
Recently, I have been thinking a lot about the “lack of empirical evidence” label that hounds culture change enthusiasts. Here are two examples:
- I just read an article from The Gerontologist, (2008), in which Rahman and Schnelle reviewed the history of the long-term care culture change movement in the U.S. over the previous decade. They noted an increased interest, momentum and visibility in the prior three years, but pointed out (correctly) the lack of well-published empirical data to date.
- After writing the New England Journal of Medicine to criticize the recent antipsychotic withdrawal study (see my January 15, 2013 post), the authors responded by saying that person-directed approaches were certainly promising, but had yet to be well tested in empirical trials.
I was trained in science and am a big believer in empirical methods, wherever they can be applied. I would also love to see more published evidence of the efficacy of the transformational models of care being developed within the culture change movement. These are often difficult to study, due to the slow, multifaceted nature of transformation, but at the very least, we need more well-planned studies that compare a variety of outcomes between culture change adopters and traditional models.
All of that is well and good. Here’s my problem: Innovation is too often held to a standard that traditional approaches never had to meet.
Let’s go back to the two examples above:
- There have never been empirical studies to evaluate whether our current system of long-term care produces quality outcomes. Maybe that’s because it’s the only system we’ve known for half a century. But consider what we know about: staff turnover rates, antipsychotic and physical restraint usage, reports of abuse, failures to meet regulatory standards, and the public perception of life in a nursing home. We actually have a wealth of data proving that our current long-term care system is an abject failure. And yet we hold up change efforts, because we need better evidence.
- Next, let’s talk about person-directed approaches to dementia. Once again, they are hard to study empirically for a variety of reasons, not the least of which is the hold of Big Pharma on funding of research in this area. But once again, let’s scrutinize the current widespread use off-label use of antipsychotics — the best studies show no more than 18% improvement behavior, with 50-60% higher mortality… and yet over a million Americans with dementia take these drugs and it is still accepted as good practice. Drugs like Ritalin and Neudexta have been liberally sprinkled into the dementia cocktail with little empirical study to back them up. The FDA has approved a larger (read: newly patented and expensive) form of Aricept, even though the studies showed no added benefit and increased side effects.
So my problem is that new ideas shouldn’t have to jump over so many hurdles to funding and implementation if the old ideas have such a terrible track record. Let’s apply the same scientific standards to both, rather than throwing up smokescreens to preserve a failed status quo.
Love it, Sonya – thanks!
Agreed! We also need to consider that in comparing outcomes between traditional and person-centered models, the outcomes we traditionally have measured might need to be re-evaluated or even re-invented. What are the important outcomes for demonstrating the person-centered model is better? Better according to whom?
I couldn’t agree more. For a decade I have used an approach called Compassionate Touch with elders in long term care with dementia. The impact of human touch is profound to help ease anxiety and agitation, not to mention build strong caregiver relationships. I’ve often said that the impact of humanistic approaches are difficult to measure but it’s the world we live in. Fortunately there is some evidence base for skilled touch in eldercare. I’d rather credit was given to what we experience rather than trying to fit into a structure that is so clearly ineffective. I’ll keep on keeping on with trying to make a difference by teaching caregivers how powerful touch can be.
Thanks go to the author of this blog, i personally disagree with the promoters of medication only as final solution in management of dementia among Older Persons.
I believe that there is need to apply both medication and psycho-social support or package.
Thanks
Best wishes to you all.
I recently had a conversation with another like minded nurse, about doing more research in person directed care practices, because of this issue of how to meaure “happiness”. She hopes to team up with a noted research facility in our state. I encouraged her and will continue to support her in this direction of “change”. We know in our hearts that this is the right way to go, how do we prove this? Evidence based person centered care? Keep on questioning the way things have always been done!