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Advanced care of patients with cognitive impairment

By: Mullane Harrington, MPH, BSN, RN-BC

A proactive strategy to reduce workplace violence and improve staff satisfaction.


  • Proactive care strategies can prevent unwanted behaviors in patients with cognitive impairment.
  • Reducing disruptive behaviors decreases workplace violence incidents.
  • Investing in the professional development of nurses and supporting them with the right resources improves staff satisfaction.

In 2016 at PeaceHealth Saint Joseph Medical Center (PeaceHealth), a 256-bed facility in Bellingham, WA, a pattern emerged during a routine caregiver assault incident review. Most of the events involved patients with cognitive impairment such as dementia. As a clinical nurse educator with specialty certification in psychiatric and mental health nursing who provides training in verbal de-escalation and safe management of escalated patients, I detected a limitation with the training—it didn’t address the unique needs of individuals with cognitive impairment who came to the facility in crisis.

With leadership support, I developed the Advanced Care of Patients with Cognitive Impairment program, which is designed to decrease assault incidents and improve care of hospitalized patients with cognitive impairment.

Understanding the issue

Healthcare is known for having higher rates of violence injuries compared to other types of workplace injury. Despite growing national attention to healthcare workplace violence prevention, many still believe violence by patients and family members is part of the job. Governing bodies with regulatory influence have long asserted that organizations must take a stand on behalf of healthcare workers, and verbal de-escalation training has been a focus. Organizations are quick to show evidence that these trainings are being offered, but their rates of assault against employees remain relatively unchanged.

Standard workplace violence reduction approaches that use verbal de-escalation strategies are designed for verbally and cognitively intact patients. However, a 2014 study of assaults against nurses (in emergency and non-emergency departments combined) found that 49.9% involved patients with cognitive impairment or Alzheimer’s disease. Because verbal de-escalation isn’t appropriate for these patients and no specialized training is available to meet their needs, nurses and nursing support caregivers are being injured.

Developing the program

To develop the program, I reviewed available training and literature, and I consulted with experts and advocates for individuals with cognitive impairment. I discovered that although a significant amount of information is available for community settings, essentially no specific information addresses caring for these patients in acute care settings, where time and relationships are restricted. The result is that patients who can’t communicate verbally are forced to communicate through their behavior, which can sometimes become violent.

I chose to adapt available long-term care best practice approaches to address violent behavior to meet acute care needs. The result is a dynamic approach to caring for patients with cognitive impairment taught in a 4-hour session. The training includes practical care strategies to prevent escalated behaviors and environment modifications with diversional activities. The training also provides empathy-building experiences and techniques for responding to escalating behavior with specific strategies to meet the unique needs of patients with cognitive impairment. 

Piloting the program

I piloted the program on a 39-bed medical-surgical unit. Approximately 100 caregivers on the unit and the entire security department attended the training within a 6-week period.

The program has two main components: empowering staff with education on advanced caregiving strategies for this patient population and providing access to diversional activities. (See Strategies and diversions.)

Strategies and diversions

The Advanced Care of Patients with Cognitive Impairment program incorporates practical care strategies and environment modifications with diversional activities to prevent escalated behavior and manage crises. The table below offers both proactive and reactive examples.

Proactive Reactive (crisis management)
Verbal communication


·      Mirror the patient’s communication style (for example, if the patient uses only one- to two-word sentences, you should do the same) ·      Stop talking
Diversional strategies


·      Set up activities that allow patients to “help”

(for example, bring items for sorting and say, “I could really use your help organizing these.”)

·      Reduce eye contact

·      Give patient additional space


The training is offered quarterly; currently, 35% of all acute care staff have taken the course. Topics include an overview of cognitive impairment with statistics and implications for health outcomes, an empathy-building activity that highlights lost and distorted sensory input and overstimulation, an introduction to cognitive function and memory theory, practical care strategies for preventing unwanted behaviors, music and other diversional activities, de-escalation strategies specific to patients with cognitive impairment, medications, and documentation.

 Diversional activities

Items intended to give purpose to hospitalized patients with cognitive impairment were made available through donations. The items, which are organized by cognitive level and related needs, can be quickly accessed by caregivers. Most of the items can be sanitized, but some (such as a retired card deck donated by a local casino) are single-use items that the first patient who uses can keep. Old iPods provide music divided into decades so that patients can listen to songs from their teenage years.

 Pocket guides are available for staff to reference when they’re caring for a patient with cognitive impairment. They include quick tips for selecting diversional activities based on the patient’s verbal and fine motor skills. For example, for a patient who’s nonverbal and holds utensils with a palmer grasp the most appropriate activity might be sorting large, easy-to-grab items.

Pocket guide. Photo courtesy of PeaceHealth, 2019.


Making training mandatory and providing staff with ongoing resources has led to exciting and inspiring results. In periodic surveys, caregivers who access the available supplies but don’t receive training focus on the limitations of what’s available. Staff who attend the training but work outside the hospital report that the training is pointless without the supplies. Success requires both training and supplies.

A review of incident reports 6 months before and after the training showed a 97% reduction in staff injuries caused by patients with cognitive impairment. Outcomes 1 and 3 years after program initiation include reduced assaults against caregivers by patients with cognitive impairment and increased staff satisfaction. 

Opportunities exist for generating more data on the program’s efficacy and to reinforce its impact on measurable outcomes. For example, a patient with cognitive impairment rarely is admitted for his or her behavior but rather for a condition such as pneumonia. As the patient recovers, disruptive behaviors escalate, preventing a smooth discharge when no appropriate placement can be found. The result is that the hospital absorbs the unreimbursed cost of care when the patient no longer requires hospitalization and doesn’t qualify for inpatient insurance coverage. Can using the Advanced Care of Patients with Cognitive Impairment program to reduce unwanted behaviors decrease length of stay?

Making a commitment

PeaceHealth made a commitment to assert the inherent worth of each person by embracing a shift in its cultural identity and working to be in service to the most vulnerable and marginalized patients. The work of the Advanced Care of Patients with Cognitive Impairment program began over 3 years ago with experiential training, supplies, and music, much of it initially from donations and then supported by the organization’s Foundation. The cost of training and maintaining the diversional supplies is a fraction of the cost the organization pays each time discharge is delayed because of a patient’s disruptive behaviors.

The change in experience for patients and caregivers is palpable on the units that have embraced the program. Care conferences are patient-centered, collaborative conversations, and staff are empowered to be creative to meet individual patients’ needs. The heart of this program is a proactive strategy to avoid reactive crisis management. Enthusiastic reviews of the training opportunity spread beyond the pilot unit, and other staff have asked for it. Many units have hardwired the training into their new employee onboarding process. Caregivers on these units report lower rates of moral distress, higher rates of autonomy and efficacy in mitigating unwanted behaviors, and increased satisfaction in their roles. Most important, they’re all safer.

Mullane Harrington is a clinical nurse educator at PeaceHealth in Bellingham, Washington. She can be contacted at mharrington@peacehealth.org.


Alzheimer’s Association. 2019 Alzheimer’s Disease Facts and Figures. alz.org/media/Documents/alzheimers-facts-and-figures-2019-r.pdf

Centers for Disease Control and Prevention. Alzheimer’s disease and related dementias. October 9, 2018. cdc.gov/features/alzheimers-disease-dementia/index.html

Centers for Disease Control and Prevention. Autism spectrum disorder (ASD). August 27, 2019. cdc.gov/ncbddd/autism/index.html

Dressner MA. Hospital workers: An assessment of occupational injuries and illnesses. Monthly Labor Review. U.S. Bureau of Labor Statistics. June 2017. www.bls.gov/opub/mlr/2017/article/hospital-workers-an-assessment-of-occupational-injuries-and-illnesses.html

Fogg C, Griffiths P, Meredith P, Bridges J. Hospital outcomes of older people with cognitive impairment: An integrative review. Int J Geriatr Psychiatry. 2018;33(9):1177-97.

Hills DJ, Ross HM, Pich J, et al. Education and training for preventing and minimising workplace aggression directed toward healthcare workers. Cochrane Database Syst Rev. September 3, 2015. cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011860/full

Occupational Safety and Health Administration. Healthcare: Workplace violence. osha.gov/SLTC/healthcarefacilities/violence.html

Occupational Safety and Health Administration. Worker safety in hospitals: Caring for our caregivers. osha.gov/dsg/hospitals/workplace_violence.html

Sampson EL, White N, Lord K, et al. Pain, agitation, and behavioural problems in people with dementia admitted to general hospital wards: A longitudinal cohort study. Pain. 2015;156(4):675-83.

Singh I, Edwards C, Duric D, Rasuly A, Musa SO, Anwar A. Dementia in an acute hospital setting: Health service research to profile patient characteristics and predictors of adverse clinical outcomes. Geriatrics (Basel). 2019;4(1):E7.

4 Comments. Leave new

  • Donna Wellington
    May 27, 2020 1:19 am

    How do we get this program at my facility?

    • Send an email to Mullane! I work in an ER at a sister facility. I took the class (amazing class!) and have had the opportunity to implement some of her measures. And yes, they work.

  • I have had the opportunity to attend the class described by Mullane – she is a gifted instructor with such a passion for this topic. I felt better equipped to not only deal with challenging situations from these patients, but had tools to try and avoid the behavior.

  • Well written. Congrats


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