Supporting general hospital staff to provide dementia sensitive care: A realist evaluation

Dementia friendly in the context of hospitalization: A concept analysis using the Walker & Avant Method

AIM(S)

To evaluate the literature to inform and propose a conceptual definition for dementia friendly in the context of hospitalization.

METHODS

The Walker & Avant method for concept analysis was utilized for this review.

DATA SOURCES (INCLUDE SEARCH DATES)

Initial search conducted June 2022. Repeated search conducted in February 2023. Databases for the literature search include Scopus, PubMed, CINAHL, PsycINFO, and AGELINE.

RESULTS

Five attributes of the concept of dementia friendly in the context of hospitalization were identified including: staff knowledge/education, environmental modification, person-centred care, nursing care delivery and inclusion of family caregivers. Based on these attributes a conceptual definition is proposed.

CONCLUSION

A clarified definition for dementia friendly in the context of hospitalization will aid in understanding the concept, provide guidance for hospitals seeking to implement dementia-friendly interventions and benefit researchers aiming to study the impact of such programs. REPORTING METHOD: n/a.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Keeping the conversation going: How progressivity is prioritised in co-remembering talk between couples impacted by dementia

This article explores how partners keep the conversation going with people living with dementia (PLWD) when speaking about shared memories. Remembering is important for PLWD and their families. Indeed, memory loss is often equated with identity loss. In conversation, references to shared past events (co-rememberings) can occasion interactional trouble if memories cannot be mutually recalled. This article analyses partners' interactional practices that enable progressivity in conversations about shared memories with a PLWD. In previous research, both informal and formal carers have reported that they can find interacting with PLWD difficult. Identifying practices used by partners is one way to begin addressing those difficulties. Analytical findings are based on over 26 hours of video data from domestic settings where partners have recorded their interactions with their spouse/close friend who is living with dementia. The focus is on 14 sequences of conversation about shared memories. We show how particular practices (candidate answers, tag questions and single-party memory of a shared event) structure the interaction to facilitate conversational progression. When partners facilitate conversational progressivity, PLWD are less likely to experience stalls in conversation. Our findings suggest the actual recall of memory is less relevant than the sense of shared connection resulting from the conversational activity of co-remembering, aiding maintenance of individual and shared identities. These findings have relevance for wider care settings.

Facilitators and barriers to implementing a specialized care unit for persons with cognitive impairment in an acute geriatric hospital: a process evaluation

BACKGROUND

Implementing dementia care interventions in an acute hospital poses multiple challenges. To understand factors influencing the implementation, in-depth knowledge about specific facilitators and barriers is necessary. The aim of this study was to identify facilitators and barriers to implementing an interprofessional, multicomponent intervention of a specialized unit for persons with cognitive impairment in an acute geriatric hospital.

METHODS

We conducted a process evaluation as part of a participatory action research study. For data collection, semi-structured individual interviews with fifteen professionals involved in the implementation of the specialized unit. We further conducted two focus groups with twelve professionals working on other units of the geriatric hospital. We performed a qualitative content analysis following Kuckartz's content-structuring analysis scheme.

RESULTS

We identified the following barriers to implementing the specialized unit: uncontrollable contextual changes (e.g., COVID-19 pandemic), staff turnover in key functions, high fluctuation in the nursing team, traditional work culture, entrenched structures, inflexible and efficiency-oriented processes, monoprofessional attitude, neglect of project-related communication, and fragmentation of interprofessional cooperation. An established culture of interprofessionalism, an interprofessionally composed project group, cooperation with a research partner, as well as the project groups' motivation and competence of managing change facilitated the implementation.

CONCLUSIONS

The implementation faced numerous barriers that can be described using the key constructs of the i-PARIHS framework: context, recipients, innovation, and facilitation. Overcoming these barriers requires an organizational development approach, extended project duration and increased process orientation. Furthermore, strategically planned, precise and ongoing communication towards all persons involved seems crucial. Differences between the work cultures of the professions involved deserve particular attention with regard to project-related roles and processes.

Neuropsychiatric symptoms of dementia in those with and without a recorded history of psychological trauma: A comparative study from an Australian dementia support service

OBJECTIVE

To compare the number and severity of neuropsychiatric symptoms (NPS) and associated caregiver distress between those with and without a noted history of psychological trauma among those referred to a specialised national dementia NPS support service.

METHODS

This was a 5-year retrospective observational study of records from the Dementia Support Australia NPS support service. NPS were reported by formal or informal caregivers at service entry using the Neuropsychiatric Inventory Nursing Home version or Questionnaire version. A history of psychological trauma was recorded in the person's social or medical history and/or endorsed as a contributor to NPS by a trained dementia consultant after a comprehensive clinical review. Regression was used to examine the impact of a recorded history of psychological trauma on NPS severity and associated caregiver distress, controlling for age and sex.

RESULTS

Among 41,876 eligible referrals with dementia, 6% (n = 2529) had some reference in their records to a history of psychological trauma. Referrals with a recorded history of psychological trauma were rated with a higher rate of both NPS severity (mean = 12.0) and associated caregiver distress (mean = 16.5) at service entry than those without a recorded history of psychological trauma (means = 10.7 and 14.5, respectively). A recorded history of psychological trauma was associated with higher odds of psychotic symptoms, agitation/aggression, irritability, disinhibition, affective symptoms and night-time behaviours.

CONCLUSIONS

Traumatic stress symptoms may represent a neglected target for intervention to reduce the impact of NPS in people with dementia.

Building Clinical Leadership Competencies When Caring for Hospitalized Adults Experiencing Dementia

PURPOSE AND OBJECTIVES

Attempting to improve the experience of hospitalized adults with dementia and reduce patient attendant costs, we addressed hospital nursing staff confidence managing responsive behaviors through education, mentorship, and individualized patient care planning for adults with dementia.Responsive behaviors (such as pacing, calling out) is a term used to describe behaviors demonstrated by a person with dementia as a way of responding to something negative, frustrating, or confusing in their social and physical environment.

DESCRIPTION OF PROJECT

Under time restraints, we performed a rapid environmental scan and developed internal clinical resources and a learning strategy that informed a quality improvement initiative that focused on dementia care of hospitalized patients.

OUTCOME

Using quantitative and qualitative evaluation methods, the interventions increased confidence, competency, and leadership in clinical nursing leaders and improved person-centered care planning practices. The cost of patient attendant usage for this patient population decreased by 28% in 1 year.

CONCLUSION

This intervention, which was not a copyrighted program associated with administration costs, improved hospital-based dementia care and staff confidence in dementia care and reduced annual costs associated with patient attendant useage.

Development of a decision-support framework to support professionals and promote comfort among older hospital inpatients living with dementia

BACKGROUND

Acute hospital wards can be difficult places for many people living with dementia. Promoting comfort and wellbeing can be challenging in this environment. There is little evidence-based support for professionals working on acute care wards on how to respond to distress and maximise comfort and wellbeing among patients living with dementia.

OBJECTIVES

Our overall aim was to codesign an evidence-based easy-to-use heuristic decision-support framework, which was acceptable and practical but acknowledges the complex and acute nature of caring for patients with dementia in the hospital. This paper presents the development process and resulting framework.

METHODS

A codesign study was informed by data from (1) a literature review of the care and management of people living with dementia in acute hospitals; (2) a cohort study of comfort and discomfort in people with dementia in acute hospitals; and (3) interviews with family carers and health care professionals. We synthesised evidence from these data sources and presented to key stakeholders through codesign meetings and workshops to produce our decision-support framework.

RESULTS

The framework consists of a series of flowcharts and operates using a three-stage process of: (1) assess comfort/discomfort; (2) consider causes of discomfort; and (3) address patient needs to manage the discomfort.

CONCLUSION

Working with key stakeholders, synthesising diverse quantitative and qualitative evidence to build a clinical framework is a feasible approach to help address the needs of patients living with dementia in an acute hospital setting. The result is a framework which is now ready for evaluation and implementation.

PATIENT AND PUBLIC CONTRIBUTION

We worked closely with people living with dementia and family carers throughout this study, including the development of the study protocol with input on study development and design, through to inclusion in stakeholder workshops and codesign of the decision support framework.

The use of constant observation with people with dementia in hospitals: a mixed-methods systematic review

OBJECTIVES

Constant observation is used in hospitals with people with dementia to manage their safety. However, opportunities for proactive care are not consistently recognised or utilised. A systematic review of constant observation was conducted to understand measures of effectiveness and facilitators for person-centred approaches.

METHOD

Electronic databases were searched between 2010 and 2022. Four reviewers completed screening, quality assessments and data extraction with 20% checked for consistency. Findings were presented through narrative synthesis (PROSPERO registration CRD42020221078).

FINDINGS

Twenty-four studies were included. Non-registered staff without specific training were the main providers of constant observation. Assessments and processes clarifying the level of observation encouraged reviews that linked initiation and discontinuation to a patient's changing needs. Examples of person-centred care, derived from studies of volunteers or staff employed to provide activities, demonstrated meaningful engagement could reassure a person and improve their mood. Proactive approaches that anticipated distress were thought to reduce behaviours that carried a risk of harm but supporting evidence was lacking.

CONCLUSION

Non-registered staff are limited by organisational efforts to reduce risk, leading to a focus on containment. Trained staff who are supported during constant observation can connect with patients, provide comfort and potentially reduce behaviours that carry a risk of harm.

Specialist dementia nursing models and impacts: a systematic review

PURPOSE OF REVIEW

Dementia policy priorities recommend that people who are living with dementia and their family should have access to support and interventions delivered by dementia specialists, including specialist nurses. However, specialist dementia nursing models and role-related competencies are not clearly defined. We systematically review the current evidence regarding specialist dementia nursing models and their impacts.

RECENT FINDINGS

Thirty-one studies from across three databases, and grey literature were included in the review. One framework defining specific specialist dementia nursing competencies was found. We did not find convincing evidence of the effectiveness of specialist nursing dementia services, relative to standard models of care from the current, limited evidence base, although families living with dementia valued it. No Randomised Controlled Trial (RCT) has compared the impact of specialist nursing on client and carer outcomes relative to less specialist care, although one nonrandomised study reported that specialist dementia nursing reduces emergency and inpatient service use compared with a usual care group.

SUMMARY

Current models of specialist dementia nursing are numerous and heterogeneous. Further exploration of the specialist nursing skills and the impact of specialist nursing interventions is needed to usefully inform workforce development strategies and clinical practice.

Exploring the experiences of people living with dementia in Dementia Friendly Communities (DFCs) in Northern Ireland: a realist evaluation protocol

BACKGROUND

The aim of this study is to 1) explore the experiences of people living with dementia interacting with DFCs and 2) identify factors that influence empower and support people living with dementia to live successfully in DFCs. The main elements of a DFC are related to people; communities; organisations and partnerships. There are over 200 organisations recognised as dementia-friendly in Northern Ireland (NI). This realist evaluation is to understand how DFCs work for people living with dementia, how positive outcomes are achieved, for whom and in what contexts do DFCs work best.

METHODS

A realist evaluation using case study methodology. The process evaluation includes a realist review of the literature, non-participant observation of people living with dementia in their local communities, semi-structured interviews to explore the facilitators and barriers to living well in DFCs and focus groups comprised of people living with dementia, family caregivers and people working in DFCs to support Context- Mechanisms and Outcomes (CMOs). This four-stage realist assessment cycle is used, including iterative rounds of theory development, data gathering, and theory testing. In the end, analysis will reveal context mechanisms that influence how dementia-friendly communities operate and present an initial theory of how people think, which, if adopted, may be able to alter current contexts so that "key" mechanisms are activated to generate desired outcomes.

DISCUSSION

To give confidence in moving from hypothetical constructions about how DFCs could function to explanations of possible or observable causal mechanisms, the realist evaluation of a complex intervention incorporates a variety of evidence and perspectives. Despite playing a significant role in a person with dementia's everyday life, it appears that little is known about how communities function to achieve intended results. Even though there has been a lot of work to pinpoint the fundamentals and crucial phases of building DFCs, it is still unclear how people living with dementia benefit the most from these communities. This study intends to advance our understanding of how outcomes are produced for people living with dementia by contributing to the underlying theory of DFCs as well as addressing the primary research objectives.

Experience of Operating Room Health Care Providers in the Management of Patients With Dementia

The management of hospitalized patients with dementia is more complicated compared to patients without dementia, specifically in the surgery ward. The aim of the current study was to explore the experiences of operating room health care providers in the management of patients with dementia. A descriptive qualitative study was designed. Twenty semi-structured interviews were conducted with surgical professionals. Content analysis was performed. Four main themes emerged: Communication Issues, Experience-Based Protocol, Emotions, and Perceived Needs. Health care providers in a surgical ward face numerous challenges when attending to patients with dementia and tend to use strategies based on their own experience due to lack of specific action protocols. Therefore, specific training of the surgical team and protocols are needed to ensure quality care. [Research in Gerontological Nursing, xx(x), xx-xx.].

A narrative review of staff views about dementia care in hospital through the lens of a systems framework

Background

Significant numbers of people with dementia are admitted into acute settings. They are likely to face poor health outcomes during hospitalisation. There is the need to fully understand the care provided to people with dementia through novel methods such as a systems approach (i.e. human interactions, policy, environment and equipment).

Aim

The aim of this literature review is to explore hospital practitioners' views on dementia care and to analyse findings using a systems approach.

Methods

We conducted a narrative review of primary studies that examined dementia care in acute settings. We analysed a total of 33 papers using Thomas and Harden's thematic synthesis guidelines.

Results

Thirty-three papers met the inclusion criteria for the review. The findings were as follows: (1) staff-patient relationships (e.g. coping with difficult behaviour), (2) staff-family relationships (e.g. the benefits of involving families in patient care), (3) staff-staff relationships (e.g. building a robust multidisciplinary team), (4) staff-patient care decisions (e.g. decisions directly related to the patient), (5) the environment (e.g. difficulty in adjusting to the hospital environment), (6) policies (e.g. hospital bureaucratic processes) and (7) equipment (e.g. pain assessment tools).

Conclusion

The paper revealed multidimensional challenges in the provision of dementia care within hospitals. We conclude that training programmes, hospital policies and processes aimed at improving outcomes for patients with dementia should adopt a systems approach which focuses on the relational, environmental, procedural and instrumental aspects of the hospital system.

Dementia Care Competency Model for Higher Education: A Pilot Study

A statewide landscape analysis was initiated to identify workforce development and educational needs concerning the support of persons with Alzheimer's Disease and Related Dementias (ADRD). Educational programs preparing healthcare professionals were targeted since people with ADRD, and their families/caregivers, often have frequent, ongoing contact with healthcare providers. A literature review and thematic analysis discovered a dearth of research and a lack of consistent competency identification for healthcare education. A crosswalk comparison of various competency models led to the development of a five factor model. A survey based on this model was sent to educators statewide evaluating confidence in ADRD-specific competency attainment in graduates. Descriptive statistics and factor analysis led to a revision of the original five factor model to a three factor model, including competencies in Global Dementia knowledge, Communication, and Safety, each with various sub-competencies. Identifying ADRD-specific competencies for graduating healthcare students is essential. This three factor competency framework will support educational programs in examining curricular offerings and increasing awareness concerning the needs of the ADRD population. Furthermore, using a robust competency model for healthcare education can assist in preparing graduates to address the needs of those with ADRD as well as the needs of the family/caregiving system and environment.

A realist evaluation of a community of practice for dietitians and nutritionists working in Aboriginal and Torres Strait Islander health

BACKGROUND

Communities of practice have been proposed as a workforce development strategy for developing dietitians, yet little is known about how they work and for whom, as well as under what circumstances. We aimed to understand the mechanisms by which dietitians working in Aboriginal and Torres Strait Islander health benefit from communities of practice.

METHODS

A realist evaluation of 29 interviews with non-Indigenous dietitians and nutritionists was employed, which was conducted over the course of two communities of practice (2013 and 2014) and follow-up interviews in 2019. Programme theory was developed from analysis of initial interviews and used to recode all interviews and test theory. The identification of patterns refined the programme theory.

RESULTS

Six refined theories were identified: (1) a community of practice fosters the relationships that support navigation of the many tasks required to become more responsive health professionals; (2) committed and open participants feel supported and guided to be reflexive; (3) sharing, reflexivity, feedback and support shift awareness to one's own practice to be able to manoeuvre in intercultural spaces; (4) through sharing, feedback, support and collaboration, participants feel assured and affirmed; (5) connection through feelings of understanding and being understood contributes to commitment to remain working in the area; and (6) through sharing, feedback, support and collaboration, participants with varied experience and roles see the value of and gain confidence in new perspectives, skills and practices.

CONCLUSIONS

Further research is required to test this model on a much larger scale, with communities of practice inclusive of Aboriginal and non-Aboriginal health professionals together, and across a diverse group of dietitians.

Dementia care in acute hospitals: A framework for practice development and theory-based evaluation

AIM

The aim was to generate a framework for dementia care in acute hospitals.

DESIGN

Framework development with logic modelling.

METHODS

In phase one, we identified relevant elements of the framework by analysing several sources and by critically discussing them within the research team. We created the framework with logic modelling. In phase two, we adapted the framework in expert workshops and by reanalysing the included sources. We used the first stage of CReDECI 2 checklist for reporting.

RESULTS

The framework describes necessary activities within four main bundles of measures: "developing structures and processes," "developing competences and attitudes," "building relationships" and "ensuring a social environment and adequate stimulation." The overarching outcome is a person-centred hospital culture, manifesting itself on different levels. The framework illustrates the necessity of an organization-wide person-centred culture for achieving positive outcomes for people with dementia, their relatives and health professionals.

New horizons for caring for people with dementia in hospital: the DEMENTIA CARE pointers for service change

Approximately two-thirds of hospital admissions are older adults and almost half of these are likely to have some form of dementia. People with dementia are not only at an increased risk of adverse outcomes once admitted, but the unfamiliar environment and routinised practices of the wards and acute care can be particularly challenging for them, heightening their confusion, agitation and distress further impacting the ability to optimise their care. It is well established that a person-centred care approach helps alleviate some of the unfamiliar stress but how to embed this in the acute-care setting remains a challenge. In this article, we highlight the challenges that have been recognised in this area and put forward a set of evidence-based 'pointers for service change' to help organisations in the delivery of person-centred care. The DEMENTIA CARE pointers cover areas of: dementia awareness and understanding, education and training, modelling of person-centred care by clinical leaders, adapting the environment, teamwork (not being alone), taking the time to 'get to know', information sharing, access to necessary resources, communication, involving family (ask family), raising the profile of dementia care, and engaging volunteers. The pointers extend previous guidance, by recognising the importance of ward cultures that prioritise dementia care and institutional support that actively seeks to raise the profile of dementia care. The pointers provide a range of simple to more complex actions or areas for hospitals to help implement person-centred care approaches; however, embedding them within the organisational cultures of hospitals is the next challenge.

Protocol for the IMPART study: IMplementation of the preterm birth surveillance PAthway - a RealisT evaluation

INTRODUCTION

New guidance, from NHS England (Saving Babies Lives Care Bundle Version 2 Element 5 (SBLCBv2)) has recommended a best practice pathway for women at risk of preterm birth (the Preterm Birth Pathway). This is to help meet the Department of Health's aim to reduce preterm birth from 8% to 6% by 2025. Considering most hospitals do not currently have a preterm prevention clinic, implementing this pathway will require significant coordination.

METHODS AND ANALYSIS

The study will aim to investigate key features of contexts, mechanisms and outcomes, and their interactions in the implementation of the asymptomatic prediction and prevention components of the SBLCBv2 Preterm Birth Surveillance Pathway. This will be through a theory driven realist evaluation, utilising mixed methods (interviews with staff and women, observational analysis and analysing routinely collected hospital and admin data) in three case sites in England. The study has a Project Advisory Group composed of five women who have recently given birth.

ETHICS AND DISSEMINATION

The study has ethical approval (King's College London REC approval number: MRSP-20/21-20955, and, IRAS:289144). A dissemination plan will be fully created with the Project Advisory Group, and we anticipate this will include presenting at conferences, publications, webinars, alongside dissemination to the wider population through parent and baby groups, the media and charities.

TRIAL REGISTRATION NUMBER

ISRCTN57127874.

Testing the sensitivity of two dementia knowledge instruments in dementia workforce education

BACKGROUND

The importance of dementia education in improving the care and support that people living with dementia is well established. Previous research has shown ceiling effects in pre and post educational intervention measures of dementia knowledge using Knowledge in Dementia Scale (KIDE) on post-registered health and social care staff in Scotland. The aim was to test the sensitivity of two dementia knowledge instruments, namely the (KIDE) and the Dementia Knowledge Assessment Scale (DKAS).

DESIGN

A pre and post evaluation comparison of two dementia knowledge scales.

SETTING

The tenth cohort of Scotland's National Dementia Champions Education Programme, September 2019-March 2020.

PARTICIPANTS

Post-registered Health and Social Care staff (n = 117).

METHODS

Both the DKAS and KIDE scales were administered pre and post programme delivery. Wilcoxon signed-rank tests were performed to examine T1 - T2 differences in dementia knowledge for both validated measures.

RESULTS

Ceiling effects continued to be present for the KIDE scale at T1 and T2. The DKAS responses showed a different score distribution than that achieved by the KIDE. Ceiling effects noted for KIDE at T1 were not present for the DKAS. Further, at T2, only 6% of respondents scored the maximum on the DKAS.

CONCLUSIONS

The DKAS appears to be a more useful instrument for measuring knowledge in post-registered health and social care staff; however, there was some evidence of ceiling effects post-intervention. There is a need for both scales to be tested in more educationally diverse populations, so educators and researchers can make informed decisions about the instrument's target range. Additionally, further research is needed to develop new sets of dementia knowledge items suitable for use in trained health and social care staff.

Mechanisms of impact and contextual aspects of a dementia special care unit in long-term care: a process evaluation

BACKGROUND

In long-term care, persons with dementia are often cared for in specialised facilities, which are rather heterogeneous in regard to care concepts. Little information is available on how these facilities and care concepts bring about changes in the targeted outcomes. Such knowledge is needed to understand the effects of care concepts and to consciously shape further developments. This study aimed to explore the mechanisms of impact of a specific care concept from a dementia special care unit and the contextual aspects that influence its implementation or outcomes.

METHODS

Using a qualitative approach to process evaluation of complex interventions, we conducted participating observations and focus groups with nurses and single interviews with ward and nursing home managers. Data were collected from two identical dementia special care units to enhance the contrasts in the analysis of two non-specialised nursing homes. We analysed the data thematically. We conducted 16 observations, three group interviews and eleven individual interviews.

RESULTS

We identified seven themes in three domains related to mechanisms that lead to outcomes regarding residents' and nurses' behaviour and well-being. The themes include the development of nurses' skills and knowledge, the promotion of a positive work climate, adjusted spatial structures, adjusted personnel deployment strategy "dedicated time for activities", promotion of relaxation, of engagement in activities and of engagement in social interaction of residents. The implementation and outcomes of the care concept are influenced by contextual aspects relating to the (target) population and cultural, organisational and financial features.

CONCLUSIONS

The study found expected and unexpected mechanisms of impact and contextual aspects. The care concept of the dementia special care unit results in higher levels of relaxation, activities, and social interaction of residents. Its implementation highly depends on the shared understanding of nursing and the skills of the nursing team. Changes in residents' characteristics result in altered effects of the concept.

TRIAL REGISTRATION

DRKS00011513 .

Evaluation and Effectiveness of Dementia Staff Training Programs in General Hospital Settings: A Narrative Synthesis with Holton's Three-Level Model Applied

Background:

People with Dementia (PwD) are frequently admitted to hospital settings. The lack of proper dementia knowledge, poor communication skills, negative attitudes toward dementia, and lack of confidence affects the quality of care, thus development of dementia trainings has increased. Nevertheless, literature regarding the effectiveness of training implementation is limited.

Objective:

The aim of this narrative synthesis is to 1) identify the characteristics of training programs and 2) explore the effectiveness of these training programs in everyday clinical practice.

Methods:

A systematic search in PubMed, PsycINFO, CINAHL, and Cochrane was conducted, including qualitative and quantitative peer-reviewed studies. Holton’s evaluation model with its three outcome levels (learning, individual performance, and organizational results) was adopted. 14 studies were included.

Results:

The synthesis of the results was divided into two parts: 1) to describe the characteristics and content of trainings 2) to evaluate the effectiveness of training programs according to the three outcome levels of Holton’s model, taking into consideration its construct domains: ability, motivation, and environment. Learning outcomes were assessed in all selected studies: 13 studies observed changes in individual performance, four studies reported changes within the organizational level, and only five showed sustainable changes over time.

Conclusion:

Person-centered care (PCC) approaches, interactive and varied teaching methods, supporting conditions like champions, action plans, and setting care policies, are all characteristics of effective trainings. Successful programs should be sustainable over time, demonstrating positive outcomes across the organization. Based on current findings, there is a lack of adequate evaluation with regard to training programs on the organizational level.

Trauma-informed care in geriatric inpatient units to improve staff skills and reduce patient distress: a co-designed study protocol

Background

Geriatric hospital wards are highly medicalised environments with limited opportunities for choice and control, and can be distressing for older survivors of psychological trauma. While trauma-informed models of care (TIC) are effectively applied across mental health and other settings, the utility of these models in aged care settings has not been assessed. The objective of this study was to examine whether TIC can reduce responsive behaviour, chemical restraint, and improve staff skills and patient experiences in inpatient geriatric settings.

Methods

Four wards participated in this type I hybrid implementation-effectiveness study across southern Adelaide, Australia, including 79 beds. Using a co-design method, the principles of TIC were transformed into an implementation strategy including staff training, establishment of highly trained ‘champions’ on each ward, screening for trauma-related needs, and amending ward policies and procedures. Primary outcomes will be examined using an interrupted time-series design and are monthly incidence of responsive behaviour incidents and use of chemical restraint. Process evaluation will be used to examine secondary, implementation outcomes including the acceptability, feasibility, and fidelity to the implementation strategy.

Discussion

Trauma-informed care has potential to improve the safety and accessibility of hospital wards for older people who have survived psychologically traumatic events and has an extensive evidence base supporting its effectiveness in other settings. Identifying trauma-related needs and amending care to reduce the risk of re-traumatisation and distress may also reduce the incidence of responsive behaviour change, which has a significant impact on the quality of life of hospital patients and staff and is very costly. The inclusion of a process evaluation will allow us to identify and report changes made on each ward and make recommendations for future implementation efforts.

Evaluation of coercive measures in different psychiatric hospitals: the impact of institutional characteristics

BACKGROUND

Epidemiological studies have demonstrated considerable differences in the use of coercive measures among psychiatric hospitals; however, the underlying reasons for these differences are largely unclear. We investigated to what extent these differences could be explained by institutional factors.

METHODS

Four psychiatric hospitals with identical responsibilities within the mental health care system, but with different inpatient care organizations, participated in this prospective observational study. We included all patients admitted over a period of 24 months who were affected by mechanical restraint, seclusion, or compulsory medication. In addition to the patterns of coercive measures, we investigated the effect of each hospital on the frequency of compulsory medication and the cumulative duration of mechanical restraint and seclusion, using multivariate binary logistic regression. To compare the two outcomes between hospitals, odds ratios (OR) with corresponding 95% confidence intervals (CI) were calculated.

RESULTS

Altogether, coercive measures were applied in 1542 cases, corresponding to an overall prevalence of 8%. The frequency and patterns of the modalities of coercive measures were different between hospitals, and the differences could be at least partially related to institutional characteristics. For the two hospitals that had no permanently locked wards, certain findings were particularly noticeable. In one of these hospitals, the probability of receiving compulsory medication was significantly higher compared with the other institutions (OR 1.9, CI 1.1-3.0 for patients < 65 years; OR 8.0, CI 3.1-20.7 for patients ≥65 years); in the other hospital, in patients younger than 65 years, the cumulative duration of restraint and seclusion was significantly longer compared with the other institutions (OR 2.6, CI 1.7-3.9).

CONCLUSIONS

The findings are compatible with the hypothesis that more open settings are associated with a more extensive use of coercion. However, due to numerous influencing factors, these results should be interpreted with caution. In view of the relevance of this issue, further research is needed for a deeper understanding of the reasons underlying the differences among hospitals.

Avoiding repair, maintaining face: Responding to hard-to-interpret talk from people living with dementia in the acute hospital

People living with dementia (PLWD) are almost always admitted to the acute hospital for reasons unrelated to their dementia, finding themselves in the unfamiliar environment of a Health Care of Older Persons acute ward. The effect of this environment creates a challenge not just for a PLWD themselves, but also for the staff who care for them. Concerns have been raised by both policy makers and staff about the quality of communication between hospital staff and PLWD. Using conversation analysis, we examined 41 video recordings of healthcare professional (HCP)/PLWD interactions collected across three acute inpatient wards in a large teaching hospital in the UK. In this paper, we focus our analysis on hard-to-interpret talk (talk where there are problems in hearing, speaking and/or understanding), and the ways in which healthcare professionals respond to this. Repair of hard- to- interpret talk is common in ordinary interaction, but we find that HCPs in this setting use a range of approaches to avoid direct repair. These approaches are: the use of non-committal responses and continuers such as 'yeah' or nods; the use of repetitions or partial repetitions; responding to the emotional tone displayed in the PLWD's utterance; closing the current topic and shifting to the next; and treating the PLWD's talk as related to the task at hand. We suggest that the use of these approaches may be one way in which HCPs manage respecting the personhood of the PLWD, by preserving face and enabling a continuation of an interaction in which the PLWD can take an active part. Our paper provides an empirical demonstration of the high level of interactional skill involved in dementia care work. It also illustrates how these skills can be described and specified, and hence incorporated into the recommendations and tips that are produced for communication with PLWD.

Understanding the knowledge and engagement of facilities management with dementia-friendly design in Irish hospitals: an exploratory study

Purpose

This exploratory study stems from research conducted between 2015–2018 focussing on dementia-friendly design (DFD) in hospitals (Grey T. et al. 2018). Specifically, this study focusses on facilities management (FM) staff in Irish hospitals to gain a preliminary understanding of the level of knowledge and engagement of FM in the implementation of dementia-friendly hospital (DFH) design.

Design/methodology/approach

A mixed-methods approach based on a series of ad hoc semi-structured interviews, and an online survey. The aims were, namely, assess the extent of FM engagement in hospital works; measure the level of awareness regarding DFD; and identify facilitators and barriers to DFD in hospital settings. Participants (74) comprised FM staff in 35 Irish acute care hospitals. The research findings are based on thematic analysis of ad hoc semi-structured interviews (participants, n = 4) and survey responses (participants, n = 13).

Findings

While FM staff reported to possess important knowledge for building DFH, they also mentioned a lack of engagement of FM in design processes and hospital works.

Practical implications

The research has gained insight into the role of FM in promoting a dementia-friendly approach. Lack of or poor engagement of FM in design processes and hospital works means not fully tapping into rich expertise that would be invaluable in the development, implementation and maintenance of DFH. Universal design is a key driver for facilitating their engagement in the design, implementation and maintenance of DFH environments.

Originality/value

This is the first study exploring the role of FM in supporting a DFD approach in acute care hospitals.

Implementing Silent Disco Headphones in a Hospital Unit: A Qualitative Study of Feasibility, Acceptance, and Experience Among Patients and Staff

INTRODUCTION

Music is so widely available and inexpensive in the modern world; it is a common option for stress reduction, comfort and enjoyment. Silent disco headphones are used among young people; however, no study has yet investigated whether it is feasible to use these headphones to support mental health and well-being among older people with dementia in hospital settings.

OBJECTIVE

The study's main objective is to explore whether music delivered by silent disco headphones was feasible and acceptable to a sample of inpatients staying in an older adult mental health unit of a large urban hospital.

METHODS

We employed a video-ethnographic design in data collection, including conversational interviews and observations with video recording among ten patient participants in a hospital unit. A focus group was conducted with ten hospital staff on the unit.

RESULTS

Our analysis identified three themes that represented experiences of patients and staff: (1) perceived usefulness, (2) perceived ease of use, and (3) attitude. Patient participants reported the music delivered by the headphones brought positive benefits. Witnessing the positive effects on patients influenced the staff's view of how music could be used in the clinical setting to support patients' well-being.

CONCLUSIONS

The music delivered by the silent disco headphones in an older adult mental health unit was found to be an acceptable and feasible intervention for patients. Leadership support is identified as an enabling factor in supporting technology adoption in the clinical setting. The findings can be used to inform practice development and future research.

Effects of a Person Centered Dementia Training Program in Greek Hospital Staff-Implementation and Evaluation

People with Dementia (PwD) are frequently admitted in general hospitals. However, health care professionals have lack of dementia knowledge, negative attitudes toward dementia, and lack of confidence in caring those patients. The aim of this study is to develop, implement and evaluate a dementia staff training program in Greek general hospitals. It was a repeated-measures research design. Fourteen (14) two-day workshops were conducted, consisting of six targeted and interactive modules. Staff members (N = 242) attended the program and were assessed according to (1) individual performance: questionnaires about attitudes towards dementia, confidence in care, knowledge about dementia and anxiety before, immediately after the training and three months later, (2) an overall training evaluation immediately after the training and (3) an evaluation of training implementation three months later. Positive attitudes towards dementia, improvement of confidence in care and decrease of feeling of anxiety as a trait, were sustained over time. Knowledge about dementia also increased after the training and sustained, with, however, a slight decrease over time. A well applied training program seems to provide the basis of a better care in PwD during hospitalization. However, changes in the organizational level and a transformation of care culture are necessary for training sustainability over time.

The prevalence rates and sequelae of delirium at age older than 90 years

OBJECTIVE

Although age and pre-existent dementia are robust risk factors for developing delirium, evidence for patients older than 90 years is lacking. Therefore, this study assesses the delirium prevalence rates and sequelae in this age group.

METHOD

Based on a Diagnostic and Statistical Manual (DSM)-5, Delirium Observation screening scale (DOS), and Intensive Care Delirium Screening Checklist (ICDSC) construct, in this prospective cohort study, the prevalence rates and sequelae of delirium were determined in 428 patients older than 90 years by simple logistic regressions and corresponding odds ratios (ORs).

RESULTS

The overall prevalence delirium rate was 45.2%, with a wide range depending upon specialty: intermediate and intensive care services (83.1%), plastic surgery and palliative care (75%), neurology (72%), internal medicine (69%) vs. dermatology (26.5%), and angiology (14.5%). Delirium occurred irrespective of age and gender; however, pre-existent dementia was the strongest delirium predictor (OR 36.05). Delirious patients were less commonly admitted from home (OR 0.47) than from assisted living (OR 2.24), indicating functional impairment. These patients were more severely ill, as indicated by emergency (OR 3.25) vs. elective admission (OR 0.3), requirement for intensive care management (OR 2.12) and ventilation (OR 5.56-8.33). At discharge, one-third did not return home (OR 0.22) and almost half were transferred to assisted living (OR 2.63), or deceased (OR 47.76).

SIGNIFICANCE OF RESULTS

At age older than 90 years, the prevalence and sequelae of delirium are substantial. In particular, functional impairment and pre-existent dementia predicted delirium and subsequently, the loss of independence and death were imminent.

Creating a toolkit with stakeholders for leveraging tablet computers to support person-centred dementia care in hospitals

Introduction

People with dementia may refuse care because they feel overwhelmed by an unfamiliar environment. Everyday technology such as tablets have the potential to support person-centred dementia care in hospitals.

Aims

We aimed to identify barriers and enabling factors in order to develop a toolkit to support the use of tablets in engaging individual and group activities, especially to play family videos, for hospitalized older people with dementia.

Methods

A participatory action research approach was employed. We facilitated staff focus groups and conducted interviews with stakeholders. A toolkit was developed based on participants’ perspectives on how to support successful adoption.

Results

Our analysis identified two enabling factors: users’ engagement in developing a toolkit for support and adapting implementation to meet local needs. Barriers included staff and family inexperience, mechanical instability of hardware, issues around privacy and data access, technology use and personalization of messages. The toolkit includes short videos, a brochure for family caregivers, and a pocket card for staff.

Discussion and implications: Staff, family and patients start with varying levels of experience with the use of tablets, making education and support vitally important to implementation. Health organizations should involve staff, patients, and families to find practical solutions.

Understanding and improving experiences of care in hospital for people living with dementia, their carers and staff: three systematic reviews

Background

Being in hospital can be particularly confusing and challenging not only for people living with dementia, but also for their carers and the staff who care for them. Improving the experience of care for people living with dementia in hospital has been recognised as a priority.

Objectives

To understand the experience of care in hospital for people living with dementia, their carers and the staff who care for them and to assess what we know about improving the experience of care.

Review methods

We undertook three systematic reviews: (1) the experience of care in hospital, (2) the experience of interventions to improve care in hospital and (3) the effectiveness and cost-effectiveness of interventions to improve the experience of care. Reviews 1 and 2 sought primary qualitative studies and were analysed using meta-ethnography. Review 3 sought comparative studies and economic evaluations of interventions to improve experience of care. An interweaving approach to overarching synthesis was used to integrate the findings across the reviews.

Data sources

Sixteen electronic databases were searched. Forwards and backwards citation chasing, author contact and grey literature searches were undertaken. Screening of title and abstracts and full texts was performed by two reviewers independently. A quality appraisal of all included studies was undertaken.

Results

Sixty-three studies (reported in 82 papers) were included in review 1, 14 studies (reported in 16 papers) were included in review 2, and 25 studies (reported in 26 papers) were included in review 3. A synthesis of review 1 studies found that when staff were delivering more person-centred care, people living with dementia, carers and staff all experienced this as better care. The line of argument, which represents the conceptual findings as a whole, was that ‘a change of hospital culture is needed before person-centred care can become routine’. From reviews 2 and 3, there was some evidence of improvements in experience of care from activities, staff training, added capacity and inclusion of carers. In consultation with internal and external stakeholders, the findings from the three reviews and overarching synthesis were developed into 12 DEMENTIA CARE pointers for service change: key institutional and environmental practices and processes that could help improve experience of care for people living with dementia in hospital.

Limitations

Few of the studies explored experience from the perspectives of people living with dementia. The measurement of experience of care across the studies was not consistent. Methodological variability and the small number of intervention studies limited the ability to draw conclusions on effectiveness.

Conclusions

The evidence suggests that, to improve the experience of care in hospital for people living with dementia, a transformation of organisational and ward cultures is needed that supports person-centred care and values the status of dementia care. Changes need to cut across hierarchies and training systems to facilitate working patterns and interactions that enable both physical and emotional care of people living with dementia in hospital. Future research needs to identify how such changes can be implemented, and how they can be maintained in the long term. To do this, well-designed controlled studies with improved reporting of methods and intervention details to elevate the quality of available evidence and facilitate comparisons across different interventions are required.

Study registration

This study is registered as PROSPERO CRD42018086013.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 43. See the NIHR Journals Library website for further project information. Additional funding was provided by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Nurses' perceptions in caring for people with dementia in Dutch acute hospitals

Aims and objectives

Overall, this study aimed to describe nursing care for patients with dementia in acute hospitals, with the objectives of describing the provided nursing care (a), nurses’ attitudes and perceptions in caring for patients with dementia (b), and exploring how nurses deal with challenging behaviour (c). Additionally, we determined background variables associated with caring for people with dementia.

Background

Due to comorbidities, people with dementia are frequently admitted to acute care hospitals. Here, they are at high risk of complications. Nurses strive for good care but regularly experience insufficient knowledge and skills regarding caring for people with dementia.

Design

A cross‐sectional survey study design.

Methods

Data were collected in seven Dutch acute hospitals and through social media. In total, 229 hospital nurses completed the questionnaire. We used the Geriatric In‐Hospital Nursing Care Questionnaire and two subscales of Hynninen on managing challenging behaviour. This report followed the STROBE checklist.

Results

Nurses express that they often apply general preventive interventions not explicitly related to dementia care. In general, nurses have mixed feelings about the nursing care provided in their department. For challenging behaviour, a variety of approaches, including restrictive measures and medication, is applied. The nurses’ attitudes and perceptions are influenced by the type of hospital where the nurses work, the level of education, the number of hours nurses work, and if the nurses completed a course on dementia in the last year.

Conclusions

Despite a positive attitude, nurses do not have the specific knowledge and skills needed to provide proper care. Nurses who recently completed a course on dementia had more positive attitudes and perceptions towards caring for patients with dementia.

Relevance to clinical practice

The results of this research can be used to improve the quality of nursing care for patients with dementia in acute hospitals.

The prevalence rates and adversities of delirium: Too common and disadvantageous

Objective

The prevalence rates and adversities of delirium have not yet been systematically evaluated and are based on selected populations, limited sample sizes, and pooled studies. Therefore, this study assesses the prevalence rates and outcome of and odds ratios for managing services for delirium.

Methods

In this prospective cohort study, based on the Diagnostic and Statistical Manual (DSM) 5, the Delirium Observation Screening (DOS) scale, and the Intensive Care Delirium Screening Checklist (ICDSC) construct, 28,118 patients from 35 managing services were included, and the prevalence rates and adverse outcomes were determined by simple logistic regressions and their corresponding odds ratios (ORs).

Results

Delirious patients were older, admitted from institutions (OR 3.44–5.2), admitted as emergencies (OR 1.87), hospitalized twice longer, and discharged, transferred to institutions (OR 5.47–6.6) rather than home (OR 0.1), or deceased (OR 43.88). The rate of undiagnosed delirium was 84.2%. The highest prevalence rates were recorded in the intensive care units (47.1–84.2%, pooled 67.9%); in the majority of medical services, rates ranged from 20% to 40% (pooled 26.2%), except, at both ends, palliative care (55.9%), endocrinology (8%), and rheumatology (4.4%). Conversely, in surgery and its related services, prevalence rates were lower (pooled 13.1%), except for cardio- and neurosurgical services (53.3% and 46.4%); the lowest prevalence rate was recorded in obstetrics (2%).

Significance of results

Delirium remains underdiagnosed, and novel screening approaches are required. Furthermore, this study identified the impact of delirium on patients, determined the prevalence rates for 32 services, and elucidated the association between individual services and delirium.

Nurses' experiences of providing "sensitive nursing care" for terminally-ill individuals with cancer: A qualitative study

PURPOSE

To explore the sensitive nursing care provided by nurses who care for terminally-ill individuals with cancer.

METHODS

In-depth interviews were conducted using Colaizzi's phenomenological approach. Participants were 16 hospice specialists and four non-specialist nurses with experience in caring for terminal cancer patients in hospice specialized institutions in South Korea.

RESULTS

Eight theme clusters were drawn from the data and these clusters had two dimensions consisting of sensitive attitudes and sensitive nursing behaviors. The sensitive attitudes included reflecting on past experiences, developing an accepting attitude toward death, using intuition to address critical situations, and having an open mind regarding collaborating with colleagues. The sensitive nursing behaviors contained listening to patients' needs, responding to patients in a manner suitable to their conditions, quickly responding to patients' problem, and providing a moment saying farewell.

CONCLUSIONS

Teamwork and role models can help hospice specialists and non-specialist nurses caring for terminally-ill individuals with cancer to improve the sensitive nursing care. The sensitive attitudes and behaviors can be used as basic data for training programs designed to enhance nurses' sensitivity.

Exploring the perceptions of people with dementia about the social robot PARO in a hospital setting

New technology, such as social robots, opens up new opportunities in hospital settings. PARO, a robotic pet seal, was designed to provide emotional and social support for older people with dementia. We applied video-ethnographic methods, including conversational interviews and observations with video recording among 10 patient participants while they were using the robot. We also conducted semi-structured individual interviews and focus groups with nursing staff to gain contextual information. Patient and family partners were actively involved in the study as co-researchers. This study reports our findings on the perceptions of 10 patients with dementia about their experiences with PARO in a hospital setting. Thematic analysis yielded three substantive themes: (a) ‘it’s like a buddy’ – the robot helps people with dementia uphold a sense of self in the world, (b) ‘it’s a conversation piece’ – the baby seal facilitates social connection and (c) ‘it makes me happy’ – PARO transforms and humanizes the clinical setting. Our findings help provide a better understanding of the perspectives of patients with dementia on the use of social robots.