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For most patients, a hospital is a safe space to receive care. But when some of those patients have dementia, that same hospital becomes an environment where a patient's world is out of control.
This destabilizing feeling can lead to what clinical experts call "responsive behaviours" – when a patient is agitated, aggressive and sometimes resorts to biting or scratching staff, or worse.
Over the last few years, the Toronto Western Hospital (TW) General Internal Medicine (GIM) in-patient units noted a steady increase in responsive behaviours among their patients with dementia, as well as an uptick in requests to use restraints or pharmaceutical interventions to manage them.
"It's not an ideal situation for patients or for staff to resort to these interventions, but is necessary at times for everyone's safety," says Janet Pilgrim, Nurse Manager, GIM 8B Fell, TW. "However, we thought there must be another alternative and started looking for other ways to not only de-escalate but prevent this behaviour without having to use pharmaceuticals."
GIM units are the most likely department to care for patients with dementia who need treatment in an acute care setting. But responsive behaviours can create a worsening cycle: long-term care facilities sometimes delay accepting patients with these behaviours until they improve.
However, without intervention, the unfamiliar hospital environment can aggravate these behaviours, creating more obstacles to discharge.
The team knew there was an opportunity to do better for their patients.
Research showed success with baby dolls
Janet, along with nurses Alicia Brancier from 8B and Patricia Carrillo from GIM's 8A unit, geriatric Clinical Nurse Specialist (CNS) Joyce Reardon and psychiatric CNS Regina Sawh, undertook a review of existing research on therapeutic approaches to decrease responsive behaviours.
Well-known research showed that pet therapy had proven useful, but the pet therapy program available at TW was inconsistent and only occurred at set times – so what could they provide on a daily basis instead?
The review finally led to an interesting idea: research in nursing homes and long-term care facilities had shown that dolls – baby dolls to be exact – could have a positive influence on responsive behaviours. It couldn't just be any doll, however, the doll's eyes had to open and close and it needed to have a soft, squishy body.
Despite this positive research, the intervention – called doll therapy – did not have any findings for an acute care setting, but the team decided to give it a try.
"At the time, we had an anxious patient on the unit and the research showed a doll might help," recalls Alicia. "We thought it was worth trying and bought 15 dolls for both GIM units to see if it would work."
Unlike children, patients are not given the dolls to play with. Dolls are left in a patient's room or nearby environment for them to choose whether and how they will interact with it – will they treat it as a doll or as a real baby? The clinical team then takes cues from the patient on how to interact with the doll so that everyone is following the same reality.
'The dolls give patients a different focus'
The anxious patient chose to interact with the doll as a baby, and became very nurturing toward it. As the patient continued to care for the baby, the person's anxiety began to decrease.
All patients who adopt a doll interact with it differently. Staff noted some sing to the doll, feed it or just talk about it, or to it, despite the patient having not spoken at all since coming to the unit.
"The dolls give patients a different focus other than just sitting in a hospital – it helps to focus their energy," says Janet. "And as our patients focus on the babies, it brings back a part of them.
"It's been really nice for staff to see these patients flourish again."
The initial trial with the dolls went so well, the team submitted a proposal to the Krembil Nursing Awards and received funding for 30 dolls for all TW GIM units. They also received approval from the Research Ethics Board to collect findings in an acute setting of the therapeutic benefits of the dolls.
Doll therapy is now an option for patients, providing another way for staff to interact with their patients who sometimes have trouble communicating because of their dementia. Families consent to have their loved one participate in the program, and each patient receives their own doll, which have different colour bodies to tell them apart.
Patients also get a rest from taking care of doll
As a patient interacts with their baby, a care plan is also developed for the doll so that staff know what works best to tell a patient when the doll needs to be taken away.
"The dolls need to enhance and not interfere with a patient's care," Joyce explains. "So when a patient has to go for tests or needs rest, staff will take the baby for a 'bath' or 'diaper change' or other activity so that the patient doesn't get upset about being separated from his or her baby.
"We also want to give patients a rest time to avoid them feeling they have to take care of the baby all the time."
Since implementing the project, patients who participate in doll therapy have consistently been discharged home or gone on to long-term care facilities. They also get to keep their doll which helps with the transition.
"These dolls have really helped to change our patients' lives," Janet says.
"They provide a level of comfort, they help patients find a purpose in their lives, and they help staff provide patients with a feeling of safety in a moment when their world might not make sense. Doll therapy has really helped individualize our care for the betterment of our patients."