Sliding doors: Did drama-based inter-professional education improve the tensions round person-centred nursing and social care delivery for people with dementia: A mixed method exploratory study

This educational intervention takes place when the population of older people with dementia is increasing. Health and Social care professionals must work jointly in increasingly complex contexts. Negative attitudes towards older people are cited as a contributor to poor care delivery, including the use of dismissive and/or patronising language, failing to meet fundamental needs and afford choice. ‘Sliding Doors to Personal Futures’ is a joint, drama-based, educational initiative between NHS Education Scotland and the Scottish Social Services Council, delivered using interprofessional education (IPE) towards encouraging person-centred health and social care.This paper considers whether ‘Sliding Doors’ had an impact on social work and nursing students' attitudes to older people, person-centred care and interprofessional collaboration. Two groups of third year students were studied; one from nursing and one from social work. A mixed methods approach was taken and attitudes and attitudinal shifts measured and discussed.Quantitative results demonstrated that social work students made positive attitudinal shifts in some questionnaire items and collectively the social work students were more person-centred than nursing students in their care approaches. The qualitative data however, drawn from focus groups, illuminated these results and highlighted the link between the ability for a professional to be person-centred and the conceptual view of risk within the particular profession. Risk acceptance, the theoretical position of social work, may facilitate person-centred care, whereas the perceived risk-averse nature of the nursing profession may inhibit it. Students' attempts to understand the quantitative results, without understanding the restrictions and parameters of each other's profession, led them to revert to stereotypes and negative views of each other as practitioners.The paper concludes that there is an important difference between nurses' and social workers' frames of reference. It is suggested that IPE in its current form will not impact positively on outcomes for older people, unless both professions can openly acknowledge the reality of their professional contexts and develop an understanding of each other's professional restrictions, opportunities and aspirations.     

The use of life story work with people with dementia to enhance person-centred care

mckeown j., clarke a., ingleton c., ryan t. & repper j. (2010) The use of life story work with people with dementia to enhance person-centred care. International Journal of Older People Nursing 5 , 148–158 Background. Person-centred care has been linked with quality of care but difficulties remain in person-centred care being implemented in care practice. This study explores the use of life story work to enhance person-centred care with people with dementia. Aims and objectives. The study investigates how life story work is: understood and developed in practice; experienced by all participants and affects the delivery and outcomes of care. Design and methods. The experience of older people with dementia, family carers and care staff in using life story work was explored within an NHS Health and Social Care Trust. A multiple case study design was adopted within a constructivist approach. Semi-structured interviews, observation, conversations were employed. Findings. Life story work has the potential to: enable care staff to see the person behind the patient; allow family carers to uphold their relatives’ personhood; enable the voice of the person with dementia to be heard, verbally and non-verbally; be enjoyable for all concerned and enable the person with dementia to feel proud about themselves and their lives. Conclusion and implications for practice. Life story work has the potential to enhance person-centred care for older people with dementia and their families. Taking a practice development approach ensures that life story work can be implemented sensitively and is sustained in practice.     

The use of drama to support reflection and understanding of the residents’ situation in dementia care: a pilot study

Background. One key aspect of person‐centredness is striving to understand both the patients’ experiences and behaviours from their perspective. These aspects are precisely those that staff in dementia care highlight as causing them most difficulty because the people in their care have major problems expressing themselves. There is thus a need to develop a method to help the staff to achieve interpretation through reflection. Aim. The aim of this study was to explore the use of drama as a tool to support reflection among staff working in the residential care of people with dementia. Design. A qualitative evaluation of a programme consisting of three drama sessions with staff working in residential care (n = 10 nurse assistants). Methods. Data comprised observations and tape recordings of the sessions, the researchers’ reflections after each session and a focus‐group interview with the participants. The texts were analysed using qualitative content analysis. Results. The analysis showed that: (i) the exercises stimulate reflection about daily caring practice; (ii) the participants must receive extensive information about the purpose of the sessions; (iii) the research team must secure the defined frames and conditions and have practical knowledge about caring for people with dementia and (iv) the management needs to be stable, committed and supportive. Conclusion. Drama seems to be a valid tool to aid reflection, but several adjustments are needed concerning both the content of the sessions and the methodology. When designing a larger intervention study, it would be preferable to the sessions to be combined with staff support to effect changes in care provision resulting from their increased awareness of the residents’ situation and experience. Implications for practice. Our results showed that drama can be a means to enhance reflection among staff in residential care for people with dementia. Further research is however needed concerning the effects for the staff's situation and nursing care quality.     

Knowledge,facilitators and barriers to the practice of person-centred care in aged care workers: a qualitative study

The current study describes aged care workers' interpretation of the concept of person-centred care; and identifies the barriers that exist to impede its practice, and the facilitators that encourage person-centred care practice. Data were collected from interviews with aged care workers from two residential aged care facilities providing both high and low care for residents with and without physical and psychological issues based in Australia. Data were analysed to identify and explore categories of meaning for barriers and facilitators. Analysis is grounded in Brooker's VIPS framework for person-centred dementia care which is utilised as a comparative tool for analysing participants' understanding of person-centred care. Findings revealed that aged care workers have a reasonable but incomplete understanding of person-centred care. Insufficient time and residents' dementia behaviours acted as barriers to care workers' provision of person-centred care. Teamwork was found to facilitate person-centred care by increasing instrumental and relationship resources     

Developing person-centred practice: nursing outcomes arising from changes to the care environment in residential settings for older people

mccormack b., dewing j., breslin l., coyne-nevin a., kennedy k., manning m., peelo-kilroe l., tobin c. & slater p. (2010) Developing person-centred practice: nursing outcomes arising from changes to the care environment in residential settings for older people. International Journal of Older People Nursing 5 , 93–107 Aim. To present the nursing outcomes from the evaluation of developments in the care environment in residential settings for older people. Design. The evaluation data reported here is derived from a larger national programme of work that focused on the development of person-centred practice in residential services for older people using an emancipatory practice development framework. A multi-method evaluation framework was utilised. Outcome data were collected at three time points between December 2007 and September 2009. The data reported here were collected using an instrument called the ‘Person-Centred Nursing Index’. Findings. Heavy workload was the main cause of stress among nurses. Personal and professional satisfaction with the job was scored highest by the total sample of nurses. Nineteen factors were examined using the Person-Centred Nursing Index. Statistically significant changes were observed in 12 of these. In addition, there were statistically significant changes in nurses’ perceptions of caring, indicating a shift from a dominant focus on ‘technical’ aspects of care, to one where ‘intimate’ aspects of care were more highly valued. Relevance to clinical practice. The findings highlight the importance of the development of effective teamwork, workload management, time management and staff relationships in order to create a culture where there is a more democratic and inclusive approach to practice and space for the formation of person-centred relationships.     

Dementia, dignity and quality of life: nursing practice and its dilemmas

manthorpe j., iliffe s., samsi k., cole l., goodman c., drennan v. & warner j. (2010) Dementia, dignity and quality of life: nursing practice and its dilemmas. International Journal of Older People Nursing 5 , 235–244
doi: 10.1111/j.1748-3743.2010.00231.x Aims. The need for healthcare practitioners to respect the dignity of older people is widely recognised in England, where it has been given attention by politicians, professionals and health service regulators. This article aims to provide examples of how such ambitions may be used in practice development. Methods. This article reports the use of five vignettes discussed by dementia care practitioners that explored the areas of dementia diagnosis, lying, incontinence, behavioural and psychological distress, and end of life care. Findings. Each vignette promoted discussion of differences of perspectives about the ways to enhance the dignity of people with dementia in hospital, care home and community settings. The discussion confirmed that while dignity may be one quality indicator of good care potentially enhancing quality of life, it is not always straightforward. It may be more easily conceptualised when talking of physical care and treatment than other areas. Conclusion. The opportunity to debate the subject and to discuss practice examples revealed differences of opinion and moral perspectives between practitioners about the use and relevance of the term dignity. These need to be acknowledged in any debates about objective and subjective definitions of quality of life.     

Evaluating the effectiveness of the abilities-focused approach to morning care of people with dementia

sidani s., streiner d. & leclerc c. (2012) Evaluating the effectiveness of the abilities‐focused approach to morning care of people with dementia. International Journal of Older People Nursing 7 , 37–45 doi: 10.1111/j.1748‐3743.2011.00273.x Background and purpose. The abilities‐focused approach demonstrated efficacy in promoting engagement of residents with dementia in care. The extent to which these resident outcomes can be replicated when the abilities‐focused approach is implemented by nursing staff under the conditions of day‐to‐day practice was investigated in this study. The aim was to examine changes in resident outcomes before and after nursing staff’ implementation of the abilities‐focused approach and the contribution of this approach to resident outcomes. Methods. A one‐group pretest–post‐test design was used. Observational data were obtained from 65 residents with dementia. The data pertained to the implementation of abilities‐focused strategies during episodes of morning care and residents’ level of agitation, participation in morning care and physical and psychosocial functioning. Results. The number of abilities‐focused strategies used during morning care increased at post‐test. No clinically important changes in resident outcomes were observed over time. However, the implementation of some strategies was associated with residents’ participation in care and functioning at post‐test. The results provided preliminary evidence of the effectiveness of the abilities‐focused approach in maintaining functioning in people with dementia. Additional research is needed to understand the mechanism underlying the effects of this person‐centred approach to care on resident outcomes. Implications for practice. Implementation of the abilities‐focused approach assists people with dementia to participate in morning care.     

A mapper's reflection on Dementia Care Mapping with older residents living in a nursing home

Aim and objective.  This paper explores reflection stemming from a Dementia Care Mapper's own learning and development concerning person-centred care with older residents living in a dementia specific nursing home.
Background.  Dementia Care Mapping has been employed in few Australian residential care facilities to promote person-centred care and the well-being of residents. Reflection has also been used selectively in some practices to improve and evaluate the care process. However, contemporary nursing literature has failed to highlight the usefulness of applying reflection following Dementia Care Mapping with older residents.
Method.  The mapper's reflections arose from the Dementia Care Mapping observation of five older residents and writing a daily reflective journal.
Findings.  From the reflection, a dominant major theme emerged named as the Learning Experience from Mapping Residents with two sub-themes entitled Mapper's Identification of Resident's Unique Needs and Mapper's Empowerment of Clinicians. Dementia Care Mapping recommendations from the mapper's experience highlighted effective approaches to conducting Dementia Care Mapping in residential care facilities.
Conclusions.  The valuable process of reflection to Dementia Care Mapping provided the mapper with clinical insights. Further from the mapper's final reflection, a poem entitled Come Back Mind, Come Back to Me was conceived and penned.
Relevance to clinical practice.  The mapper's engagement in ongoing reflection incorporated with Dementia Care Mapping has the potential to promote best practice for the care of older people living in aged care facilities.     

People with severe dementia exhibit episodes of lucidity. A population-based study

Aims and objectives. To describe frequency and characteristics of people with severe dementia who according to care providers, exhibit ELs in a population of those with dementia in institutional care. Background. There are reports in the literature concerning episodes when the resident unexpectedly says or acts in a way that surprises the care provider because the resident seems to be much more aware of her/his situation than usual. This is labelled ‘episodes of lucidity’ (ELs). Design. The study is based on data from a point prevalence study from institutions for the older people in northern Sweden in May 2000. Methods. Out of 3804 residents, assessed by key care providers, by means of the Multi‐Dimensional Dementia Assessment Scale (MDDAS) with questions about ELs added, 92 residents were found to have severe dementia and difficulties with verbal communication. The key care providers’ competence in assessing severe dementia was not evaluated. An ethics committee approved the study. Results. Fifty‐two residents (57%) were assessed as exhibiting ELs. Residents who showed ELs had higher orientation scores and expressed more emotions than residents who did not show ELs. More residents who exhibited ELs took outdoor walks with their care providers exhibited ELs than those who did not (P = 0·001). Conclusions. Every second resident with severe dementia and difficulties with verbal communication showed ELs. Relevance for clinical practice. The fact that every second resident with severe dementia and difficulties with verbal communication showed ELs and that this was noticed especially when care providers took outdoor walks with the residents imply that closer contact between care providers and residents with severe dementia could change the care providers’ expectations and enhance communication between the parties.     

Aggressive behaviour by people with dementia in residential care settings: a review

This paper considers the phenomenon of aggressive behaviour perpetrated by people with dementia in residential care settings. Aggressive behaviour is defined in the context of people with dementia, and the problem of ascertaining the incidence of aggression among people with dementia is discussed. The emotional impact of assaults on nurses and other professionals is highlighted, and differing perspectives on the causation of aggressive behaviour are considered. Management strategies derived from the physical/pharmacological; environment management; behaviour modification and person-centred approaches are reviewed. Our conclusion is that while certain strategies appear to reflect good and common sense practice, in particular those deriving from the person-centred approach, there is no clear research evidence for the general effectiveness of any one management approach, and each has drawbacks of a practical or ethical nature. There is also little empirical information about how professional carers actually manage aggressive behaviour in practice.     

An Educational Intervention to Increase Internists’ Confidence With and Provision of Preventive Services to Adolescents and Young Adults

Background: Internal medicine (IM) physicians report inadequate preparation to care for adolescents and young adults. Purpose: The aim is to (a) improve IM residents’ comfort and confidence caring for adolescents/young adults and (b) increase the percentage of adolescent/young adult patients receiving preventive healthcare. Methods: Fifty-two PGY1 IM residents were assigned to treatment or control groups. Residents in the treatment group interviewed and received feedback from adolescent instructors. We developed a survey to measure residents’ comfort and confidence caring for adolescents/young adults and evaluated their adherence to screening guidelines for patients ages 16 to 26. Results: Significantly more residents in the intervention group felt confident identifying sexually transmitted infections (STIs) and substance abuse and treating STIs, substance abuse, and depression compared to residents in the control group. Residents in the intervention group were no more likely to screen adolescents/young adults for Chlamydia, HIV, alcohol misuse, or depression in the 6 months following the intervention. Conclusions: An educational intervention utilizing adolescent instructors improves resident confidence but does not increase adherence to screening guidelines.     

Enhancing students’ preparedness to care for older people: A mixed methods analysis

BackgroundNursing students’ positive attitudes towards ageing and older people are central to developing person-centred care. Perceptions about older people are influenced by social and generational values and beliefs, including a general understanding that older people need to be cared for. Nursing students often undertake early clinical placements in aged care settings, where residents’ needs are complex, yet the nursing experience is often considered ‘basic’ care. Illustrating that older people have rich personal histories and are valuable contributors to society can balance students’ perceptions and expectations and outcomes of clinical placements. Educational interventions using photo-elicitation and in-depth dialogue may surface students’ assumptions and challenge their misperceptions of older people before the first clinical placement.AimTo examine the impact of the innovative Depth of Field: Exploring Ageing © (DOF) resource as preparation for nursing students’ clinical placement in residential aged care facilities.MethodsMixed methods, block randomised controlled study with first year students. Students attending clinical laboratory groups received either usual preparation (control, n = 108) or DOF plus usual preparation (intervention, n = 99). Pre/post surveys included: Geriatric Attitudes Scale (GAS) and demographics. Eight students from the intervention group participated in focus groups post-clinical.FindingsGroups were similar at baseline. There were statistically significant changes following the intervention (p ≤ .05) for 9/13 individual GAS items and difference in overall mean scores (intervention group: M = 0.26; SD = 0.27; control group: M = 0.01; SD = 0.27). Focus group themes included: preconceptions toward older people; feelings of being emotionally unprepared; and perceptions of the DOF intervention in preparing students to connect with the older person.DiscussionThe DOF vignette provided opportunity for students to preflect on ageing. Translation to practice was evidenced with students seeing beyond residents’ physical care requirements to the value of connecting with the older person’s story to facilitate person-centred care.ConclusionsThe DOF intervention assisted students to adopt positive attitudes and a broader perspective of older people, as preparation for placement in residential aged care facilities.     

Explanatory models of dementia: links to end-of-life care

We will describe four models used to understand dementia: as a neurological condition; as a neuro-psychiatric condition; as a normal part of ageing; and seeing dementia from a person-centred perspective. Adopting the last of these allows an engagement with palliative care that has the potential to enrich the end-of-life experience of people with dementia, of their families and of the professional care staff who work with them. In this article, it will be argued that our perceptions of what is possible for practising person-centred care at the end of life are constrained by the paradigms we work within. There is developing evidence about how approaches to end-of-life care for people with dementia can move beyond what was, at best, therapeutic pessimism and at worst ill-treatment towards something that optimizes the capacities of those with dementia and mobilizes imaginative care practice.     

Development of a model of situational leadership in residential care for older people

lynch b.m., McCormack b. & McCance t. (2011) Journal of Nursing Management 19, 1058–1069
Development of a model of situational leadership in residential care for older people Aim The aim of the present study was to present the process used to develop a composite model of situational leadership enacted within a person-centred nursing framework in residential care. Background Transforming the culture of the residential unit from a restrictive institution to a vibrant community of older adults requires transformational leadership. Situational leadership is one form of transformational leadership, which claims that there is not one leadership style that works in all situations. Method A model of situational leadership in residential care was developed through a series of systematic steps that identified direct linkages between situational leadership and the main constructs of the Person-Centred Nursing Framework. The process included reviewing the evidence, undertaking a comparative analysis, identifying key concepts, connecting the concepts and developing a model. Conclusion A conceptual model is presented which integrates person-centredness with leadership thinking in order to effectively impact on the follower’s performance in managing the care environment and delivering person-centred care. Implications for Nursing Management Currently the model is being utilized in an action research study to evaluate the role of leaders in the practice setting of long-term care. While some of the connecting concepts have been identified in the present study, more work needs to be done to unravel these connections in further study of leaders in practice.     

Perceptions of person-centred care amongst individuals with chronic conditions who consult complementary medicine practitioners

ObjectivesChronic conditions require continuous, multi-factorial care – such as person-centred care – to address patients’ individual health needs and quality of life. Many patients with chronic conditions seek additional care outside mainstream medicine, often consulting complementary medicine (CM) practitioners. This study examines person-centred care experienced by patients with chronic conditions consulting CM practitioners.DesignCross-sectional survey.SettingCM clinics around Australia, conducted November 2018 to March 2019.ParticipantsPatients with chronic conditions (n = 153) consulting osteopaths (n = 39), naturopaths (n = 33), massage therapists (n = 29), chiropractors (n = 28) and acupuncturists (n = 24).Main outcome measuresPatient-Centred Care Scale, Perceived Provider Support Scale, Empowerment Scale, and Patient Assessment of Chronic Illness Care measure.ResultsPatient perceptions of person-centred care were consistently high during consultation with CM practitioners (Patient-centred Care scale mean range 4.22–4.70; Perceived Provider Support scale mean range 4.39–4.69; Empowerment scale mean range 2.20–2.50; Patient Assessment of Chronic Illness Care mean summary 3.33). Ratings of person-centred care were higher for consultations with CM practitioners than for medical doctors. Patients of naturopaths reported the highest means for perceived person-centred care. Variation in participant ratings for different items between professions indicate nuance in consultation experiences across different CM professions.ConclusionsPerson-centred care appears characteristic of CM consultation, which may reflect holistic philosophies. Variations in patient experiences suggest diverse practices across CM professions. CM practitioners may present a resource of person-centred care for addressing unmet needs of individuals with chronic conditions, and reducing the health burden associated with rising rates of chronic conditions.     

Family caregiver perspectives on social relations of elderly residents with dementia in small‐scale versus traditional long‐term care settings in the Netherlands and Belgium

Aims and objectives. To provide insight into family caregiver perspectives on social relations within the ‘caregiving triangle’ between family caregiver, professional caregiver and elderly resident with dementia. Results were compared between traditional versus small‐scale long‐term care settings in the Netherlands and Belgium. Background. Residential dementia care is shifting towards a more holistic and person‐centred approach. Until now, little is known about family caregiver perspectives. Design. A quasi‐experimental longitudinal design. Methods. This study was part of a larger research project focusing on the quality of life of residents with dementia in traditional and small‐scale settings (n = 179). This study focused on family caregivers related to these residents (n = 64). They filled in a questionnaire containing 25 items (baseline and after 12 months) related to their perspectives on the interaction within the ‘caregiving triangle’. Analyses were performed using mixed models and logistic regression. Results. Compared to traditional settings, family caregivers of relatives with dementia living in small‐scale settings had more contact with the professional caregivers, were more satisfied with this contact and felt that staff paid more attention to their feelings as family members. They also reported that staff showed better listening skills towards the residents. Furthermore, compared to those in Belgium, family caregivers in the Netherlands perceived staff to be less hurried and more accepting of help from family and felt that staff more often takes the resident seriously. Conclusion. In the move towards more person‐centred care for residents with dementia, this study finds preliminary evidence for the importance of integrating the family perspective. Relevance to clinical practice. Gaining more insight into the perspectives of family caregivers on the social relations within the ‘caregiving triangle’ may provide knowledge about the importance of the social system surrounding elderly residents with dementia and can provide pointers for future research.     

Screening for Hematuria,Glucosuria and Proteinuria in People Aged 55-64 Technical,Clinical and Cost-benefit Experience from a Pilot Study

Objective. To identify the attitudes and perspectives of the family physician towards the caregivers of demented relatives and to describe the caregivers’ satisfaction. Design. Systematic review. Subjects. The studied population consisted of dementia family and their general practitioners. Main outcome measures. Outcome measures were the generic tasks and skills of the general practitioner to improve home care from the perspective of the family caregiver. Caregivers were assessed on satisfaction regarding the care provided by their general practitioner. Results. The general practitioner is aware of his/her skills and limits in all aspects of dementia care and his/her role towards the family caregiver. They also acknowledged the importance of an adequate diagnostic process, but they felt uncomfortable disclosing the diagnosis to both the patient and the caregiver. They reported having more confidence in treatment matters than in diagnostic stages. Caregivers’ reports on the attitude of their general practitioner in the diagnostic process were rated from helpful to poorly empathized. General practitioners found themselves to be highly involved in dementia home care, but caregivers rated their involvement to be insufficient. The lack of appropriate communication skills of general practitioners was also not appreciated by the caregivers. A lack of time and reward was considered by the general practitioner to be a major obstacle in dementia care. Conclusion. The key role of general practitioners as care providers and care planners is consolidated by the family caregivers’ confidence in their skills. Clear guidelines from early diagnosis to adequate referrals should improve the ability of the general practitioner to support these time and energy-consuming home-care situations. Intervention studies addressing the gaps in the skills of the general practitioners in dementia home care management could be helpful in supporting the family caregiver.