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 Principal Matron Dr. a .j. Stals Care and Rehabilitation Centre Defining the Problems Associated with the Care of the Severely and Profoundly Retarded 3.1 Outlining the

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 T 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 self-care 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. 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. 2.2 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. 2.3 Residents develop a feeling o f group-cohesion in small family-like groups. 2.4 By grouping patients together who have the same needs, organisation is sim plified. 2.5 Residents may aspire to be prom oted to a higher category …

T 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.
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.2.2 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.

2.3
Residents develop a feeling o f group-cohesion in small family-like groups.2.4 By grouping patients together who have the same needs, organisation is sim plified.2.5 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

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.
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.

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.

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 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.

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

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.

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.

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').

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 ') .

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

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.
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.

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.

Implementation o f the Plan
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.

Full-scale Assessment of Patients
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.
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.

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.

Each group programme must include times for:
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.

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.
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.
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.

Individual Activities
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.
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.

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.

Outings
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.