Relationship Centered Model of Care in Dementia and the Six Senses Framework

Anticipating and enhancing the health and wellbeing of the older person with dementia in hg HWOP02 A1

Alzheimer’s Scotland (2014) estimate that there are 88,000 people in Scotland with dementia and two thirds of these people live in the community with support from family carers. Therefore, providing sensitive and appropriate support for people with dementia and their carers is one major challenge facing the health care system in supporting quality care. Firstly, this assignment provides a definition of dementia, then identifies Relationship Centred Care (RCC) and the six senses framework.

Furthermore this assignment discusses the development of relationship centred care and it’s relevance to dementia. Extending on this, my assignment will cover the use of the senses framework by Nolen et al. (2001) to develop relationship centred care. My assignment will then discuss what the individual six senses mean to the individual with dementia, as well as their family and carers when developing RCC. The second and final section of my assignment will use a case study to discuss the application of the relationship centred care model using the three senses of; purpose, continuity and security recognised within the six sense framework for a person with dementia who has family support at home.

To be able to put this assignment in context, an understanding of dementia is needed in order to define what Relationship Centred Care (RCC) and the senses framework means to individuals diagnosed with dementia. Dementia is defined by the Department of Health as a ‘syndrome which may be caused by a number of illnesses in which there is a progressive decline in multiple areas of functioning, including decline in memory, reasoning, communication skills and the ability to carry out daily activities’ (2009 pg.

15). Alzheimer Scotland (2011) have developed ten warning signs of the disease, these include symptoms such as; memory loss which disrupts daily life, challenges in planning, difficulty completing familiar tasks and confusion over time and place. It is therefore not surprising dementia can severally affect quality of life and relationships. Due to dementias progressive nature, a person with dementia gradually loses the ability to act autonomously and must therefore rely on the decisions and support of others, primarily their relatives when living at home (Hughes et al. 2001).

Beach and Inui (2006) suggests that RCC can simply be defined as care in which all participants appreciate the importance of their relationship with one another. Nolan et al. (2001) Senses framework identifies the subjective and perceptual dimensions related to caring relationships. Within this Nolan et al. (2001) incorporates the interpersonal and intrapersonal elements of giving and receiving care to ensure the highest quality. The framework is centred on six themes which all individuals involved in RCC should experience, this includes; security, belonging, continuity, purpose, achievement and significance. Over the past decade, there has been much written about the notion of patient centred care, however, it has been argued for some time that care giving can only be understood within the context of relationship (Nolan et al. 2004). The national dementia strategy (Department of Health 2009) identifies providing person centred care as one of the key standards of living well with dementia. Kitwood (1993) changed the focus of care for people experiencing dementia from a biomedical approach to an approach he labelled ‘person centred care’.

For an individual with dementia person centred care is characterised by the need to value people with dementia, to treat them as individuals, to view the world from their perspective and to create a positive environment (Brooker 2004). Sheard (2004) review on health services found that often services consider the needs of people with dementia and their carers separately. Kitwood’s (1997) approach offers all health care professionals a way to care for an individual with dementia, however it does not take into consideration the importance of the interaction among people as the foundation of any therapeutic or healing activity in health care. Post (2001) supports this statement and suggests that living with dementia is not about quality of life but rather about quality of lives. Wadensten and Carlsson (2003) suggestion that the most common models of nursing dementia patients provide little more than guidance on how to work positively with older adults.

Sheard (2004) therefore called for a development of an approach where an individual with dementia is seen within the context of important and significant relationships. Nolan et al. (2004) therefore argues that RCC is one of the most comprehensive ways of doing this in order to promote a more holistic vision of health care to include; social, economic, environmental and culture into care practice. RCC was developed by the Pew-Fetzer Task Force (1994) who examined how relationships formed between patient and practitioner, practitioner and community and practitioners and practitioners. Pew-Fetzer task force (1994) argued that although the patient centred care model promotes personhood it is not inclusive enough to embrace the relationships formed during illness.

To establish RCC, Pew-Fetzer (1994) united the biomedical with the psychosocial element of care to conceptualise health care and recognise that the nature and the quality of relationships is necessary to broaden the health care delivery system. Beech and Unui (2006) Founded four principles of successful RCC, these included; relationships in health care should include the personhood of the individuals, that affect and emotion are important components of relationships in health care, that all healthcare relationships occur in context of reciprocal influence, and finally that RCC should have moral foundation This in relevance to dementia care is important, as often the family play a pivotal role in the care of an individual with dementia with support from many different health professionals. However many researchers have found that little is known about how to develop and sustain such relationships in a health care environment (Dewar and Nolan 2013). Nolan et al. (1999) considered how positive relationships can be created and sustained and developed the ‘senses framework’. Nolan et al. (2001) suggests that individuality certainly shouldn’t be ignored in dementia care, but rather that for most people relationships are crucial in determining quality care.

This framework comprises of the six senses; security, continuity, belonging, purpose, achievement and significance. The fundamental premise of Nolan et al. (2001) vision of relationship centred care, is that these senses need to be experienced by all groups involved in order to deliver good care based on relationships. Arksey et al. (2004) in his systematic review concluded that trusting and supportive relationships with staff are essential in dementia care, where good relationships are supported by communication with staff to draw on carers’ expertise and views of what is best for the person with dementia. Due to a lack of time to establish RCC Baillie et al. (2012) suggests that the senses framework in dementia care is very difficult to achieve in an acute ward, where the turnover of patients is often very high. The 8 pillar model of community support (Alzheimer Scotland 2012) provides a case example of how ‘supportive relationships’ form and develop into dementia care triads.

RCC in dementia care provides a complementary philosophy of care, uniting the biomedical approach with the psychosocial of health care, recognising that the nature and quality of relationships are central to the health and care of individual and can be achieved when all participants appreciate the importance of their relationship with each other (Beach and Unui 2006). The senses framework recognises six senses which should be experienced during RCC, three of these are; security, belonging and continuity. Nolan et al. (2004) suggests that continuity creates a subjective sense of security and belonging for older people with dementia. To a person with dementia a sense of security, belonging and continuity is essential in RCC and often involves open negotiation of the service they would like with attention to the physiological and psychological needs with the same support worker (Nolan et al. 2008). Alzheimer’s Scotland (2011) five pillar model of post diagnostic support suggests that individuals with newly diagnosed dementia who receive personalised and flexible support, which is delivered proactively and sensitively over the course of a year by a skilled and well-trained person will feel these senses.

Froggatt et al. (2006) in relation to the need for information developed a welcome booklet for care homes to capture what was special about the care home environment and what was available to residents and their careers. This resulted in a perceptual sense of security for carers and individuals, as they felt they knew something about the environment and the staff working there. When looking at a sense of security, belonging and continuity from a health professional’s view, it is suggested that it involves having a positive experience working with an individual with dementia, being free from physical threat, rebuke or censure and to have secure conditions of employment and their emotional demands recognised (Nolan et al. 2008). Many studies have looked into health professionals and stress in providing dementia care, it is suggested that many people leave the profession due to lack of security and continuity (Dupluis et al. 2014).

Through education about the senses Nolan et al. (2004) found that in training staff in effective management of dementia care, the greatest reward comes from witnessing carers and nurses realise that compassionate communication is at the heart of supporting RRC. Hobbs (2009) suggests that workshops and role-play establish ‘steps’ that enable people to meaningfully connect with their environment, feel more supported via discussion groups and ultimately creates a sense of belonging amongst staff. For family and carers, these senses mean being confident in the knowledge that they are providing good care without detriment to their own personal wellbeing and ensures the standard of care is maintained to a high standard. Olsson et al. (2012) study recognised that relatives of people with dementia often struggle to create a situation of security in daily life for themselves and the individual with dementia.

Flynn and Mulcahy (2013) suggest that to do this, family and carers need support not only in meeting their physical needs but also their emotional and social needs. The Alzheimer’s Scotland (2012) 8 pillar model of community support recognises that security and continuity can be achieved through personal support, environment aids and the use of health professional’s knowledge in dementia care. Through using Nolan et al. (2001) senses framework a sense of purpose achievement and significance can be created for carers, people with dementia and staff supporting RCC. For people with dementia these senses can be achieved through purposeful activity, to work towards therapeutic goals and valuing the person’s wellbeing (Barker and Board 2012). A workshop by Nolan et al. (2004) suggests that that these senses highlight the important aspects of care, which are often taken for granted in a care home. For a support worker achieving these senses means they can improve care for the individual by having direction and a clear set of goals and to feel that their expert opinion matters.

In Brown et al. (2012) study they found that the sense of significance can be fulfilled through staff taking an interest in the individual. For instance Brown et al. (2013) study found that when staff got the family and individual in care involved in creating memory boxes, participants felt a sense of perceptual significance, through reminders of who the person is. This also helped to initiate more meaningful conversations and acted as a reminder for the individuals about their life achievements. Nolan et al. (2008) model suggests that for the family carers the sense of purpose achievement and significance can be achieved through, maintaining their dignity and wellbeing through support of their emotional needs such as recognising the time and effort they have committed to the individual with dementia. Often a carer can feel that their best isn’t good enough (Dupluis et al. 2014). Family relationships may already have become strained with the sufferer hiding their memory problems. These are often already strained because all of the participants are adjusting to living with dementia (Steeman et al. 2006).

However through a RCC approach Nolan et al. (2008) suggests that family carers can feel achievement and significance through support from health professionals to establish their needs in the care process. Alzheimer’s Scotland (2012) suggests that family carers often need to communicate their concerns with a trained professional to overcome any hurdles they face and seek reassurance. Carers need to be recognised as individuals with their own needs. In taking on the identity of a carer, a person often risks losing aspects of what it meant to be themselves (Ter Meulen and Wright 2012). Alzheimer’s Scotland (2012) also recognise the importance of family carers and work with the family to incorporate their needs such as seeking respite or creating a package of care for the individual with dementia so that the family member can take time out for themselves. The Senses framework often reminds health professionals involved in the RCC about the family carers as well as the individual in creating good care.

Ben is a 75 year old retired engineer, living with his 70 year old wife, Mary. They live in Perth, Scotland, in a semidetached house, purchased when they were first married 60 years ago. Ben received diagnosis of mild Alzheimer’s a month ago, after being referred to a neurologist by his GP. On a mini mental examination he scored 22/30. Being diagnosed was a fraught time, for Ben and his wife. Ben and Mary have two children and four grandchildren who all live close by, but are not aware of his diagnosis. Over the past year Mary had become concerned about Ben as his mood appeared to become low and his anxiety increased. She also noticed that his short term memory and ability to perform daily activities had declined. Ben has difficulty performing household tasks, such as preparing meals, which he had previously enjoyed doing. On several occasions he has left dinner on the cooker and forgot all about it, leaving it to burn.

Mary feels scared to leave Ben alone because of this so very rarely leaves the house. Mary used to enjoy going to choir practice in the evening, however, with Bens decline in cognitive function she hasn’t felt able to do this. Mary is a retired receptionist who at present has no significant medical conditions and describes herself as Ben’s only carer. Mary also feels that their relationship isn’t as close as it used to be. Ben avoids answering questions or talking to her, and often loses his tempter when he doesn’t understand. Ben used to be a keen motorist and often entered his prize winning beetle into many vintage car shows with his old work colleagues. Since his diagnosis, he has been told not to drive and has neglected his car. He is still able to perform basic activities of daily living, such as personal hygiene and dressing, and with prompting from Mary do instrumental activates like emptying the dishwasher.

Ben has become increasingly worried about what will happen to himself and Mary as his condition deteriorates, however, wishes to stay at home as long as possible. Ben is also worried about legal and financial affairs. Ben’s only past medical history is osteoarthritis which he takes regular painkillers for. For his newly diagnosed Alzheimer’s, his GP has also prescribed three acetylcholinesterase (AChE) inhibitors Donepezil, Galantamine and Rivastigmine. Ben presently feels uncertain about the future for him and his wife. Ben has an appointment with a dementia practice co-ordinator in a couple days and is keen to seek advice and help for them both. Nolan et al. (2001) suggests that security for Ben can be achieved through RCC. In Ben’s case, security is recognising his physiological and psychological needs and to feel safe from harm and pain (Ryan et al. 2008). From the case study, some of the issues Ben and his wife are experiencing, in being able to develop a sense of security are; fear of diagnosis, finical worries, safety at home and the future. For Ben, becoming aware that something is wrong, has affected his sense of security with in his relationship with Mary and friends.

His relationships have declined because of his insecurity. It is not uncommon for someone newly diagnosed with dementia to feel fear, depression, disbelief and uncertainty which in turn puts stress on their interpersonal relationships (Pratt and Wilkinson 2001). Social interaction can be used in the transitional phase involved in coping with dementia to support all individuals involved in care and friends, often peer support groups, can improve wellbeing (Steeman et al. 2006). Interactions with professional caregivers such a dementia care support workers can often build a relationship where education about dementia can be given and discussions had to make Ben and Marys opinions heard. The information should help individuals to understand what is happening and how disease changes can be modified so they can live a fulfilled life (Olsson et al. 2012). However, it is suggested by Young (2002) that health professionals may silence the person with dementia and the carer.

Therefore the use the 5 pillar model can prove beneficial in structuring care around everyone’s needs (Alzheimer Scotland 2011). Advice can be given on how to create security in the home to ensure Ben’s safety and about sorting out finical and legal affairs whilst Ben is still able to do to so. A lasting power of attorney enables Ben to nominate Mary as his attorney. This means when Ben is no longer able to make decisions for himself about his health care or finances, Mary will be able to act on his behalf. This ensures security for Ben and Mary through ensuring the right choices are made for Ben and that Mary still has a home (Ouldred and Bryant 2008). In this case study, Mary is concerned about Ben’s security in their own home, as he regularly leaves the cooker on. Georges et al. (2008) conducted a large survey, which found relatives of people with dementia often spend 10 hours or more a day caregiving. However, it is acknowledged by Wimo et al. (2002) that a great deal of a relative’s time has been reported to concern supervision/surveillance.

Olsson et al. (2011) study suggests that technology could be used in managing daily life. For instance, smoke detectors could be installed to make Mary aware sooner of fire and ensure Ben’s safety when cooking. Also home improvements could be made to help Ben as his condition progresses, such as good lighting to prevent falls and the use of clocks and calendars as a reminder of time and date. Enhancing security can often be linked to continuity in RCC, which can be used to ensure everyone’s wellbeing. Continuity, as described by the six senses, recognises the person with dementia as an individual and offers a chance for family to maintain shared pursuits with constant care, whilst maintaining a positive experience of work for health care professionals. In this case study, Ben is worried about future care. The support needs of Ben and Mary will become evident through discussion. These range from concerns about maintaining their home, continuing to live on their own, or wanting to continue to do the things that they enjoy (Cook et al. 2012).

Through discussion of care, all individuals involved in Ben’s care can put a plan in place to support these needs. The care plan should enable constant and stable staffing which allows RCC to form thorough knowledge of each other (Cook et al. 2012). Continuity of Ben’s care should recognise his medical history of osteoarthritis and offer ways to manage his pain (Buffum and Haberfelde 2007). As Ben’s Alzheimer’s progresses, he may not be able to communicate his pain as effectively, this is when pain assessment tools such as the abbey pain scale could be used to ensure he gets adequate pain relief (Buffum and Haberfelde 2007). It may be necessary to educate Mary on these tools so she feels able to asses Ben’s pain and give competent care. Despite Ben’s diagnosis, his daily routine should maintained where possible to promote personhood. This for professional carers means respecting Ben and Mary’s daily routine and home environment. At present Mary feels she can cope at home with Ben, so enforcing home care services at this point may disempower Mary.

Support services should be made easily available to Mary when required (Ouldred and Byrant 2008). It is suggested by Van De Steen (2012) that mental health care is particularly well served by continuity of management and co-ordinating health services. Continuity of health professionals involved in Ben’s care means Ben and Mary do not have to repeat themselves over and over again and a health professional who knows Ben can easily recognise any changes. There are many tools a health professional could use to assess the effect that Ben’s Alzheimer’s is having on him and his care needs, including tools such as the care needs assessment package (Cameron and O’neil 2005). This assessment helps to establish goals for everyone involved in care, especially the health care assistant as they can prioritise needs and create continuity. Mary wants to ensure that Ben is well cared for weather it be by her or another carer, therefore her involvement in the decision about where Ben is cared for and how, is crucial in creating a sense of continuity. RCC can support Ben, Mary and his carers in feeling a sense of purpose (Nolan et al. 2004).

In this case study, Ben and Mary’s social lives have both been affected by his dementia, they have also yet to establish a relationship with a health care professional. Ben can be supported in many ways to engage in purposeful activity, including the pursuit of his hobbies. In most localities, there are community-based services that can support people to maintain their independence and fulfil their aspirations (Cook et al. 2012). However Cook et al. (2012) often states that there is a lack of information on support in the community. Alzheimer Scotland (2013) funds local Dementia Advisors, who support people with dementia, their partners, families and carers within the local community to access services. The support workers are highly trained to work with each person at home, to support a purposeful relationship where goals can be met. The support worker can suggest local community groups which have been created to offer a dementia friendly place for people like Ben and Mary to meet up for a chat.

Support workers also attend this event and it is a chance to really get to know the people involved in care outside of the home. Dementia often affects the sense of purpose for all individuals involved in care (Nolan et al. 2001). Alzheimer Scotland (2013) offers a wide range of welcoming community activities across Scotland, such as singing groups, football memories groups, walking groups, cinema groups and much more. If Mary wishes, she can arrange for a personal assistant to come to the house to be with Ben so she could go to choir practice. Whilst the personal assistant is with Ben, he can be supported to do the things he likes to, like clean his car and take part in meaningful conversation about his interests. The most important support an informal carer can have regarding the feeling of purpose, is the recognition that they are partners in the care of the dependent person (Ter Meulen and Wright 2012). Driving is closely associated with an adult’s personal identity and self-perceived role in family and society. An individual’s inability to drive can therefore affect their sense of purpose (Alder 2007).

Taking the car keys away from Ben is a life-changing event, both for him and Mary that crystallises the devastating impact of the diagnosis. However, through support, Ben can still be encouraged to pursue his love of vintage cars via car rallies and show visits. This can be done in a number of ways using RCC, a carer could support this for example or family members, who are educated about Ben’s needs, could enjoy pursing such events as a family outing, providing a sense of purpose in fulfilling Ben’s personhood. In conclusion, as the number of people with dementia is on the increase, the provision of sensitive and appropriate support for all individuals involved in caring for people with dementia, is needed. This assignment identified the RCC model and the six senses framework in relation to dementia care. Making connections with the senses that are often involved in everyday activity for all individuals involved in care, to promote RCC. This assignment also concluded that recognition of the six senses; security, continuity, belonging, purpose, achievement and significance, reflect the varying dimensions necessary for quality dementia care.

The senses framework captures the subjective and perceptual dimensions of caring relationships in order to create tailored and seamless care. When using RCC and the senses framework model in a case study, it allowed a biographical approach of care planning structured through ensuring the six senses are met. A greater understanding of the person with dementia can be achieved through using the six senses accurately. However if the future of care is going to change from patient centred care to RCC, more education on the subject is needed.

Reference list
ADLER, G., 2007. Intervention approaches to driving and dementia. Health & social work, 32(1), pp. 75-79. ALZHIEMER SCOTLAND, September 2011, 2011 – last update, The five pillar model of post-diagnostic support [Homepage of Alzheimer Scotland], [Online]. Available: http://www.alzscot.org/assets/0001/1226/Getting_post_diagnostic_support_right

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