteers are always more attracted to Best Friends programs.
  
  
• Students often are required to get experiential learning or to engage in community service as part of their educational programs. This book is a good resource for students, teachers, and program leaders designing hands-on learning programs. It also can be used as a textbook in gerontology and long-term care courses.
  
  
• Family members will discover that this book encourages them to be a partner with the long-term care community or day center serving their loved ones. Although the book is written for a professional audience, it is not technical. Families can feel comfortable mining the book for ideas that cover all aspects of Alzheimer’s care, and staff should share relevant sections of the book with families.
  
  
• Others who work in or have an interest in long-term care, including individuals in Alzheimer’s Association chapters, public policy settings, geriatric care management firms, ombudsman programs, faith communities, service and community clubs, and university or educational settings, will find that this book challenges many conventional notions about staff development and programming. New and long-established programs also will benefit. The authors hope that The Best Friends Staff will provide readers with inspiration and ideas to build and support better programs in this growing and dynamic sector of long-term care.

One notable concept used in The Best Friends Approach to Alzheimer’s Care appears again in The Best Friends Staff. To illustrate certain concepts, the first book told true stories of almost 50 persons diagnosed with Alzheimer’s disease. Instead of composite stories or fictitious examples, the identity and brief biography of every person was disclosed, and written permission was received from the person or a responsible party.

In The Best Friends Staff more than 35 long-term care programs are identified that have either adopted or embody the Best Friends approach. Also, 30 professionals and consultants in the field of dementia care from around the world have shared their experiences. They lend the material authenticity, allow the reader to benefit from the expertise of others, and give individuals interested in staff development people with whom to network. These contributors are listed in the

Acknowledgments and in Appendixes A and B. The Best Friends Staff was written as a companion volume to The Best Friends Approach to Alzheimer’s Care but can stand alone. The first book is particularly helpful to family members or staff who are seeking more information about this approach to care. 

Chapter 1 reviews the Best Friends model. The Alzheimer’s Disease Bill of Rights is presented along with an overview of the model and introduction to one of the core concepts, the knack. Knack is the art of doing difficult things with ease, the art of using clever tricks or strategies to solve problems. Knack is what the Best Friends staff should embody. The elements of caregiving knack are listed along with examples of knack from many programs in the United States and other countries.

Chapter 2 discusses staff recruitment and development in an always-challenging labor market. One administrator at a national conference said with exasperation that the job market is so competitive in her area that she just needs “warm bodies” to show up to provide care. The need for creative recruitment and staff training and development is greater than ever before. The Best Friends approach incorporates experiential and interactive learning. It is a perfect vehicle for helping staff become empowered, to help them succeed as individuals and as employees. Just because a program starts with warm bodies does not mean that it cannot end up with warm hearts.

Chapter 3 discusses how to train staff members in the basics of the medical and research issues surrounding dementia. The chapter offers some key concepts that need to be taught to staff and suggests that the Best Friends staff must have a solid grounding in dementia care. This knowledge base should be sustained with continuing education opportunities, newsletter subscriptions, and appropriate Internet access. Still, the chapter notes that the basics of the medical and research issues surrounding dementia sometimes are taught at the expense of other topics. A balance must be struck.

Chapter 4 reveals the critical importance of teaching staff to empathize with the person in their care. Until staff members learn to “walk a mile in the shoes” of the person with Alzheimer’s disease, high-quality care is not possible. Staff can also teach families this important lesson. This chapter offers a number of valuable exercises that will help staff grasp that Alzheimer’s disease is as real as a broken leg or arthritis. 

Chapter 5 argues that the assessment of individuals with Alzheimer's disease should be strengths-based rather than focus on disability and loss. Careful assessment allows Best Friends staff members to set appropriate expectations that can guide their overall care plan and their daily interactions. This chapter teaches staff members to think on their feet and to “stop, look, and listen” on a daily basis when caring for persons with dementia. 

Chapter 6 goes to the heart of the Best Friends model. When staff members explore their own attitudes toward friendship, they can begin to be a Best Friend to the person in their care. This chapter demonstrates that the program philosophy of Best Friends is multicultural and one that speaks to staff of varying educational backgrounds. Everyone has the potential to be a Best Friend. 

Chapter 7 describes how Best Friends programs can improve the social histories (“the life story”) of its residents and participants. The chapter discusses techniques that encourage staff members and volunteers to learn and use these stories. The chapter concludes that good programs use facts from the person’s life story regularly, including their values, traditions, and beliefs, to enhance all aspects of care. 

Chapter 8 puts a new spin on one of the most critical topics of staff training — communication. Persons with dementia retain the desire to communicate. This chapter discusses how to teach staff effective methods of nonverbal and verbal communication. Some communication is possible with almost every person with dementia. 

Chapter 9 helps program leaders develop strategies to greatly enrich and expand activity programming. The Best Friends model insists that every interaction be an activity and that all staff should think in these terms. For a Best Friends staff, activities can be spontaneous and inexpensive. Personal care also can be transformed into an activity rather than framed as a chore or task.

Chapter 10 discusses family issues surrounding Alzheimer’s disease that can have an impact on staff. In general, families respond favorably to the improved ambiance and morale of a Best Friends program. This chapter focuses attention on how staff members learn to listen to families, understand boundaries, and help families move from denial to acceptance. 

The Conclusion demonstrates the ultimate link between staff development and programming in long-term care communities or day centers, noting that the goals are surprisingly similar. The Best Friends approach creates a caring community in which staff members feel challenged, enjoy their work, and build their careers. At the same time, it benefits all aspects of care for persons with dementia, whatever the care setting. 

A number of quotations appear in the margins of most of the chapters and provide commentary or complementary examples of the concepts being discussed in that chapter. The authors hope that these quotations from staff members, persons with dementia and family members, and famous writers will speak to the reader and provide another tool for relating the material in the book to the reader’s own work situation.

At the end of Chapters 2 through 10, a Training Tool Kit is presented to help readers learn and teach concepts from the specific chapter. These sections contain a variety of materials that can be copied or adapted for quick-and-easy training programs. The tools were developed by the authors and long-term care professionals from around the world. The elements of each Tool Kit include the following:

Warm-ups — These suggested exercises can be used to begin each training class to focus staff attention on the task at hand, work as a team, and even have a few laughs. Sometimes just taking several minutes for a funny story, joke, or a group exercise can build a sense of togetherness in staff. These activities are often called “icebreakers,” but the authors prefer the more friendly image of “warm-ups.”  

Program Pointers — These handouts, checklists, originals for transparencies, articles for bulletin boards or newsletters, and other items can build a Best Friends program. Program leaders can use them as they are or adapt them for their own facilities. 

Games for Learning —These group activities or games reinforce the material covered in the chapter. They also help staff work with the concepts being taught and make them their own. This is active learning at its best. 

Knack and No-Knack Exercises — These exercises feature a series of statements/myths about Alzheimer’s care that the group leader can discuss with staff. They also can serve as the basis of fun role-play skits that can be acted out for staff discussion and learning.

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