Development of a Sensory Stimulation Care Integrated in Daily Practice for Nursing Home Residents with Moderate to Severe Dementia: An Action Research Approach

Special Article - Long-term Care Staffing Policies and Programs

Gerontol Geriatr Res. 2017; 3(1): 1029.

Development of a Sensory Stimulation Care Integrated in Daily Practice for Nursing Home Residents with Moderate to Severe Dementia: An Action Research Approach

Kwong EWY¹*, Lai CKY², Tse MMY², Liu JYF² and Leung S³

¹School of Nursing, Tung Wah College, China

²School of Nursing, The Hong Kong Polytechnic University, China

³Alice Ho Miu Ling Nethersole Nursing Home, China

*Corresponding author: Enid WY Kwong, School of Nursing, Tung Wah College, Wyllie’s Road, Kowloon, Hong Kong, China

Received: May 19, 2017; Accepted: June 12, 2017; Published: June 19, 2017


Purpose: An action research design was adopted in this study to elicit the process of change in care staff’s Sensory Stimulation (SS) care to nursing home residents with later dementia and to finally develop a sensory stimulation care integrated to daily practice.

Methods: Three nursing home residents with moderate to severe dementia and their family caregivers, and the care staff who provided direct care to nursing home residents with later dementia from a nursing home participated in this study. Two action research cycles of the SS care integrated to daily practice were carried out by the care staff members. There were two rounds of interviews with the family members and the care staff conducted after the implementation of the SS care. The data were collected between March and July 2015.

Results: In triangulation of the data collected from the care staff and the family members, four main themes were identified after the two cycles of implementation. They were behavioral (Reduction in agitated behavior, Decrease in suspicion), psychological (Increase in positive emotional responses) and social changes (Increased social interaction with care staff and family members, Improved motivation to participate in activities) of the residents and also increased job satisfaction of the care staff. At the end of the second cycle, the SS care integrated in daily practice was finally developed.

Conclusion: Overall, the finalized SS care was well-accepted by the care staff and the family members but availability of sufficient resources and manpower should be ensured for the sustainability of this SS care.

Keywords: Alzheimer disease; Nursing homes; Sensory stimulation care


Care to nursing home residents with moderate to severe dementia

In 2011, 47% of all nursing home residents in the United States had a diagnosis of dementia [1],while in Hong Kong 31.6% of institutionalized people aged 60 or above were identified as suffering from dementia in 2009 [2], a figure projected to nearly by double between 2009 to 2039 in Hong Kong [3]. The majority of nursing home residents with dementia are at the moderate to severe stage of the disease, in which Behavioural and Psychological Symptoms Of Dementia (BPSD) are prevalent [4]. As the disease progresses, the residents become less aware and responsive as the severity of their dementia increases and their cognitive function decreases [5].

Nursing home residents with moderate to severe dementia usually lack adequate stimulation and human social interaction [6], which leads to an increase in their BPSD [4] and a decrease in their awareness and responsiveness [7]. Together with the BPSD, an increase in disabilities and morbidity among the residents will lead to more and/or prolonged hospitalizations and higher healthcare costs [8]. Staff caregivers in nursing homes will also have to spend more time managing the BPSD of these residents and will be more likely to experience distress in their care giving [9]. Their interaction with the residents may decrease, while their frustration with their job will increase [10], leading to burnout and a high staff turnover rate. This would negatively affect the quality of the care that is delivered to the residents [9].

Sensory stimulation-oriented care

Given this situation, there is an urgent need to improve the quality of the care delivered to residents with moderate to severe dementia. A non-pharmacological approach should be the first line of care [11]. A sensory stimulation-oriented approach that makes no appeal to intellectual abilities is feasible for people at the later stages of dementia [12]. Session-based Multisensory Stimulation (MSS) or Snoezelen in a room has been commonly used on older people with moderate to severe dementia [13-17] and on patients with dementia of all stages with BPSD, [18-21] in order to reduce their BPSD. In a recent review [22] of original studies of various designs and employing various experimental protocols to examine the impact of MSS on people with dementia [15,19,21,23,24], it was concluded that, in general, MSS has a positive effect on the behavior and mood of patients and/or on staff-patient communication, but that the effect of the stimulation only lasted as long as it was provided. Another review [25] of MSS for dementia patients, which included only two Randomized Controlled Trials (RCTs) [14,26], reported that MSS had no significant effects on the patients [14], with the exception of some short-term effects on behavior and mood from an MSS care programme that had been integrated into morning daily care [26].

Integrating sensory stimulation care in daily care

Indeed, psychosocial treatments, including a stimulationoriented approach to dealing with dementia, may not provide lasting effects; thus, those that can be embedded in daily care are practical and beneficial [27]. vanWeert reported the same trial in two studies [26,28] testing the effect of MSS integrated in daily care. There was more improvement in several specific types of behavior, in the mood of the residents [26], and in communicational interaction between the residents and care staff within the sessions [28] among those in the experimental group than in the control group, who were provided with the usual care. In short, the immediate and short-term effect of providing Sensory Stimulation (SS) to older people in the later stages of dementia is promising. Therefore, SS activities which are integrated into daily care may not only fulfill the unmet needs of people with dementia for environmental stimulation, but also for daily social interaction [29]. Thus, the effect on the residents is likely to be long-lasting.

As integrating sensory stimulation care in daily practice involves changing the care practices of staff in nursing homes, the staff are most likely to be fear and uncertain with changes, resulting in their resistance to such changes. Thus, our research team designed such care for care staff to provide while managing care staff’s change in their daily practice through action research approach.

Study Objectives

1. Elicit the process of changing care staff’s practice in sensory stimulation care

2. Development of a sensory stimulation-oriented care which is integrated in daily practice


Study design

We adopted action research for this study. Action research is a process of self-reflection and evaluative inquiry conducted by participants who are “actors” engaging in an “action” to change an “action” by improving or refining it. Unlike other research methodologies, the major characteristics of action research are participation and democratic impulse [30] Participants perceive the need to change and are willing to play an active part in the change, and they, not the researchers, will lead the change. The process of action research is a bottom-up approach that allows direct communication and open discussion among the participants (care staff participants and family caregiver participants) to enhance their understanding of the change. It also allows them to become involved in identifying problems and planning, implementing, and evaluating the change, and provides a sense of ownership to the participants. All of these are principles for managing changes in organizations. The participants will ultimately decrease their resistance to change, resulting in increased acceptance of the change [30,31]. A number of authors have recognized the potential of action research in the development of care practices through changes [31,34], as well as in the implementation of research findings [35,36].

Setting and sample

We used purposive sampling, residents and their family members, and various types of care staff from a nursing home in Hong Kong. The nursing home (1) was operated by a Non-Governmental Organization (NGO), (2) perceived a need for a change in care of residents with later stage of dementia and (3) was willing to play an active role in improving the care. There were three resident participants who were aged 65 or above, suffered from moderate to severe dementia as diagnosed by medical officers, and at stage 5 or 6 of the Functional Assessment Staging Test (FAST), but with no additional diagnosis of a psychiatric nature (Table 1). Three family member participants were the primary caregivers of the three resident participants, and they visited the resident participants at least twice a week. The care staff participants were professional nurses, health care workers, personal care workers or service assistants who had opportunities to care of these three residents. All of the participants voluntarily took part in the study. There were only three resident participants in this study because the nursing home wanted to preliminarily try this programme to see the acceptance of the residents and the care staff and hoped to develop this programme for future adoption.