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.     

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     

Dementia care mapping: an approach to quality audit of services for people with dementia in two health districts

The audit reported in this paper and submitted to the Psychiatry of Old Age Management group, assessed six units within each of two health districts in the UK. Using a nonparticipatory observation method in the units selected, the aim was to measure quality and the environment of care. Dependency levels of the clients/residents were also estimated to give a clearer picture of the setting and the care requirements. This was intended to establish a baseline for the units mapped and to enable care developments to be focussed upon intended outcomes. Results led to a number of observations related to the levels of interaction between staff and clients/residents, the need for a wider range of activities to promote person-centred care, and a suggested route to the improvement in quality of life for this vulnerable group of people. Assessment of dependency levels linked to the results of the mapping showed that high dependency does not lead automatically to a lower quality of person centred care.     

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.     

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.     

Reconciling mental health recovery with screening and early intervention in dementia care

If early intervention in dementia care is to be enhanced, it is important to have a critical debate over how this should be realized. In this paper, we offer a synthesis of two approaches to care: mental health recovery and person-centred care, and apply them to early-stage dementia care. 'Person-centred care' has become a catchphrase for good dementia care. However, many people have not experienced improvements in care, and other lynch pin concepts, such as 'mental health recovery', might have utility in driving reform. The similarities and differences between the two approaches are drawn out, and the difficulties of using the word 'recovery' when discussing a degenerative disease are highlighted. The implications of this discussion for early intervention are discussed. It could be seen that the two bodies of knowledge have much to offer each other, despite initial dissonance with the label of recovery in dementia care.     

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.     

Impact of a person-centred dementia care training programme on hospital staff attitudes,role efficacy and perceptions of caring for people with dementia: A repeated measures study

BackgroundPeople with dementia occupy up to one quarter of acute hospital beds. However, the quality of care delivered to this patient group is of national concern. Staff working in acute hospitals report lack of knowledge, skills and confidence in caring for people with dementia. There is limited evidence about the most effective approaches to supporting acute hospital staff to deliver more person-centred care.ObjectivesThis study aimed to evaluate the efficacy of a specialist training programme for acute hospital staff regarding improving attitudes, satisfaction and feelings of caring efficacy, in provision of care to people with dementia.DesignA repeated measures design, with measures completed immediately prior to commencing training (T1), after completion of Foundation level training (T2: 4–6 weeks post-baseline), and following Intermediate level training (T3: 3–4 months post-baseline).SettingOne NHS Trust in the North of England, UK.Participants40 acute hospital staff working in clinical roles, the majority of whom (90%) were nurses.MethodsAll participants received the 3.5 day Person-centred Care Training for Acute Hospitals (PCTAH) programme, comprised of two levels, Foundation (0.5 day) and Intermediate (3 days), delivered over a 3–4 months period. Staff demographics and previous exposure to dementia training were collected via a questionnaire. Staff attitudes were measured using the Approaches to Dementia Questionnaire (ADQ), satisfaction in caring for people with dementia was captured using the Staff Experiences of Working with Demented Residents questionnaire (SEWDR) and perceived caring efficacy was measured using the Caring Efficacy Scale (CES).ResultsThe training programme was effective in producing a significant positive change on all three outcome measures following intermediate training compared to baseline. A significant positive effect was found on the ADQ between baseline and after completion of Foundation level training, but not for either of the other measures.ConclusionsTraining acute hospital staff in Intermediate level person-centred dementia care is effective in producing significant improvements in attitudes towards and satisfaction in caring for people with dementia and feelings of caring efficacy. Foundation level training is effective in changing attitudes but does not seem to be sufficient to bring about change in satisfaction or caring efficacy.     

Collecting data on the experiences and perspectives of people with dementia in the acute care hospital setting: A systematic scoping review

Background

People with dementia frequently experience poor health outcomes that require hospitalisation; however, the hospital setting is generally unsuitable for these patients. While it is well-recognised that understanding patient perspectives is crucial to providing person-centred care, current clinical care guidelines do not describe how to effectively collect feedback from people with dementia. Historically, people with dementia have generally been neglected from data collection exercises among practitioners and academic researchers, alike.

Objective

The objective of this review is to describe the data collection processes from peer-reviewed evidence sources that include direct consultation with, and elicit feedback from, patients with dementia about their care experience in the hospital setting.

Methods

The protocol for this systematic scoping review was pre-registered ( https://doi.org/10.6084/m9.figshare.16614667.v1 ). The review considered primary quantitative and qualitative research involving people with dementia as research participants, regarding the quality of hospital care from the patient's perspective. Four databases were searched (MEDLINE, CINAHL Complete, APA PsycINFO and Embase), with 14 studies meeting the eligibility criteria.

Results

There has been an increased interest in gaining the perspectives of people with dementia on their health care over the past 5 years. Sundry methodologies were employed by these studies, but most used informal qualitative interviews to support and enable participants with diverse symptoms and functional abilities to take part. Procedures concerning recruitment, ethics and consent, and data collection processes were, likewise, varied and not reported consistently across this body of evidence.

Conclusions

People with dementia can be meaningfully consulted as research participants in the hospital setting. Increased rigour when reporting the methodologies and strategies used during data collection is needed to provide guidance for health services and researchers to further enable the inclusion of people with dementia.

Implications for practice

Including people with dementia in data collection endeavours in the hospital setting is essential to improving health outcomes, increasing equity and providing better hospital service delivery to this vulnerable cohort.     

People with dementia and their relatives: personal experiences of Alzheimer's and of the provision of care

Little is known about the experiences of people with dementia, as there has been relatively little research carried out that includes their perspectives. In the past, user perspectives on experiences of dementia and on services have mostly been solicited from family carers, rather than from people with dementia themselves. It has been suggested that these studies may lack information and insight into the experiences of people with dementia. This study aimed at eliciting the views and feelings of people in all stages of dementia, as well as those of their relatives, on care services and on experiences of dementia. Twenty-seven people with dementia from residential and day care settings were interviewed and their daily lives videotaped. Interviews were also conducted with next of kin. This article reports on findings and issues arising from the study.     

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.     

Experiences of physical strain during person transfer situations in dementia care units

Caring for residents with dementia impose a higher challenge and workload on the nursing staff because of a higher degree of motor function and cognitive decline among the residents. Training in person transfer tasks for nursing staff has mostly been concentrated on ergonomics irrespective of the nature of the resident's functional decline. An increased knowledge about the nursing staffs' experiences of physical workload in dementia care and in how to reduce their physical strain is needed.
Aim:  The aim of the study was to describe nurse's aids' experiences of physical strain during person transfer tasks at dementia care units.
Method:  Four focus group interviews with altogether 16 nurses' aids, working at special care units for people with dementia, were performed.
Results:  The results show that knowledge about the disease and personality of residents in dementia care units can help to decrease the physical strain on nurses' aids in person transfer situations.
Nurse's aids need to be flexible when performing transfer tasks to accommodate variations in the resident's functional ability. Physical strain associated with person transfer tasks is not related to the weight of the resident. Misunderstandings because of cognitive decline and communication problems increase physical strain on nurses' aids. Specialized training in person transfer tasks is needed for nurse's aids working in dementia care.
Conclusions:  These results may serve to guide physiotherapists working in dementia care units in assessing residents' functional ability, in when to use assistive devices and mobility aids and in training and supervising nurse's aids in person transfer tasks.     

Healthcare staffs’ experiences and perceptions of caring for people with dementia in the acute setting: Qualitative evidence synthesis

BackgroundDementia is a global issue, with increasing prevalence rates impacting on health services internationally. People with dementia are frequently admitted to hospital, an environment that may not be suited to their needs. While many initiatives have been developed to improve their care in the acute setting, there is a lack of cohesive understanding of how staff experience and perceive the care they give to people with dementia in the acute setting.ObjectivesThe aim of this qualitative synthesis was to explore health care staffs’ experiences and perceptions of caring for people with dementia in the acute setting. Qualitative synthesis can bring together isolated findings in a meaningful way that can inform policy development.SettingsA screening process, using inclusion/exclusion criteria, identified qualitative studies that focused on health care staff caring for people with dementia in acute settings.ParticipantsTwelve reports of nine studies were included for synthesis. Data extraction was conducted on each report by two researchers.MethodsFramework synthesis was employed using VIPS framework, using Values, Individualised, Perspective and Social and psychological as concepts to guide synthesis. The VIPS framework has previously been used for exploring approaches to caring for people with dementia. Quality appraisal was conducted using Critical Appraisal Skills Programme (CASP) and NVivo facilitated sensitivity analysis to ensure confidence in the findings.ResultsKey themes, derived from VIPS, included a number of specific subthemes that examined: infrastructure and care pathways, person-centred approaches to care, how the person interacts with their environment and other patients, and family involvement in care decisions. The synthesis identified barriers to appropriate care for the person with dementia. These include ineffective pathways of care, unsuitable environments, inadequate resources and staffing levels and lack of emphasis on education and training for staff caring for people with dementia.ConclusionsThis review has identified key issues in the care of people with dementia in the acute setting: improving pathways of care, creating suitable environments, addressing resources and staffing levels and placing emphasis on the education for staff caring for people with dementia. Recommendations are made for practice consideration, policy development and future research. Leadership is required to instil the values needed to care for this client group in an effective and personcentred way. Qualitative evidence synthesis can inform policy and in this case, recommends VIPS as a suitable framework for guiding decisions around care for people with dementia in acute settings.     

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.     

A critical literature review exploring the challenges of delivering effective palliative care to older people with dementia

Aim. This paper considers the challenges of delivering effective palliative care to older people with dementia and the possible strategies to overcome barriers to end-of-life care in these patients. Background. In UK alone, approximately 100 000 people with dementia die each year and as the number of older people increases, dementia is set to become even more prevalent. Dementia is a progressive terminal illness for which there is currently no cure. Patients dying with dementia have significant health-care needs and in recent years it has been recognised that palliative care should be made available to everyone regardless of diagnosis, as this improves comfort and quality of life. Despite this, patients dying with dementia are often still not given access to palliative care services. Method. A review of English language literature published after 1996 to the present day relating to older people with dementia during the terminal phase of their illness. Results. Twenty-nine articles met inclusion criteria for the review. Most originated from North America and UK and were mostly quantitative in nature. Four key themes were identified: difficulties associated with diagnosing the terminal phase of the illness (prognostication); issues relating to communication; medical interventions; and the appropriateness of palliative care intervention. Conclusions. This review reinforces the importance of providing appropriate palliative care to individuals suffering from end-stage dementia and identifies some of the barriers to extending such specialist palliative care provision. Relevance to practice. There is an urgent need to improve palliative care provision for older people with end-stage dementia and, in addition, more research is required on the needs of patients entering the terminal phase of dementia to assist the allocation of appropriate resources and training to ensure quality and equality in the provision of end-of-life care.     

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.     

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.     

Attitudes toward dementia‐related aggression among staff in Japanese aged care settings

Aim and objective. This study investigated attitudes of Japanese aged care staff toward aggression by people with dementia. Relationships between staff attitudes, professional characteristics and clinical practice were explored. Background. Aggressive behaviour is often demonstrated by people with dementia and may be influenced by many factors including an inability by the individual to appropriately express their needs, difficulties with assessment, as well as organisational and practice issues. Design. Survey. Method. Twenty‐seven facilities/organisations located in the western and middle parts of Japan were surveyed. Staff (n = 675) employed in these facilities provided personal and professional information and completed the Attitudes Towards Aggression Scale. Results. Staff who were older, had more clinical experience, higher education and/or a higher position reported more positive attitudes towards patient aggression. Staff with negative attitudes towards patients who are aggressive reported using chemical and/or physical restraint more often than staff with positive attitudes. Conclusions. Dementia education as well as restraint policy will be useful in addressing negative staff attitudes, in particular it may help to reverse the myth that restraint is necessary for staff protection. Furthermore, staff counseling may help to reduce stressors and to change staff negative attitudes towards people with dementia who display aggression. Relevance to clinical practice. The findings show that negative staff attitudes may adversely affect clinical decision making and patient care. Measuring attitudes can identify areas requiring education or skill development and enable changes in attitudes to be monitored over time.