A survey of staff attitudes and responses to people with dementia who are aggressive in residential care settings

Aggression is reportedly common among older people with dementia in residential care. The attitudes of staff in care homes and strategies they use are under researched. Theoretical models that may be used to both understand and respond to such behaviour exist. They are the standard and person-centred paradigms. The aim of this study was to explore the views of nursing staff about aggressive behaviour in people with dementia and strategies used in practice. A survey of the attitudes of staff in six dementia care units using the Management of Aggression in People with Dementia Attitude Questionnaire was conducted including an audit of aggressive incidents using the Staff Observation Aggression Scale-Revised over a 3-month period. Staff expressed views reflective of a person-centred as opposed to standard paradigm. They viewed aggressive behaviour by people with dementia as deriving from the environment, situation or interactions with others. Participants strongly supported interpersonal means of responding to aggression, the moderate use of medication, and were largely opposed to physical restraint. Aggressive incidents were managed using less intrusive strategies such as distraction and de-escalation. Responses to aggressive behaviour, while pragmatic, were largely underpinned by a person-centred ethic as reflected in the attitudes expressed by staff.     

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.     

Using drama to improve person-centred dementia care

kontos p.c., mitchell g.j., mistry b. & ballon b. (2010) Using drama to improve person-centred dementia care. International Journal of Older People Nursing 5 , 159–168 Aims and objectives. We implemented a 12-week drama-based educational intervention to introduce to dementia practitioners person-centred care that emphasizes the notion of embodied selfhood (defined as non-verbal self-expression). Background. Person-centred dementia care guidelines emphasize the assessment of individual needs, and where appropriate, the use of non-pharmacological interventions before resorting to pharmacological management. However, dementia care is not consistent with these guidelines suggesting conceptual limitations and reliance on passive knowledge translation strategies. Design and methods. Focus groups and semi-structured interviews with practitioners (n = 24) in two nursing homes in central Canada were undertaken to assess the effectiveness of the drama-based components of the intervention. Results. Our findings suggest that drama was effective as an educational modality, and helped implement the person-centred approach into practice. Significant practice outcomes included: new awareness that residents’ body movements and dispositions can convey meaning; seeking biographical information from families; increased time efficiency; and supporting residents’ independence. Conclusions. Our findings make an important contribution to person-centred dementia care by broadening the notion of personhood, and by facilitating implementation using drama. Implications for practice. As an enhancement of person-centred care, the support of embodied selfhood may significantly improve residents’ quality of life, quality of care, and practitioners’ care-giving experience.     

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.     

Promoting positive approaches to dementia care in nursing

This article provides an overview of factors relevant to dementia care today. The number of people experiencing dementia is increasing and dementia is at the forefront of health policy. The evidence base for person-centred approaches and interventions in dementia is expanding and nurses are central to implementing these across care settings. This is an exciting and challenging time for dementia care and nursing has a major role in leading and developing these changes in practice. The article discusses the importance of wellbeing and the Mental Capacity Act in assessing and caring for people with dementia. Psychosocial and pharmacological approaches to dementia care are described and the need to support carers of people with dementia is emphasised.     

Exploring the usefulness of a recovery-based approach to dementia care nursing

Exploring new approaches to dementia care nursing is vital to enable services to cope with the expected rise in demand for healthcare due to an ageing population. A comparison between the current person-centred care approach in aged care and recovery-based approach that underpins mental health nursing was reviewed in the literature to determine which is more useful to dementia care nursing. The recovery model is the conceptual framework that underlies the recovery-based approach. It broadens the current person-centred care approach through the fostering of hope, facilitative rather than directive care, and enhances autonomy. This promotes positive outcomes for older people with dementia through empowerment to make choices in the way they wish to live within the community. This essay proposes that the recovery-based approach is more useful to dementia care nursing than person-centred models.     

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     

Person-centred care for people with dementia: a quality audit approach

This paper addresses the concept of person-centred care for people with dementia by consideration of an audit process using dementia care mapping as the audit tool. It is argued that this tool is best for identifying the lived experiences of the people in receipt of care. As a result it is able to identify the overall culture of care and its level of 'person-centred' approach. The audit was conducted on 12 units, half of which were day units and the others catering for inpatients. Five patients were mapped on each day for a 4-day period. The results give some idea of the quality of care and identify where improvement is necessary. Scores such as well-being values and the Dementia Care Index give clear signposts to the level of person-centred care and highlight where staff development is necessary. Recommendations are given to aid on-going planning.     

How education can improve care for residents with dementia

Meeting the needs of people with dementia is topical in health and social care. However, the care of older people, including those with dementia, has received much negative media coverage over the past few years. Colten Care, a care home group in the south of England, asked staff from the School of Health and Social Care at Bournemouth University to develop and deliver an educational programme to 20 staff working at three of the group's care homes. The programme adopted a person-centred approach to residents and staff and focused on empowering staff to influence practice in the homes where they worked. This article explores the content of the programme and how aspects of it were incorporated in participants' care homes. The programme was positively evaluated and formed the basis for the development of Colten Care's inhouse two-and-a-half day education programme.     

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.     

A Nurse Practitioner initiated model of service delivery in caring for people with dementia

The increasing number of people with dementia in aged care facilities is reported to have a high burden of care among staff. The Nurse Practitioner role can be beneficial in the provision of dementia care particularly when difficult and aggressive behaviour is being displayed. The model of service described in this paper is designed in such a way to make the outreach team contribute to staff sustainability. Such a service is different to other outreach services and focuses on a number of key deliverables. In practice, the service ensures that recommendations made by the team at the initial assessment are implemented. In addition, they work with the staff in managing the resident's behaviour, train and model suggestions for practice in interventions. Evaluation of the service is a work in progress and will highlight important aspects about the workforce for the improvement of quality of life for residents with dementia.     

Practice development: individualized care

This article describes the development of a person-centred approach to working with older people. The main focus is on developing the ward leader as a key facilitator of practice development work. This process was enabled through external facilitation of the role and project management. The stages of the project work are outlined using an established practice development framework, which ensured a systematic approach to the change process. Registered nurses developed their skills and knowledge in clinical leadership and by the end of the project, nursing care had moved away from meeting the physical needs of the patients only, to a more individualized approach to patient care.     

The challenges of achieving person-centred care in acute hospitals: A qualitative study of people with dementia and their families

Background

Person-centred care has been identified as the ideal approach to caring for people with dementia. Developed in relation to long stay settings, there are challenges to its implementation in acute settings. However, international policy indicates that acute care for people with dementia should be informed by the principles of person-centred care and interventions should be designed to sustain their personhood.

Objectives

Using Kitwood's five dimensions of personhood as an a priori framework, the aim of this paper was to explore the way in which current approaches to care in acute settings had the potential to enhance personhood in older adults with dementia.

Design

Data collected to explore the current experiences of people with dementia, family carers and co-patients (patients sharing the ward with people with mental health problems) during hospitalisation for acute illness were analysed using a dementia framework that described core elements of person centred care for people with dementia.

Settings

Recruitment was from two major hospitals within the East Midlands region of the UK, focusing on patients who were admitted to general medical, health care for older people, and orthopaedic wards.

Participants

Participants were people aged over 70 on the identified acute wards, identified through a screeing process as having possible mental health problems. 34 patients and their relatives were recruited: this analysis focused on the 29 patients with cognitive impairment.

Method

The study involved 72 h of ward-based non-participant observations of care complemented by 30 formal interviews after discharge concerning the experiences of the 29 patients with cognitive impairment. Analysis used the five domains of Kitwood's model of personhood as an a priori framework: identity, inclusion, attachment, comfort and occupation.

Results

While there were examples of good practice, health care professionals in acute settings were not grasping all opportunities to sustain personhood for people with dementia.

Conclusions

There is a need for the concept of person-centred care to be valued at the level of both the individual and the organisation/team for people with dementia to have appropriate care in acute settings.     

Understanding the arousal of anger: a patient-centred approach

The aim of this article is to enable reflection on practice by exploring a nurse-patient scenario and identifying what factors trigger anger and aggressive behaviour. It recommends strategies that can be used to tackle anger among patients, and emphasises the importance of the therapeutic relationship. Anger management, which usually refers to cognitive behavioural therapy designed to enable people to manage anger, is not explored.     

Seeing the person behind the patient: enhancing the care of older people using a biographical approach

Recent policy statements have stressed the need for fundamental changes to the NHS, especially to the hospital care of older people. Person-centred care underpins such changes. If practitioners are to deliver person-centred care, then they need to learn more about the patient as an individual. One way that this might be achieved is through biographical approaches. This paper describes the findings of a developmental study undertaken over a 6-month period to investigate the introduction of a biographical approach to care on a unit in a NHS hospital. It concentrates on the views of the practitioners who used the approach. The study aimed to explore whether a biographical approach - in the form of storytelling - might be used to encourage person-centred practice. Using a practice development approach, the study explored the views of older people, their family carers and practitioners regarding their participation in life story work. Initial data were collected by focus groups with staff from a nursing home who regularly used life stories as a basis for care planning. Further data were collected through focus groups, semistructured interviews and observation - undertaken before and after the introduction of life story work - with older people, family carers and practitioners. Findings revealed that life stories helped practitioners to see patients as people, to understand individuals more fully and to form closer relationships with their families. Support workers also said how much they enjoyed using the approach to inform their care. Further longitudinal research is required to investigate biographical approaches more fully and to work more closely with practitioners to explore how biographical approaches can be undertaken as part of standard practice and be integrated into the culture and management of care.     

Development and acceptability of the person-centred observation and reflection tool for supporting staff and practice development in dementia care services

Background

Observational tools can support the understanding of the complex needs of older people with dementia and aid delivery of person-centred care. However, existing tools are complex and resource intensive to use.

Objectives

To develop and evaluate the acceptability and feasibility of a low-resource, observational tool to support staff reflection and practice development.

Methods

Intervention development of the Person-Centred Observation and Reflection Tool (PORT) and acceptability and feasibility study, using surveys and focus groups in the UK, Norway and Spain.

Results

PORT was reported as easy, accessible and acceptable to use. The observation was identified as powerful for individual staff development and provided an evidence-based source for underpinning individualised care planning. Potential time challenges associated with implementation were identified.

Conclusion

Initial evaluation indicates PORT is an acceptable and feasible tool for use in health and social care settings for older people. Further research is needed on implementation models and the impacts of PORT use.

Implications for Practice

PORT may be a useful tool to support individual staff development in care settings and person-centred care planning for people with dementia.     

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.     

Interventions for confusion and dementia. 5: Changing cultures

Previous articles in this series (Vol 7(15): 891-94; Vol 7(17): 1018-20; Vol 7(19): 1145-49; Vol 7(20): 1247-50) have explored the promotion of quality of life for people with dementia and how this can be achieved through existing interventions. This final article moves from discussing specific interventions to cover wider issues around healthcare beliefs and values. A brief historical overview of dementia care is given, outlining the inherited structures and values. Much valuable work has been carried out by the Bradford Dementia Group, who has described changes in dementia care as moving from an 'old' to a 'new' culture. This 'new culture', offering a comprehensive person-centred approach to holistic care, is explored with reference to the work of Kitwood, who has done much to promote quality of life for people suffering from dementia.