Kitwood's approach to dementia and dementia care: a critical but appreciative review

This paper critically examines the recent work of Tom Kitwood and his colleagues at the Bradford Dementia Group After initial details relating to Kitwood's early work and the development of the research group, the paper sets out Kitwood's ideas regarding the nature of dementia and dementia care Four areas of contribution made by Kitwood are outlined Problems relating to Kitwood's research methods are then put forward In conclusion, it is suggested that while Kitwood's work will undoubtedly help enhance the care given to elderly demented people, more work needs to be done to ensure the validity of his methods     

Concerns relating to the application of frameworks to promote person‐centredness in nursing with older people

There is an increasing need to develop a multi‐dimensional discussion and critique around the concept of ‘person‐centred’ in the context of the delivery of nursing care for older people. As the context of nursing being considered here, it is primarily nurses who should be leading with this discourse, although drawing on a broad range of ideas from outside of nursing. The person‐centred movement, commonly believed to originate in the care of those with dementia in the UK, is growing, especially in the UK and Australia, with signs of it moving across parts of Western Europe and North America. Person‐centredness has a big emotional appeal to many nurses working with older people, perhaps because it ‘has the right feel’ for them and nurses believe it ‘feels right’ for older people. It has grabbed the attention of many practising nurses in the UK in a way that humanistic nursing theory and the various associated nursing models from previous decades, seemed to have missed. This paper contributes to the discussion by suggesting that there are conceptual frameworks that nurses can draw on to help them understand and enhance their practice. However, it is suggested that these frameworks are either in their infancy or incomplete and they still need to convince nurses of their utility for day to day practice. It is also pointed out that the underpinning concept of ‘personhood’ has not yet been fully clarified by nursing.     

Expanding the dialogue on dementia: (Re)positioning diagnosis and narrative.

The biomedical model that guides the processes of assessment and diagnosis of dementia is based on assumptions and approaches which, while critical to medicine, may render them less consequential for nursing. Although gerontological nurses' research concerning dementia frequently uses the diagnosis as an inclusion criterion for projects, and screening tools are often employed to evaluate the impact of interventions, we may wish to consider expanding our views of assessment and evaluation to include the person's narrative. The purpose of this paper is to argue for this expanded dialogue and to suggest that nurses reposition the medical diagnosis behind the narrative of the individual patient. To that end, this paper explores and critiques the limitations of the diagnostic process and questions its relevance to nursing.The alternative considerations that are discussed include constructionist and interpretivist approaches, the exploration of assumptions, and a relational approach to supporting personhood.     

Levels of personhood: a model for dementia care

"Personhood" is a concept that may be seen as insignificant to health care delivery, yet it has strong relevance to people suffering from dementia in nursing home settings. When the dementia disease process negatively affects residents' cognition, memory, and the ability to communicate effectively, nursing home caregivers may approach care in a paternalistic manner, similar to a parent's authority over a child. Based on attributes of personhood identified in the literature, 3 levels of personhood are defined, discussed, and related to the naturally occurring dementia disease progression. Challenges to, and benefits of, the promotion of personhood in current nursing home dementia care are discussed. The author proposes a Personhood Model for Dementia Care that is based on the 3 identified levels of personhood. The model provides a structure for organizing existing person-centered interventions and strategies in dementia care. In addition, the proposed model provides a framework for understanding and testing the potential value and significance of future person-centered interventions as they are developed and implemented.     

Dementia, personhood, and nursing: learning from a nursing situation

Appreciation of the personhood of people with dementia calls for care that looks beyond the disease to the person within. In this column the author discusses the concept of personhood for people with dementia and presents a method of teaching person-centered care developed within the theoretical framework of nursing as caring. The study of an aesthetic expression of a nursing situation, written by a nurse who cares for people with Alzheimer's disease in a nursing home, is presented to assist nurses to learn to see beyond the disease to the person and to develop relationships that nurture personhood.     

Special observation and older persons with dementia/delirium: a disappointing literature review

Background. In gerontological practice, special observation is a known nursing activity across different settings. The group that possibly are most effected by this intervention are older persons with dementia and/or delirium. The research literature about special observations in the mental health field is small, more disappointingly there appears to be little published literature about special observations in regard to older persons with dementia and/or delirium. Aims. The aims of this study are to (i) establish the state of current published research on special observations in regard to older persons with dementia and/or delirium and (ii) make recommendations for research and practice. Design and method. A literature review. Results. Most literature pertains to adult mental health practice and services. Themes were generated and discussed in relation to gerontological practice. Conclusion. This review has established there is variance in the usage of the terms ‘special observation’ and ‘constant observation’. It concludes that there is no published research on special or constant observations in relation to older people with dementia/delirium or the purpose of this activity. There is therefore a clear need to establish a research base in the topic. Implications for practice. Given the limited evidence, practitioners and managers need to be cautious when writing and implementing policies about special observation. However, until gerontological research is improved, research from mental health nursing will need to be drawn on with caution and the purpose of special observation determined locally. To be of therapeutic value and to be cost effective, special observation should be seen as a skilled nursing intervention and not a passive ‘watching’ or ‘sitter’ activity.     

Preserving personhood of individuals with advanced dementia: Lessons from family caregivers

This article reports on a phenomenological study of 15 family caregivers who admitted their spouse or parent with probable Alzheimer's disease to long-term care. The caregivers were attuned to the needs, desires, moods and concerns of their family members with dementia; thus, they were attuned to personhood. Caregivers also reported observations of care by nurses and nursing staff. Observations were of individualized care and actions that promoted personhood and impoverished care delivered with minimal or no communication. These family caregivers' perspectives can inform the care of individuals with advanced dementia by nurses and nursing staff.     

Geriatric nursing in the baccalaureate curriculum.

Increased gerontological nursing content is needed in the curriculum of schools of nursing because of a dramatic increase in the number of older persons, many of whom will need specialized health care. A review of the gerontological nursing content in the current courses of a college of nursing led to specific recommendations for change and additions to the curriculum. A published list of suggested gerontological nursing content was used as a guide to determine which topics needed to be integrated into the curriculum. An ongoing evaluation of the curriculum is needed to determine the appropriateness of the content changes and to determine if students perform better as a result of these changes.     

Representations of people with dementia – subaltern,person, citizen

GILMOUR JA and BRANNELLY T. Nursing Inquiry 2010; 17 : 240–247
Representations of people with dementia – subaltern, person, citizen This study traces shifts in health professional representations of people with dementia. The concepts of subaltern, personhood and citizenship are used to draw attention to issues around visibility, voice and inclusion. Professional discourses and practices draw upon, and are shaped by historical and contemporary representations. Until recently, people with dementia were subaltern in nursing and medical discourses; marginalised and silenced. The incorporation of contemporary representations foregrounding personhood and citizenship into health professional accounts provide space for transformative styles of care. Privileging personhood centralises the person with dementia in social networks, focusing on their experiences and relationships. Respecting citizenship involves challenging discrimination and stigma: nursing from a rights‐based approach necessitates listening and being responsive to the needs of the person with dementia. Incorporating contemporary representations in health professional practice requires the discarding of the historically dominant elite and authoritarian accounts of dementia still apparent in some nursing texts along with, perhaps, the historically burdened term of dementia itself.     

Nursing Best Practice Guidelines: reflecting on the obscene rise of the void

Aim(s)  Drawing on the work of Jean Baudrillard and Michel Foucault, the purpose of this article is to critique the evidence-based movement [and its derivatives – Nursing Best Practice Guidelines (NBPGs)] in vogue in all spheres of nursing.
Background  NBPGs and their correlate institutions, such as the Registered Nurses' Association of Ontario (RNAO) and 'spotlight' hospitals, impede critical thinking on the part of nurses, and ultimately evacuate the social, political and ethical responsibilities that ought to distinguish the nursing profession.
Evaluation  We contend that the entire NBPG movement is based on the illusion of scientific truth and a promise of ethical care that cannot be delivered in reality. We took as a case study the Registered Nurses' Association of Ontario (RNAO), in the province of Ontario, Canada.
Key issues  NBPGs, along with the evidence-based movement upon which they are based, are a dangerous technology by which healthcare organizations seek to discipline, govern and regulate nursing work.
Conclusion(s)  Despite the remarkable institutional promotion of 'ready-made' and 'ready-to-use' guidelines, we demonstrate how the RNAO deploys BPGs as part of an ideological agenda that is scientifically, socially, politically and ethically unsound.
Implications for nursing management  Collaborations between health care organizations and professional organizations can become problematic when the latter dictate nursing conduct in such a way that critical thinking is impeded. We believe that nurse managers need to understand that the evidence-based movement is the target of well-deserved critiques. These critiques should also be considered before implementing so-called 'Nursing Best Practice Guidelines' in health care milieux.     

Specialized care unit: family and staff perceptions of significant elements

Specialized care units (SCUs) for nursing home residents with dementia are increasingly prevalent. Although reported to promote positive resident outcomes, the specific characteristics of SCUs most likely to yield these outcomes have not yet been identified. This article presents the findings of a qualitative study that investigated the perceptions of family members and staff about SCU characteristics that contribute to positive outcomes for residents with dementia. All family and staff members interviewed agreed that the SCU fostered feelings of personal space, personhood, and an unforced routine. These findings are discussed and provide specific direction for care of nursing home residents with dementia.     

Agonizing care: care ethics,agonistic feminism and a political theory of care

'Care' is central to nursing theory and practice, and has been described in a variety of ways. Intense conversations about care have been developing in other fields of study as well, from the social sciences to the humanities. Care ethics has grown out of intellectual exchange between feminist thought, moral theory and the critique of traditional western political philosophy. However, care ethics is not without its critics, as these accounts of care have also sparked vigorous challenges. This paper traces the construct of care through nursing theory, care ethics, feminist critiques of moral and political theory and agonistic feminism to outline a set of problematics that a political theory of care should engage. It discusses how care is conventionally posited in more or less essentialist, universalizing and naturalizing terms. It introduces the ideas of feminist theorists who resist dichotomizing care and the political, and situate care in the context of power and politics. The tensions between care feminism and agonistic feminism are highlighted in order to explore the potential of theorizing both care and nursing in political terms.     

Attitudes of registered nurses towards patients with severe dementia

Meeting the needs and wishes of people with severe dementia is difficult and demanding for carers, and a number of approaches can be used in encounters with dementia sufferers. The aim of this study was to explore how registered nurses in a northern Norwegian county thought about approaching people with severe dementia. A patient case was used as a vignette, followed by a questionnaire with 13 sets of statements, each set containing two alternative approaches (one reality orientation approach and one personhood focused approach). In 12 out of the 13 sets of statements the reality orientation alternative was usually chosen, but responses to the statement regarding the meaning of confusion tended more towards the personhood focused approach. RNs with more than the basic education and staff nurses working in a team nursing system, chose the personhood focused approach significantly more often than RNs with no post-basic education and nurses working in a primary nursing system. The article discusses how reflection on daily experiences can improve one's ability to reflect on one's own experiences and encourage a personhood focused approach. Working in a team means gaining opportunities to reflect together with coworkers, while working in a primary nursing care system might afford fewer such opportunities.     

Gerontological nursing. 3: Valuing nursing homes and valuing staff

This, the third of five articles considering the future of gerontological nursing, focuses on practice within nursing homes. The important contribution of such environments is highlighted and it is argued that work within long-term care settings must be recognized and valued if the quality of care provided is to improve.     

Working with older people: what do the next 10 years hold?

This article briefly considers the challenges facing gerontological nursing over the next 10 years. It suggests that future quality of care will depend largely on the ability to recruit and retain staff who actively choose to work with older people. This will mean raising the status and profile of gerontological nursing and identifying a philosophy that provides direction and purpose for future care practices.     

Patients who present with dementia: exploring the knowledge of hospital nurses

With the older population growing, there is likely to be an increase in the numbers of people with dementia on acute hospital wards. This article presents some of the findings from a Masters study (Ballard 2005) that explored the knowledge, understanding and implications for care of adult nurses working with patients who present with dementia in general hospital wards. Kitwood's 'malignant social psychology' and 'person-centred approach' were used as the theoretical framework to develop a questionnaire distributed to nurses. The findings about nurses' knowledge and understanding of person-centred dementia care and gaps in this area are discussed, and implications for future education and training of nurses presented.     

An analysis of psychosocial theories of ageing and their relevance to practical gerontological nursing in Sweden

BACKGROUND: Theories exist to challenge current practice, create new approaches to practice and remodel the structure of rules and principles. One question is whether nurses could find in psychosocial theories of ageing a theoretical foundation on which to base support of older people in their ageing process. AIM: The aim of the present paper was to analyse five psychosocial theories of ageing and to discover what they could mean for gerontological nursing in Sweden. METHOD: A literature search was conducted to find original works. Research questions inspired by Fawcett's framework guided the analysis. FINDINGS: Psychosocial theories of ageing cover different aspects of the ageing process, but do not address crucial issues regarding the attitudes and structure of good nursing care. These theories provide no clear guidance on how to care for older people and how to support them in their ageing process. However, the analysis did show that the theories contain underlying values that influence society and staff as regards their views on the ageing process and how care of older people should be carried out. Nursing interventions to support ageing will be quite different depending on the theoretical perspective taken by nurses. CONCLUSIONS: There is a need to translate the ageing theories into guidelines, so that staff in gerontological care will have tools to use in practice irrespective of which theoretical perspective they choose to use in care. This could also promote care that is tailored to each individual older person.