Research by School of Nursing Professor Rita Jablonski, Ph.D. has changed how nursing homes and caregivers alike care for patients with dementia. One joy of working with students, she said, is "I can show them how research is a living, breathing thing."What does it take to change the world? Great mentors, happy accidents and curiosity are all part of the backstory of UAB School of Nursing Professor Rita Jablonski, Ph.D., whose research has shifted how nursing homes and families alike care for older adults with dementia.
Using insights from neuroscience, Jablonski developed strategies to overcome care-resistant behavior that put these patients at high risk for pneumonia, then proved the effectiveness of those strategies in NIH-funded clinical trials. She is now adapting the techniques to help caregivers overcome resistance to dressing and other functions of daily living.
“I’ve done some cool stuff, and I’m proud of that,” said Jablonski, who also directs the School of Nursing’s Post-Doctoral Fellowship Program. Seeing your research translate into real-world changes that touch thousands and thousands of lives is “awesome,” she said. “You get to say, ‘I did something. I put something back.’”
And, as Jablonski emphasizes to honors undergraduate students and Ph.D. candidates alike in the School of Nursing, that feeling can be addicting. “I was only going to stay in dementia for a while, then move on to something else,” she said. “But it got fun.”
What once was called “disruptive behavior” in nursing home journals is now called “care refusal” thanks to Jablonski’s work. “So many people are talking about it,” she said. “I’m even seeing people advertising themselves as dementia experts on social media, and they are using my techniques but without referencing my publications. That’s fine. A lot of my research is becoming shared in online support groups and Facebook caregiver groups. My work is a part of the wallpaper now.”
One joy of working with students is “I can show them how research is a living, breathing thing,” Jablonski said. “I take them with me to my clinic, and they see how research affects my clinical skills and my clinical interactions. Too many young nurses think it has to be all or nothing — either you are a 100 percent full-time nurse or a 100 percent researcher. I tell them, ‘You can do both.’ That way, whatever is happening on your shift is inspiring your research questions.”
Her latest project: Exploring a new approach to helping patients with dementia keep from losing function while they are hospitalized. It is the next step in a career journey that illustrates the power of research to make a difference in the real world.
"Too many young nurses think it has to be all or nothing — either you are a 100 percent full-time nurse or a 100 percent researcher. I tell them, ‘You can do both.’ That way, whatever is happening on your shift is inspiring your research questions.”
Research that brings change
In the early 1980s, when Jablonski worked as a nursing assistant at nursing home in Pennsylvania, bedside restraints were the standard of care for patients with dementia. “It was thought that if they were left to their own devices, these patients with dementia would hurt themselves,” she said.
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Jablonski did not realize it at the time, but two pioneering nurse researchers, Neville Strumpf, Ph.D., and Lois Evans, DNSc, conducted some of their research at her facility, interviewing staff about dementia and use of restraints. Their work revealed that, despite what clinicians of the era were taught, “restraints are more problematic than therapeutic,” Jablonski said. “Strumpf and Evans ended up testifying before Congress and influenced policy.”
By the time Jablonski had graduated from nursing school, earned a master’s degree and returned to the long-term environment as a clinical faculty member for the Community College of Philadelphia in the mid-1990s, “you could no longer use restraints,” she said. “Their work completely changed the landscape. That opened my eyes to what you could accomplish with research.”
Connecting research to practice
Another duo of nurse researchers — Mary Jo Grap, Ph.D., and Cindy Munro, Ph.D., of Virginia Commonwealth University — inspired the work that made Jablonski’s name as a researcher. “They were examining the relationship between oral care and ventilator-associated pneumonia, which started all this interest in hospital-acquired infections,” Jablonski said. “There was no mouth care provided in ICUs at the time because the thought was the patients would aspirate toothpaste or secretions into their lungs. Mary Jo and Cindy realized that, without mouth care, the bad bacteria were overpowering the good bacteria in patients’ mouths and migrating into the lungs and causing pneumonia. They developed practices to provide mouth care to this population.”
Jablonski, who was then also on faculty at VCU and was working toward her own Ph.D., would eat lunch with Grap and Munro. “They would talk about their research, and I thought it was fascinating,” Jablonski said. “As a nurse practitioner, I had a nursing home practice, so I started taking what they were talking about and connected it. I told Mary Jo and Cindy, ‘I have patients in the nursing home who keep getting pneumonia as well, and the common factor is they fight mouth care. I think this is an area that I can look at.’ The next thing I know, they are helping me write grants and mentoring me through the process.”
Jablonski collected pilot data on plaque and bacteria in the mouths of patients who had regular mouth care and those who refused care, which led to one NIH grant, and then a second.
Finding strategies to overcome fear
What was causing patients to fight mouth care, and how could you overcome that response? Jablonski applied for a postdoctoral fellowship from the Brookdale Foundation that allowed her to dig deep into fear responses and the brain region largely responsible for those responses, the amygdala. “It dawned on me that people with neurodegeneration are interpreting mouth care as a threat,” Jablonski said. “The nursing assistant walks in the room and attempts mouth care; but to a resident with dementia, that nursing assistant is trying to jam a foreign object into their mouth. I realized that, if we could tackle refusal, we could deal with mouth care.”
The strategies that Jablonski developed to avoid triggering a fear response in patients with dementia during mouth care were proven effective in an NIH-funded clinical trial. Now she has applied and modified the original strategies to work for refusal to dress, eat, take medicines and more.Jablonski, then at Penn State University, developed a set of strategies to avoid triggering a fear response in patients with dementia during mouth care. Each was adapted to the particular wiring of brains with dementia or with aging-related sensory changes, including an emphasis on smiling and other positive emotional cues, a low-pitched voice to improve comprehension, the importance of removing distractions, and the value of memory cues, including running water and a sink to encourage toothbrushing.
She demonstrated these strategies in a highly realistic training video that was inspired by creative thinking on a tight budget — including hiring retired Penn State faculty as actors and using part of a state-owned nursing home as her set. That video helped Jablonski secure a $1.4 million NIH R01 grant for a randomized clinical trial that demonstrated the effectiveness of her Managing Oral Hygiene Using Threat Reduction (MOUTh) protocol. (Watch the video on YouTube.)
Jablonski was recruited to UAB in 2012. She was attracted by UAB’s clinical resources and the opportunity to work with David Geldmacher, M.D., in the UAB Brain Aging and Memory Clinic to study and apply care strategies in real time with patients. In 2016, Jablonski and Geldmacher received a Department of Defense grant to “formalize an actual curriculum for helping family caregivers handle refusal behaviors,” she said. And in 2018, Jablonski received a three-year, $1.7 million Centers for Medicare & Medicaid Services grant to provide oral hygiene training to caregivers in seven Birmingham-area nursing homes.
“Now I have applied and modified the original strategies to work for refusal to dress, refusal to eat, refusal to take medicines,” Jablonski said. One strategy is “chaining,” in which the caregiver starts putting on a patient’s socks, then encourages the patient to complete the action themselves.
Studying “dementia-friendly” care for hospitalized patients
Jablonski’s latest project is pairing her with health services researcher and School of Nursing Professor and Assistant Dean for Clinical Innovation Shea Polancich, Ph.D. They are studying a new approach to caring for hospitalized patients with dementia, including prioritizing stable dosing of donepezil throughout hospitalization and getting patients regular movement during their stay to prevent them from losing function.
“I said to Shea, ‘I think we need to have a major change in how people with neurocognitive issues are cared for, regardless of where they are in the hospital,’” Jablonski said. Thanks to funding made possible by UAB Medicine Chief Nursing Executive Terri Poe, DNP, Jablonski and Polancich are working with a UAB St. Vincent’s facility to launch a pilot dementia care approach. That will give them the data they need to apply for an external grant “to do this on a bigger scale,” Jablonski said.
“Here’s the win-win,” she said. “If we get data that using a more dementia-friendly approach improves outcomes, that is important information that can guide how to make changes in our entire UAB inpatient system. We want to do whatever we can to make things better.”