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Service Delivery Innovation Profile

Hospital Volunteers Engage Dementia/Delirium Patients, Leading to Fewer Falls and Improvements in Emotional Well-Being


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Summary

Trained volunteers at Bega Hospital support inpatients with dementia and/or delirium by talking to them about past and current events; assisting with eating, drinking, and exercise; and participating in enjoyable activities such as playing cards. Volunteers communicate with nurses about any apparent patient needs and document patient activities and behaviors for inclusion in the medical record. Volunteers and staff believe the program has benefited patient outcomes, including nutrition and hydration status, safety, and emotional well-being. Although definitive evidence is not available, the program appears to have reduced patient falls but has had no meaningful impact on length of stay, use of antipsychotic medications, or mortality.

Evidence Rating (What is this?)

Moderate: The evidence consists of a prospective cohort study that compared patient falls, length of stay (LOS), use of antipsychotic medications, and mortality rates in a facility implementing the program with the same measures in a somewhat similar facility not implementing it (although this facility had a lower risk patient population); other evidence includes post-implementation questionnaire feedback from staff and volunteers involved in the program.
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Developing Organizations

Alzheimer’s Australia New South Wales Dementia Advisory Service, Bega Valley New South Wales, Australia; Southern New South Wales Local Health Network, Australia
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Date First Implemented

2009
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

A significant proportion of inpatients have dementia or delirium, and this figure will grow as the population ages.1 These patients—especially those exhibiting agitation, aggression, and wandering behaviors—have unique needs that busy staff typically do not have time to address.1
  • More inpatients with delirium and dementia: The prevalence of dementia and delirium in hospitalized older adults ranges from 22 to 89 percent, with risk factors for delirium including both institutionalization and advanced age.2 A 2008 survey at Bega Hospital found that 43 percent of medical inpatients and 25 percent of surgical inpatients had cognitive impairment. This problem will only increase as the population ages and develops a higher prevalence of dementia and delirium.1 By 2030, an estimated 7.7 million people will have Alzheimer’s disease (up from more than 5 million today); by 2050 16 million will have the disease.3
  • Little time for hospital staff to meet needs: Patient-centered care of persons with dementia and/or delirium involves sensitive and calm communication, behavioral approaches such as distraction and redirection of attention, activities such as reminiscing, and an understanding of each patient’s preferences and goals.4 Busy hospital staff often do not have time to engage patients in this manner while also handling other patient care tasks and responsibilities.

What They Did

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Description of the Innovative Activity

Trained volunteers support inpatients with dementia and/or delirium by engaging with them over the course of their hospital stay. Volunteers complete a patient profile form with the patient and family and spend time talking to them about past and current events; assisting with eating, drinking, and exercise; and engaging in leisure activities. Volunteers communicate with nurses about any needs they identify and document patient activities and behaviors for inclusion in the medical record. Key program elements include the following:
  • Identification and recruitment of eligible patients: Nurses identify those who might benefit from the program by completing an eligibility checklist on admission. The program does not serve those expected to be in the hospital less than 48 hours and those exhibiting physically aggressive behaviors that could place a volunteer at risk. Otherwise, eligible patients must meet at least one of the following criteria:
    • Age over 65 (over 50 for Aboriginal people)
    • A diagnosis of dementia and/or delirium
    • A Mini Mental State Examination score of fewer than 25 out of 30 points
    • The presence of one or more risk factors for delirium, including depression, heavy alcohol use, vision or hearing impairment, severe medical illness, previous history of delirium, or admitting diagnosis of hip fracture
  • Informed consent and volunteer assignment: A nurse explains the program to eligible patients and their family members and caregivers. After interested patients and families have consented to volunteer support, staff complete a volunteer program referral form. Volunteers wear a gold T-shirt with “Hospital Volunteer” embroidered on the front to enable staff, patients, and family members to recognize them easily. To avoid confusion and conflict among staff and volunteers, posters listing permitted and forbidden tasks for volunteers hang on unit walls.
  • Completion of patient profile form: With the help of a family caregiver if necessary, volunteers and patients complete a patient profile form that allows the volunteer to learn important personal and social information about the patient. The form includes the name the patient likes to be called; the names and relationships of close family members and friends; personal history, such as where the patient has lived and traveled, occupation(s), club memberships, hobbies, and war experience; music, movies, and television shows he or she enjoys; food and beverage likes and dislikes; and situations or comments that might make the patient upset or anxious.
  • Volunteer interaction with patient: Volunteers are scheduled for a morning or evening shift Monday through Friday. The morning shift is from 8 a.m. until 12:30 p.m. and covers breakfast and lunch, and the evening shift is from 3 p.m. until 7 p.m. and covers dinner and settling time. (Weekend volunteers can be scheduled depending on patient need and volunteer availability.) On a daily basis, staff, in consultation with the volunteers, prioritize referred patients according to their level of need. On average, one volunteer is assigned four patients per shift with the amount of time spent with each patient dependent on the patient's unique circumstances. For example, if a patient has a tendency to wander, the volunteer may spend most of his or her 4-hour shift with that one patient. Patients typically participate in the program until discharge; the average LOS during the first 6 months of the program was 15 days, with a range from 3 to 50 days. Typical interactions include the following:
    • Sitting with the patient individually or during group activities
    • Ensuring patient comfort, such as by adjusting pillows, providing drinks, or offering hand and foot massages
    • Ensuring that the patient wears his or her glasses and hearing aids (if applicable)
    • Talking to the patient about current events and surroundings
    • Assisting with menu completion, eating, and drinking
    • Accompanying or assisting the patient with walking and exercise (per nurse or physical therapist instruction)
    • Supporting the patient through enjoyable activities such as reading aloud or playing cards.
  • Communication and documentation: Volunteers communicate any concerns about patient well-being and any identified patient needs to nursing staff. They also record information on a “volunteer documentation and handover record” form, such as the patient's general condition and disposition, amount of food and fluids given to the patient, and activities and conversations (including the patient's response). At the end of the shift, volunteer place the form in a designated folder at the nursing station, and consult with staff to update the patient priority list that identifies the order in which nurses should attend to patients. After discharge, the volunteers remove the forms from the folder and give them to the ward clerk for inclusion in the patient’s medical file.

Context of the Innovation

Bega Hospital, a 74-bed acute care rural hospital in Bega Valley Shire, New South Wales, Australia, serves an aging population of approximately 33,000 in a coastal area popular with retirees. Currently, 21 percent of the area’s population is older than 65, a figure projected to increase to 35 percent by 2030. The initial impetus for the program came from Catherine Bateman, clinical nurse consultant with the Southern New South Wales Local Health Network, and Barbara Williams, dementia adviser for Bega Valley from Alzheimer’s Australia New South Wales. Both individuals had become aware of increases in agitation, distress, and functional decline in inpatients with dementia and delirium. In particular, Ms. Bateman became disturbed by her experience with a patient with delirium and dementia who had no close family and significant emotional care needs. Although staff recognized how much more settled and less anxious the patient appeared when accompanied by someone, they did not have time to provide such individualized support. The patient, who frequently became agitated, died in the hospital following a fall and subsequent development of pneumonia. Given their concerns, Ms. Williams and Ms. Bateman conceived of the program and decided to work together to recruit and train volunteers.  Since its implementation, the program has won Southern NSW (Australia) Local Health District Health Excellence awards.

Did It Work?

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Results

Volunteers and staff think that the program has had a beneficial effect on patient outcomes, including nutrition and hydration status, safety, and emotional well-being. Although definitive evidence is not available, the program appears to have reduced patient falls, but did not have a meaningful impact on LOS, use of antipsychotic medications, or mortality.
  • Improved patient well-being and less staff stress: A pilot test in Bega Hospital found that all volunteers and 96 percent of staff think that the program had a beneficial effect on several measures of patient well-being, including nutrition, hydration, safety, and emotional status (including level of anxiety and agitation). Nurses appreciated being supported in patient care (which reduces the amount of pressure on them) and think that the program should be instituted permanently.
  • (Possibly) fewer falls: A 6-month study comparing key outcomes at Bega Hospital and a similar facility (59-bed Moruya Hospital) found that the program appears to have reduced falls, with five  falls at Bega (representing 8 percent of patients), compared with eight falls (15 percent of patients) at Moruya. However, this difference did not meet the test of statistical significance. That said, program leaders think that the program's impact on falls may be understated because Bega Hospital treats more patients with dementia and dementia with delirium, suggesting a higher risk of falls.
  • Improved quality of care: Information provided in May 2013 indicates that a continuing quality improvement process using staff and volunteer feedback surveys shows ongoing high acceptance of the program by staff and volunteers. Staff perceive that the program improves the quality of care for patients with dementia and delirium and is supportive and assistive to staff in their care.
  • No apparent change in other outcomes: The study cited above found no difference between the two hospitals with respect to LOS, use of antipsychotic medication, or mortality. Again, program leaders interpret these findings as positive given the greater prevalence of dementia and dementia/delirium at Bega Hospital.

Evidence Rating (What is this?)

Moderate: The evidence consists of a prospective cohort study that compared patient falls, length of stay (LOS), use of antipsychotic medications, and mortality rates in a facility implementing the program with the same measures in a somewhat similar facility not implementing it (although this facility had a lower risk patient population); other evidence includes post-implementation questionnaire feedback from staff and volunteers involved in the program.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Ethics committee approval: Ms. Bateman sought and received approval for the initiative from the Area Health Service ethics committee.
  • Committee development: Program developers formed a committee with nurse unit managers, a clinical nurse specialist, the hospital nurse educator, and representatives from agencies providing services to this population in the community. Program developers consulted the committee periodically during design and implementation.
  • Volunteer recruitment: Program leaders recruited volunteers through a media (radio and newspaper) campaign and by approaching individuals who they knew may be interested.
  • Volunteer training: Program developers created and ran a 1-week training program consisting of four full-day sessions, plus an additional day for mandatory hospital education. Training topics included infection control, use of personal protective equipment, gentle exercise, use of hearing aids and battery replacement, menu completion/food choices, and positioning and feeding patients with swallowing problems.
  • Pilot testing and permanent adoption: Bega Hospital piloted the program with an initial group of 12 volunteers beginning in May 2009. Six additional volunteers were recruited in October 2009 to increase the available pool of volunteers. Based on its success, Bega Hospital committed to continuing the program permanently, and as of 2013 the program continues to operate.

Resources Used and Skills Needed

  • Staffing: The program requires no new employees. Ms. Bateman advocated for the program's implementation and provided ongoing monitoring and support as part of her clinical nurse consultant role. As of February 2011, 12 volunteers participate, supporting an average of 3.5 patients per day.
  • Costs: Minimal program-related expenses include the costs of producing the posters, T-shirts for the volunteers, the media campaign, and a small amount of time spent by program leaders on the initiative.
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Funding Sources

Tathra Ladies Hospital Auxiliary, New South Wales, Australia; New South Wales Institute of Rural Clinical Services and Teaching, Australia
Ms. Bateman received a grant though the New South Wales Institute of Rural Clinical Services and Teaching in Australia, which provided funding for a 1 day per week position to support the conduct of the program research.end fs

Tools and Other Resources

A staff/volunteer procedure and resource manual as well as a project implementation plan can be obtained by contacting the innovator. A volunteer training package will be developed later this year. 

Adoption Considerations

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Getting Started with This Innovation

  • Start with training and support structure: Volunteers need comprehensive training before working with patients, with a focus on understanding the boundaries related to their role. They also need nurse supervision when they first start. Over time, experienced volunteers can serve as mentors/supervisors for new volunteers.
  • Communicate with frontline staff during development: Program developers should formally communicate program goals and details to frontline staff, thus making sure they accept the program and understand the role of the volunteer (and hence do not have unrealistic expectations about what they can do). 
  • Seek volunteers with experience in caring roles: Individuals who have cared for a relative or spouse with dementia, held leadership roles, or have a nursing or health background tend to perform well in the volunteer role. Volunteers should show initiative, empathy, and a caring nature, and not have inflexible, loud, or dominating personalities.
  • Acknowledge imperfections: Volunteers may feel frustrated when faced with the realities of health care provision (such as delays in nurse responses to questions or patient needs). Managing their frustrations requires acknowledging these imperfections while at the same time expressing appreciation for their contributions.  
  • Emphasize volunteer as part of care team: Staff need to understand that volunteers serve as part of the care team, providing critically important emotional care and support to patients. Staff will recognize that the volunteers' actions help to make their jobs easier.

Sustaining This Innovation

  • Develop feedback system: Ensure that managers, staff, and volunteers have a formal opportunity to identify and address problems and issues as they arise over time.
  • Recognize value of volunteers: Volunteers will be more satisfied (and hence remain in the role longer) if they receive acknowledgment of their important contribution to patient care. Whenever possible, volunteers should be publicly praised (such as during staff meetings) and asked for their feedback and input on how to improve the program over time.
  • Measure and share data on program impact: Qualitative or quantitative results that demonstrate program benefits will keep hospital management and staff supportive of it over time.

Spreading This Innovation

Several Australian health services have adopted or plan to adopt a similar program, including Port Macquarie Hospital, Hollywood Private Hospital, Gosford Hospital Central Coast, Carrara Rehabilitation Unit in the Gold Coast Health Service, Ballart Health Service, and Lismore Base Hospital. Other rural hospital settings in New South Wales have replicated the program utilizing the project implementation plan available from the innovator.

More Information

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Contact the Innovator

Catherine Bateman
Clinical Nurse Consultant, Dementia/Delirium
Southern NSW Local Health Network
PO Box 173 Bega NSW 2550
New South Wales, Australia
Phone: (02) 64929677
E-mail: cath.bateman@gsahs.health.nsw.gov.au

Innovator Disclosures

Ms. Bateman reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.

References/Related Articles

Bateman, C. Research into practice: volunteers providing person-centered dementia care in a rural hospital. Greater Southern Area Health Service. New South Wales Health. Manuscript provided by author.

Bateman, C. Volunteers improving person centred care in a rural hospital: an intervention study [master's thesis]. Canberra, Australia: University of Canberra; 2012.

Footnotes

1 Bateman C. Research into practice: volunteers providing person-centered dementia care in a rural hospital. Greater Southern Area Health Service. New South Wales Health. Manuscript provided by author.
2 Graham J, Rockwood K, Beattie B, et al. Prevalence and severity of cognitive impairment with and without dementia in an elderly population. The Lancet. 1997;349(9068):1793-6. [PubMed]
3 Alfano S. Alzheimer's rate booms as boomers age: report says aging population main cause for 10 percent increase in past 5 years. CBS News Healthwatch. March 20, 2007. Available at: http://www.cbsnews.com/stories/2007/03/20/health/main2587100.shtml.
4 Tangalos EG. Challenges in dementia care. Medicare Patient Management. May/June 2009;4(3):23-29. Available at: http://www.medicarepatientmanagement.com/issue_04-3.php.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 22, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 14, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.