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THE IMPLEMENTATION OF THE C A SE A SSIG N M E N T METHOD OF PATIENT C A R E AT THE DR. A.J. ST A LS CARE AN D REHABILITATION CENTRE Nora L. Daniels Principal Matron Dr. A .J. Stals Care and Rehabilitation Centre

OPSOMMING Die moderne benadering tot die versorging van die geestesvertraagde in inrigtings is nie slegs meer om selfhulpvaardighede te voorsien nie, maar om elke pasiënt op te lei en te rehabiliteer om hom sodoende in staat te stel om tot sy maksimum potensiaal te funksioneer. Dit vereis dat elke inwoner se vermoëns vasgestel en ’n program vir sy opleiding na aanleiding van sy behoeftes en bekwaamhede opgestel moet word. Inwoners wat dieselfde opleidingsprogramme vereis word saam onder toesig van ’n verpleegster groepeer. Die aantal inwoners in een groep word deur hul selfhulpvaardighede bepaal. Die ingeskrewe verpleegassistent, onder toesig van die saalsuster en onder leiding van die multidissiplinêre span, kan verantwoordelikheid vir die uitvoering van die opleidingsprogramme aanvaar.

1.

Introduction

2.3

he m odern approach to the care of the mentally retarded in institutional settings is no longer to provide only custiodial care, but to train and rehabilitate each patient to be able to function at his m axim al potential. This requires th at each resident m ust have his abilities assessed and a program m e im plem ented for his training, according to his p ar­ ticular needs and capabilities. Residents requiring sim ilar training program m es are therefore grouped together under the care o f one nurse, the num ber of residents in each group depending upon their selfcare skills. The nurse is assigned the responsibility o f carrying out the training program m e under the supervision o f the W ard Sister and with the guidance o f the m ultidisciplinary team under the leadership o f the psychiatrist.

2.4

T

2.

The Value of the Case Assignment Method

2.1

The nursing process is m ore easily facilitated when the nurse stays with her group o f patients long enough for her personally to determ ine their p ro ­ blem s, plan to solve them , initiate these plans and evaluate the extent to which the plan was effective. The m entally retarded person needs to be able to form a perm anent trusting relationship with one or m ore persons. A cting out frequently occurs as a result o f constant s ta ff changes.

2.2

December 1980

2.5

Residents develop a feeling o f group-cohesion in small family-like groups. By grouping patients together who have the same needs, organisation is sim plified. Residents may aspire to be prom oted to a higher category group.

3.

Defining the Problems Associated with the care of the Severely and Profoundly Retarded

3.1

Outlining the Roles and Functions of Nursing Per­ sonnel The care and rehabilitation o f m entally retarded persons requires the skills o f m any disciplines, and questions have been asked, by the Jay Com m ittee2, for instance, whether in fact this type o f care should be adm inistered by the nursing profession. The skills o f the following disciplines are needed: Oc­ cupational T herapists, P hysiotherapists, Social W orkers, Clinical Psychologists and Psychiatric Nurses. The ratio o f param edical staff to patient does not allow for individual care to each patient, while the nursing staff are in close contact with the residents for 24 hours o f the day. M ore particularly, it is the enrolled nursing assistant, under the supervision o f the W ard Sister, who is the only person working closely and intim ately at all times with the resident.

CURATIONIS

37

gram m e. In the case assignm ent m eth o d the a c h ie v e m e n ts o f th e re s id e n t a re a ls o th e achievem ents o f th at particular group nurse, and can be used as incidents when staff reports are w rit­ ten by her supervising officer.

The registered nursing staff therefore have to en­ sure that those principles o f rehabilitation which are delegated to the nursing assistant are clearly understood by her. Close co-operation and team w ork are essential if the param edical staff are to m ake a contribution tow ards im proving the skills and knowledge o f the nursing assistant, while a clear definition o f the roles and functions o f team m em bers is essential. The skills required by the nurse are those for the creation o f a therapeutic environm ent, health education, counselling, socialising, teaching, com ­ m unicating, prom oting m ovem ent and preventing physical deform ities and providing activity p ro ­ gram m es. W hen one adds the basic technical n u r­ sing skills required, it is evident that a great deal is expected from the nursing assistant. Virginia H enderson states (1,“ the unique function o f the nurse is to assist the individual, sick or well, in the perform ance o f those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. A nd to do this in such a way as to help him gain independence as rapidly as possible” . This definition o f the function o f the nurse leaves little doubt that the care o f the retarded is as much the responsibility of the nurse as is any other specialised branch of nursing. Provided that the multidisciplinary team is prepared to work only for the best interests o f the patient, role confusion should not occur.

3.2

Education o f Nursing Personnel The case assignm ent m ethod o f care is a new con­ cept to m any o f the staff working in care and rehabilitation centres, whose basic training has been in the provision o f custodial care. Education program m es have therefore to be provi­ ded fo r all m em bers o f staff. The team m ust reach unanim ity on w hat should be taught, and how education should be given. F orm al lectures are necessary, but the team has to be prepared also to w ork closely with the nursing sta ff in the ward situation, which is tim e consum ing.

3.3

Motivation o f Nursing Personnel S ta ff have to be persuaded to become firm ly com ­ mitted to the norm alisation principle, and to believe th at all m entally retarded persons can m ake p ro ­ gress, however slow, provided that patient, consis­ tent and repetitive teaching is exercised, and realistic goals are set. In the functional system o f caring for the retarded, a nurse does not see the results o f her training p ro ­

38

CURATIONIS

4.

Stages in the Introduction of the Case Assignment Method of Rehabilitation at this Centre

4.1 Planning W eekly meetings o f the m ulti-disciplinary team were held. It was decided to use one w ard as a p ro ­ totype, and to include all the nursing s ta ff o f this w ard at these meetings.

4.2 Assessment of Patients Before program m es could be draw n up for in­ dividual groups, their capabilities had to be assess­ ed. Because o f the large num ber o f patients this assessm ent had to be done by the nursing assistant, and a schedule had to be devised which could be us­ ed by her. (For evaluation chart see A nnexure ‘A ’). The assessm ent charts were tested fo r validity and reliability for use by the nurse in the w ard situation.

4.3 Activity Programmes A system was w orked out w hereby planned and organised activities could take place in the w ards. Each group nurse w ould collect a box from the O c­ cupational Therapy D epartm ent each m orning. This box w ould contain a set o f cards outlining the daily activities and the equipm ent necessary for these activities (for exam ples o f the cards see A n ­ nexure ‘B’).

4.4 Rehabilitation Schemes Each group leader would choose one patien t from her group to w hom she w ould apply intensive rehabilitation. His gross m otor developm ent would be assessed according to A nnexure ‘C ’. T he tasks which he had already achieved w ould be noted on his record, and she would com m ence his training program m e at a task which he had not yet achieved. She would proceed in this way until he achieved his m axim al potential, and while m ain­ taining him at this level w ould proceed to the next patient. N urses were encouraged to visit the library and con­ sult the prescribed books them selves, so th at an in­ terest w ould be developed in them to do their own research. The w ard doctors were requested to give guidance to them in the im plem entation o f the scheme (see A nnexure ‘C ’) . Desem ber 1980

4.5 Physical Exercises

5.1 Involvement of Ward Staff

T he P hysiotherapist w orked with the nurses in the w ard, instructing them on the correct m anner o f seating and carrying the spastic patients, doing passive m ovem ents, and teaching o f feeding.

W hen the m ultidisciplinary team were satisfied that sufficient research had been done, the next stage was to include all the nursing staff in the im­ plem entation o f the plan. In-service education was devoted to this subject to all categories o f staff over a period o f six weeks.

L arge diagram s o f these procedures were draw n and placed on the walls o f the wards. Tw o nurses were assigned to the P hysiotherapy D epartm ent.

5.2 Full-scale Assessment of Patients

T he skills and knowledge which they obtained there were utilised by these nurses visiting the w ards and instructing the group nurses.

A n assessment was done on all residents, and the num ber in each category, subdivided into age groups, was ascertained. These residents were assigned to the location m ost suited to their needs. The precise num ber o f nursing staff required could then be allocated to each ward.

4.6 Allocation of Staff to Wards T he nurse ad m inistrators, in conjunction with the W ard Sister, ascertained how m any patients a nurse could effectively care for, by observing the nurses at w ork. It appeared th at the ideal sta ff/p a tie n t ratio should be as follows: C ategory A P atients : 1 N urse to 25 P atients C ategory B P atients : 1 N urse to 12-13 Patients C ategory C P atients : 1 N urse to 8-9 Patients C ategory D P atients : 1 N urse to 5-6 P atients T he overall total required proved to be consistent with the ideal recom m ended ratio o f 1 nurse to 3 p a ­ tients.

It was found necessary to draw up a m otivation for the appointm ent of 40 additional nursing assistants to the establishm ent. A pplicants for adm ission are interviewed and assessed before being placed on the waiting list. They are adm itted only when a bed is vacant in a suitable ward. 6.

Group Programmes

Each group nurse is responsible for m aking her own program m e. By staggering times for bathing and activities, overcrowding o f facilities is alleviated, e.g. one group will be out walking while ano th er is playing games and another is bathing.

These figures will also depend upon the physical structure o f the w ards, and m ay have to be slightly m odified according to the num ber o f patients each w ard holds and the size o f cubicles, side-w ards or dorm itories.

Each group programme must include times for: 4.7 Allocation o f Off-Duties

T he next task was to arrange the off-duty rosters so th at one nurse w ould rem ain with her group. N u r­ sing sta ff work from 07h00 to 18h00, with an hour for lunch. Tw o days o ff duty follow every 3 days on duty. O ne nurse is therefore with her group for 3 days relieved by an o th er nurse on her days off. Five nurses are required for every 3 groups. A part from being m ost econom ical in term s o f m anpow er utilisation, the nurses rem ain with their groups th ro u g h o u t the day, and do not have the discon­ tinuity which would arise from ‘split-shifts’. T he nursing sta ff allocated to a ward rem ain in that w ard for as long as possible, with only pupil nurses and pupil nursing assistants rotating. Nurses are a d ­ vised to request a change o f w ard should they so wish.

5.

Implementation o f the Plan

December 1980

M eals and teas Personal hygiene Toilet training Acitivity program m es, occupational or industrial therapy Physical exercises, passive m ovem ents and music Use o f rehabilitation scheme Provision o f entertainm ents U nstructured time W hen a nurse leaves the w ard for her own meal and tea times, two groups are cared for by one nurse.

7.

Evaluation of Progress The m ultidisciplinary team visits a w ard each week. The grouping o f patients is discussed, and each nurse is encouraged to talk ab o u t her p ro ­ gram m e and progress m ade by individual patients. If a resident is re-assessed and found to have im­ proved he is placed in a higher category in a dif­ ferent group.

CURATIONIS

39

T here are still problem s, which will continue until a full establishm ent o f staff is reached and until all the sta ff becom e totally fam iliarised with the scheme. W ith the training o f pupil nurses in the m ental retard atio n elective course, and the ap p o in t­ m ent o f the additional nursing assistants requested, it is envisaged th at the scheme should be running sm oothly within a year.

8.

II. E M O SIO N ELE ST A B IL IT E IT

1. CONCLUSION: 2. All m em bers o f sta ff at this C entre approached this project with enthusiasm and interest. W ithout the Clinical Psychologists to m ake the Assessm ent C hart, the O ccupational Therapists to m ake the Activity C harts, the contributions o f the P hysiotherapist and the M edical S taff, the co-operation o f the Nursing S taff and the guidance and leadership o f the M edical Superintendent, success would not have been achieved. PASIËNTE-EVALUERING : “ A N N EX U R E ” A ’

A = Pasiënte wat tot selfversorging, sosialisering, kom m unikasie en beroepsvaardighede in staat is, w at in staat is om in nyw erheidsterapie te werk en w at ’n program ter voorbereiding vir ontslag deurloop. B = Pasiënte wat tot selfversorging in staat is, m aar w at sosialisering, kom m unkiasie en beroepsvaar­ dighede m oet aanleer. C = Pasiënte wat hulp benodig m et die basiese selfsorgvaardighede. Hulle kan deel neem aan een o f ander aktiw iteit in die saal o f arbeidsterapieafdeling. D = Pasiënte wat oor geen van genoem de vaardighede beskik nie en 100% verpleegsorg o f noukeurige toesig benodig.

ens? (Sonder toesig 2, Gedeeltelik 1, G lad nie 0) Hoe gereeld kry die persoon epileptiese aanvalle? (Glad nie 2, M inder as 4 keer per m aand 1, 4 of meer keer m aand o f status 0)

3.

4.

5.

6. 7.

8.

Rand die persoon ander persone aan? (G lad nie 2, M inder as 2 keer per week 1, M eer as 2 keer per week 0) Beseer die persoon hom self? (Glad nie 2, M inder as 2 keer per week 1, M eer as 2 keer per week 0) Breek die persoon voorw erpe soos m eubels en vensters? (G lad nie 2, M inder as 2 keer per m aand 1, meer as 2 keer per m aand 0) Ly die persoon aan w oedebuie, skreeu, lag en vloek hy onbeheers? (Glad nie 2, M inder as 2 keer per week 1, Meer as 2 keer per week 0) Bevredig die persoon gew oonlik sy seksuele drange in die openbaar, bv. m asturbasie, o n tb lo o t van geslagsdele? (Ja 0, Nee 2) Is die persoon se seksuele gedrag sosiaal aanvaarbaar? (Ja 2, Nee 0) Is d aar ander psigiatriese afw ykings aanw esig, bv, vervolgingswaan, hallusinasies, depressie, ens.? (Ja 0, Nee 2) Is pasiënt to taal spasties? (Ja 8, Nee 0)

III. K O M M U N IK A SIE

1. 2. 3. 4.

Kan die persoon die gesproke taal verstaan? (Ja 2, Nee 0) Kan die persoon tekens en gebare verstaan? (Ja 2, Nee 0) Kan die persoon ’n gesprek voer? (V erstaan b aar 2, M oeilik verstaanbaar 1, G lad nie 0) Kan die persoon hom self v erstaanbaar m aak deur tekens en gebare? (Ja 2, Nee 0)

KRITERIA

I. 1. 2. 3. 4. 5. 6.

7.

40

P E R S O O N L IK E VOORKOM S EN SELFV ER ­ SO R G IN G Is die persoon se voorkom s norm aal? (G oed 2, Redelik 1, Swak 0) Kan die persoon hom self was? (Sonder toesig 2, G edeeltelik 1, G lad nie 0) Kan die persoon hom self aantrek? (Sonder toesig 2, G edeeltelik 1, G lad nie 0) Kan die persoon self eet? (Sonder toesig 2, G edeeltelik 1, G lad nie 0) Kan die persoon self die toilet gebruik? (Sonder toesig 2, Gedeeltelik 1, Glad nie 0) H et die persoon onaanvaarbare persoonlike gew oontes, bv. kwyl, in sy neus krap, klere skeur, kop k rap, in die openbaar defekeet o f urineer, ens.? (Ja 0, Nee 2) Kan die persoon eenvoudige takies en opdragte uitvoer, bv. gestuur w ord, sy bed opm aak, vloere vee, CURATIONIS

IV. W ER K G EW O O N TES

1.

2. 3. 4. 5. 6. 7.

Kan die persoon enige produktiew e werk verrig, bv. saalw erk, arbeidsterapie, ens.? (Ja 2, G edeeltelik 1, Nee 0) Kan die persoon sonder gedurige toesig w erk? (Ja 2, Gedeeltelik 1, Nee 0) Is die kwaliteit van die persoon se werk goed? (Ja 2, Gedeeltelik 1, Nee 0) Is die persoon b etro u b aar in sy w erk? (Ja 2, Gedeeltelik 1, Nee 0) Stel die persoon belang in sy w erk? (Ja 2, Gedeeltelik 1, Nee 0) Is die persoon betyds vir werk? (Ja 2, Gedeeltelik 1, Nee 0) H et die persoon potensiaal om m eer ingewikkelde werk te doen? (Ja 2, G edeeltelik 1, Nee 0) Desem ber 1980

V. SO SIA L ISE R IN G

Building Blocks

1.

Seat patients around a table. Give each a set o f blocks. Show them how to make a tower. Take their hands and help them by supporting their blocks until they become m ore com petent.

2. 3. 4. 5. 6. 7. 8. 9.

A anvaar die persoon opdragte van toesighouers? (Ja 2, Gedeeltelik 1, Nee 0) K om m unikeer die persoon vryelik met ander per­ sone? (Ja 2, Gedeeltelik 1, Nee 0) Kan die persoon vriende m aak met p asiën te/personeel? (Ja 2, Gedeeltelik 1, Nee 0) Kan die persoon as lid van ’n groep werk o f speel? (Ja 2, Gedeeltelik 1, Nee 0) Kan die persoon gew oonlik sy beurt afw ag? (Ja 2, Gedeeltelik 1, Nee 0) Gee die persoon sy sam ew erking aan personeel? (Ja 2, Gedeeltelik 1, Nee 0) Stel die persoon belang in nuwe aktiw iteite? (Ja 2, Gedeeltelik 1, Nee 0) Kan die persoon leierskap aanvaar? (Ja 2, Gedeeltelik 1, Nee 0) V erstaan die persoon dinge soos onselfsugtigheid, ywer, m ededeelsaam heid, ens.? (Ja 2, Gedeeltelik 1, Nee 0)

SLEUTEL VIR KLASSIFISERING

A B C D

K IN D ER S 5 6 -7 0 4 0 -5 5 1 9 -3 9 0 -1 8

VOLW ASSENES 61 - 70 A 44 - 60 B 22 - 43 C 0 - 21 D

ACTIVITY PROGRAMMES: “ A N N EX U R E ” ‘B’

Category : Group D T ake patient to toilet at the times you have already ascertained by observation th at he most frequently wets and soils him self. R ew ard him with a chipnick and warm priase im m ediately he has used the toilet. If he does not use the toilet, take him back w ithout reprim anding him , and try again later.

Walking

Place a ladder on the floor. H elp patient to walk between the rungs o f the ladder. E ncourage them not to step on the rungs.

Musical Activities

Play m arch or dance music on a tape recorder. Encourage patients to move to music. Stop music at intervals and tell the patients to sit down when the music stops. Do not restart music until all patients are sitting. Encouraging Responses and Eye Contact

Sit in front o f patient and call his nam e. Reward him with smiles and praise if he responds by looking at you. If he does not respond take his head in your hands and move his face tow ards you as you call his name. W hen this has succeeded several times, stand behind him and call his nam e, getting him to turn tow ards you.

Category : Group C

Body Image

Give each patient a cardboard doll which has its limbs and head cut off. Encourage him to assemble it, using paper clips. Seat patients in a circle and issue the following instruc­ tions: “ shake your h ead” “ close your eyes” “ clap your h an d s” “ move your toes” “ open and close your m o u th ” “ shrug your shoulders” “ bend your knees” “ stam p your feet” Marching to Music Teach patients to walk, skip, run, gallop, stop.

Individual Activities

Outings

Seat patients at a table. Give each one a piece o f play dough. Teach them how to m anipulate and cut the dought. Encourage them to m ake form s.

Take patients for a walk. Get them to identify various objects. Get them to collect items such as leaves, flowers, grasses and paste them on paper on their return.

December 1980

CURATIONIS

41

REHABILITATION SCHEME : “ A N N EX URE” ‘C ’

GROSS MOTOR DEVELOPMENT CONSULT QUESTION Does the resident: 1. M ove h is/h er limbs freely and frequently? 2. M ove h is/h er head from side to side? 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

Raise h is/h er head when lying on (stom ach) abdom en? H old h is/h e r head upright when sitting? Sit with support? Roll from side to side? Raise h is/h er body when lying on (stom ach) abdom en? Sit w ithout support? M ove forw ard when lying on h is/h e r abdom en? M ake crawling m ovem ents when supported? Pull h im /h e rself to a sitting position? Crawl? P ull h im /h e rself to a standing position? Stand w ithout support? T ake a step forw ard when supported? W alk with assistance? W alk w ithout assistance? Judge distance (Eye-hand co-ordination)? Judge distance (Eye-foot co-ordination)? H ave physical deform ities to prevent active play? T ake p art in active play? Suffer from spasticity?

W erner & Jo hnson:T ask 35 W erner & Johnson:T ask 36 W erner & Johnson:T ask 37 Uys page 46-48 W erner & Johnson: Task 38 Uys Page 52 Uys P age 51 Uys Page 53

Uys P age 49 Uys Page 54-58

W erner & Johson:T ask 77 W erner & Johnson:T asks 78-79 C onsult P hysiotherapy D epartm ent for advice W erner & Johnson:T asks 81-82 Finnie Pgs 32-67&191-199

EATING 23. 24. 25. 26. 27. 28. 29. 30. 31.

M ake a sucking m ovem ent? T ransfer food from hand to m outh? T ransfer food from spoon to m outh? E at independently with a spoon? T ransfer food from fork to m outh? D rink from a cup? D rink from a glass? Show ap p ro p riate table m anners? Suffer from spasticity?

Slides o f Jo n ath an

Finnie Pg. 111-128

TOILET TRAINING 32. Is the resident toilet trained?

W erner & Johnson:T asks 110-111 & 113-118

DRESSING Does the resident: 33. Pull up his pants? 34. Slide dow n his pants? 35. T ake o ff shirt? 36. P u t on shirt? 37. T ake o ff socks? 38. P u t on socks? 39. B utton h is/h er shirt? 42

Bensberg Pg. 87-93 & 151-156

Uys Page 66

CURATIONIS

Desem ber 1980

PERCEPTION 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50.

W erner W erner W erner W erner W erner W erner W erner W erner W erner W erner W erner

P u t identical objects together? Seperate grouped objects? Do puzzles? M atch objects to objects? D iscrim inate between objects M atch identical shapes, colours, pictures? M atch anim als with sounds? M atch m otor activities to hearing? M easure quantity? Recognise local sequences o f events? A rrange objects to duplicate a pattern?

& & & & & & & & & & &

Johnson :Tasks 214-216 Johnson :Task 217 Johnson :Task 218 Johnson :Task 219 Johnson :Tasks 220-222 Johnson Tasks 223,226, 227 Johnson Task 232 Johnson T ask 233 Johnson Task 239 Johnson Task 240 Johnson Task 238

BIBLIO G RA PH Y

1. Bensberg, G .J.: Teaching the M entally Retarded. Southern Regional Educational Board. Georgia, 1965. 2. Finne, N .R.: H andling the Young Cerebral Palsied Child at Home. E P Dulton & Co. Inc., New York, 1975. 2nd Edition. 3. Henderson, V.: The N ature o f Nursing. MacMillan C o., New York, 1966. 4. Jay, P .: Report o f the C om m ittee o f Enquiry into M ental handicap Nursing and Care. Nursing Times, 22 M arch, 1979. 5. Johnson, V.M. & R .A . Werner: A Step by Step learning Guide fo r Retarded Infants & Children. Syracuse University Press. New York, 1975. 6. Uys, L.R.: Psigiatriese verpleging van die geestesvertraagde. P .J. de Villiers. Bloemfon­ tein, 1977.

December 1980

CURATIONIS