Staff attitudes towards older patients with cognitive impairment: need for improvements in acute care

Knowledge, Attitudes, Practices, and Associated Factors Towards Care of Elderly Patients among Nurses

Background

Ethiopia's elderly care service is relatively young and little is known about the practices or readiness of nurses to provide care. Nurses need to have good knowledge, a positive attitude, and experience when it comes to caring for the elderly or patients who are chronically providing quality care. This study aimed to assess the knowledge, attitudes, and practices towards care for elderly patients and associated factors among nurses working in adult care units of public hospitals in Harar, 2021.

Methods

An institutional-based descriptive cross-sectional study was conducted from February 12 to July 10, 2021. A simple random sampling technique was used to select 478 study participants. Data were collected by trained data collectors using a pretested self-administered questionnaire. From the pretest, Cronbach's alpha for all items was above 0.7 for all items. Data were entered into Epi Data v.4.6 and exported to the Statistical Package for Social Science Version 26 for binary logistic regression analysis. A P-value of 0.05 was used to declare a significant association between variables.

Results

The study revealed that 311 (69%) had inadequate knowledge. Having a first degree and an unfavorable attitude towards nurses showed a statistically significant association with nurses' inadequate knowledge. A total of 275 (61.0%) nurses were found to have an unfavorable attitude and were significantly associated with having a diploma and first degree, learning in a private organization, 6 to 10 years of experience, lack of training, and inadequate knowledge of nurses. A total of 297 (65.9%) study units had inadequate practice towards the care of elderly patients. Nurses' practices showed a significant association with the type of hospital, work experience, and adherence to guidelines with a response rate of 94.4%.

Conclusion

The majority of nurses had inadequate knowledge, an unfavorable attitude, and inadequate practice towards the care of elderly patients. Having a first-degree and an unfavorable attitude with inadequate knowledge, lack of training and inadequate knowledge, unfavorable attitudes and less than 11 years of experience, working in non-academic hospitals, and unavailability of guidelines with inadequate practices were significantly associated.

Delivering person-centred palliative care in long-term care settings: is humanism a quality of health-care employees or their organisations?

Reflecting on sustained calls for patient-centredness and culture change in long-term care, we evaluated the relative importance of personal and organisational predictors of palliative care, hypothesising the former as weaker predictors than the latter. Health-care employees (N = 184) from four Canadian long-term care homes completed a survey of person-centred care, self-efficacy, employee wellbeing and occupational characteristics. Using backward stepwise regression models, we examined the relative contributions of these variables to person-centred palliative care. Specifically, blocks of variables representing personal, organisational and occupational characteristics; palliative care self-efficacy; and employee wellbeing were simultaneously regressed on variables representing aspects of person-centred care. The change in R2 associated with the removal of each block was examined to determine each block's overall contribution to the model. We found that occupational characteristics (involvement in care planning), employee wellbeing (compassion satisfaction) and self-efficacy were reliably associated with person-centred palliative care (p < 0.05). Facility size was not associated, and facility profit status was less consistently associated. Demographic characteristics (gender, work experience, education level) and some aspects of employee wellbeing (burnout, secondary trauma) were also not reliably associated. Overall, these results raise the possibility that humanistic care is less related to intrinsic characteristics of employees, and more related to workplace factors, or to personal qualities that can be cultivated in the workplace, including meaningful role engagement, compassion and self-efficacy.

Implementing Gentle Persuasive Approaches dementia education for staff on in-patient medicine units: A program evaluation

Older adults with dementia, when hospitalised, frequently experience responsive behaviours. Staff struggle to manage responsive behaviours without specific education. We aimed to enhance staff knowledge and confidence with care for older adults with dementia and responsive behaviours on medicine units at a Canadian hospital. An online dementia education program was disseminated to staff as part of a broader quality improvement project. Gentle Persuasive Approaches (GPA) encourages staff to reframe responsive behaviours as self-protective expressions of unmet needs and learn to assess their meaning. Participants completed online quantitative and qualitative measures of self-efficacy, competence and knowledge in dementia care at three times: immediate pre-, immediate post- and six to eight weeks post-GPA eLearning. Immediately post-GPA, participants showed significant increases relative to baseline in dementia care self-efficacy, competence and knowledge. Self-efficacy scores increased further eight weeks post-GPA. Before GPA, few participants described dementia-specific strategies for de-escalating a patient’s agitation. Eight weeks post-GPA, participants described application of tailored, person-centred, non-pharmacological interventions and successful application of GPA strategies. GPA eLearning strengthened staff preparedness to interact with older adults experiencing responsive behaviours, thus enhancing their care.

Making clinical care decisions with people living with dementia in hospital: An integrative literature review

BACKGROUND

As our population ages, the percentage of hospitalised patients diagnosed with dementia is expected to rise. However, there is emerging evidence that people living with dementia may experience discrimination and exclusion from decisions about their clinical care. Although dementia affects cognition, many patients living with dementia want to participate in decision-making processes relating to their clinical care in hospital.

OBJECTIVE

Identify the processes associated with making decisions about clinical care with people living with dementia in hospital.

DESIGN

An integrative literature review.

DATA SOURCES

Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus, EMBASE (Ovid), MEDLINE (PubMED), PsycINFO and HeinOnline.

REVIEW METHOD

One author conducted the initial screening of titles, and two authors screened in subsequent rounds for abstracts and full text. The process of making clinical decisions was the outcome of interest. Articles about people with cognitive impairment that did not include dementia, or decisions such as discharge planning or end of life care were excluded. An inductive synthesis of the findings was undertaken.

RESULTS

Nine articles were identified for review and included expert opinion or hypothetical discussion (n=5), cross-sectional survey research (n=3), and qualitative research (n=1). Three themes were identified: capacity for decision-making is conceptualised as 'all or nothing'; there are no universal principles for including people living with dementia in decision-making in acute care settings; and autonomy is recognised but superseded by beneficence.

CONCLUSIONS

Contemporary hospital practice is focused on determining capacity for decisions, with an all or nothing attitude to capacity, effectively excluding many people living with dementia from participation in decisions. While there is limited evidence to guide clinicians in this complex and situated process of making clinical decisions, emerging models of supported decision-making require further evaluation in the hospital setting.

Stroop switching card test: brief screening of executive functions across the lifespan

This study aimed to: (1) propose a novel version of the Stroop switching test, namely the Stroop Switching Card Test (SSCT), to assess the overall efficiency of executive functions (EF) and its underlying cognitive processes (conflict resolution and conflict adaptation); (2) examine the utility of the SSCT in the assessment of EF in different age groups (age range 15-75 years), compare its results with standard neuropsychological tests (SNT), and (3) examine the contribution of both the processing speed and cognitive reserve on the performance of all used tests. The SSCT showed more sensitivity to detect subtle executive dysfunction in the middle age (~50 years). Going further, the SSCT revealed a progressive decline in conflict adaptation over two life periods. The first period of decline started at ~50 years and the second at~ 65 years. The processing speed and cognitive reserve had a prominent role in our results, notably in SSCT.

The Effects of Clinical Experience on Early Career Psychiatrists' Beliefs and Attitudes Towards Older Psychiatric Patients

Although literature has documented widespread negative and stereotypical attitudes held by healthcare professionals towards the older adults, there is a current paucity of research about the perspective of psychiatrists. We aimed to identify the attitudes of Tunisian early career psychiatrists towards the older adults. This was a cross-sectional study conducted among 71 early career psychiatrists. Data were collected through anonymous online surveys. A series of 4 point Likert-type questions ("strongly agree", "somewhat agree", "somewhat disagree", "strongly disagree") asked participants about their beliefs about older patients, the characteristics of the psychiatric care of an older person and emotions related to caring for older patients. Psychiatrists agreed that the older patient: is frail and vulnerable in 64.8% of cases, does not trust his psychiatrist in 28% of cases, has problems of communication in 36.6% of the cases and shows hostile or aggressive behavior in 5.6% of the cases. A multivariate binary logistic regression analysis found that clinical experience would play an independent role in predicting the following beliefs and attitudes of early career psychiatrists towards older patients: the belief that the older patient often has perceptual disorders that he is fragile and vulnerable, that he often requires polypharmacy, and that his management exposes the psychiatrist to painful emotional experiences. Given the population aging, early career psychiatrists need to be equipped with skills to fulfil significant roles in responding to future health and support needs. Integrating clinical training in psychogeriatrics into the psychiatric curriculum is strongly recommended.

Service-Learning with older adults in care communities: Measures of attitude shifts in undergraduate students

Background: Clinicians' attitudes toward older adults can influence the quality of the care they provide. The purpose of this study was to demonstrate how to measure the impact of service-learning on undergraduate healthcare students' attitudes toward elders and people with dementia using a theory-grounded qualitative and quantitative assessment, beyond the commonly used pre-test/post-test model. Methods: One-hundred forty-five undergraduate students across two midwestern universities participated in service-learning experiences in a long-term care or assisted living environment during one semester. Students completed the Dementia Attitudes Scale (DAS) before they began service-learning and at the end of the experience. Students also completed reflective journal entries throughout their experiences. Results: Significant, positive changes in knowledge and comfort were noted in ratings from pre-to post-assessment on the DAS. Of the 4165 sentences produced by students in three analyzed journal entries, 2045 (49%) reflected the Awareness-Application Attitude theoretical framework. For the first journal entry, the proportion of positive attitude statements was significantly lower than that for neutral and negative statements while the reversed effect was observed for the last journal entry. Conclusions: Service-learning is an evidence-based pedagogy associated with positive attitude shifts for undergraduate students.

Person-centered dementia care in acute hospital wards-The influence of staff knowledge and attitudes

Person-centered dementia care practices in acute hospital wards are suboptimal and not commonly measured. Although previous research has indicated that the work environment of staff influences their perceptions of person-centeredness, few studies have examined how their personal attributes, such as their level of dementia knowledge and attitudes, influence their person-centered dementia care practices. A questionnaire was distributed to test the relationship between staff perceptions of person-centered dementia care and their dementia knowledge and attitudes in general medical wards. The results showed that staff with better dementia knowledge were significantly more critical about the extent they were using evidence-based guidelines and external expertise. Staff with better attitudes perceived themselves as using more individualized care practices. The findings demonstrate that to enhance person-centered dementia care in acute hospitals, staff training programs should develop both their intellectual and interpersonal skills to improve their knowledge and attitudes.

Investigation into attitudes towards older people with dementia in acute hospital using the Approaches to Dementia Questionnaire

Background

Health care professionals have poor recognition of cognitive impairment among older patients and often have difficulties in providing care for people with dementia in acute hospitals. There are also reported high levels of stigma and negative staff attitudes towards people with dementia.

Methodology

A one-time survey of staff working on acute medical and orthopaedic wards of five District Health Boards in New Zealand using the ‘Approaches to Dementia Questionnaire’; a 19-item Questionnaire that aims to capture two attitudinal domains (Hope and Person-Centredness), towards people with dementia. A total of 563 questionnaires were distributed. Data were analysed using R.

Results

Three hundred and four (53.99%) respondents completed the survey. Ninety-four of the respondents (31.1%) were aged 51 years or older, and nearly all (88.4%) were women. One hundred and sixty-four of the respondents (53.9%) were registered nurses, 10 were student nurses (3.3%), 24 (7.9%) were healthcare assistants, 70 (23.0%) were allied health professionals, 27 (8.9%) were doctors and 9 (3%) were pharmacists. The mean total score of 72.7 reflected positive attitudes overall on the part of the respondents. Allied health professionals, student nurses and pharmacists had high scores on both scales whilst healthcare assistants scored lowest on both scales.

Conclusion

Overall, the Approaches to Dementia Questionnaire is a useful measure, but it can be difficult to differentiate between genuine attitudinal differences and confounding influences such as level of knowledge and education amongst such a diverse group of participants. Differences between staff may be considered as a reflection of the high level of direct care that is expected of some staff and not of others. Further, the Approaches to Dementia Questionnaire may not be the most appropriate measure to accurately understand attitudes to dementia care in acute environments; and that it more usefully reveals knowledge about dementia rather than attitudes related to real-time practice.

The experiences and perceptions of care in acute settings for patients living with dementia: A qualitative evidence synthesis

BACKGROUND

Increasing numbers of people with dementia are presenting to acute care facilities for management of medical conditions and co-morbidities. They require an individual approach to care due to the confusion and disorientation which may accompany their illness. Current evidence syntheses on this topic explore how staff, family and carers view their care. This review aims to complement previous work in the area by exploring care from the perspective of the patient living with dementia.

OBJECTIVES

The aim of this qualitative evidence synthesis was to explore the experiences and perceptions of patients living with dementia on the care they receive in acute settings.

DESIGN

Qualitative evidence synthesis systematically draws the findings from individual studies together to create valid, reliable and meaningful evidence for healthcare policy development. Framework synthesis was utilised and guided by the VIPS framework; Values, Individualised, Perspective, and Social and psychological. The VIPS framework has previously been used for exploring staffs' views of care in the acute setting and provides guidance to caring for people with dementia.

REVIEW METHODS

Following screening, data were extracted and appraised using Critical Appraisal Skills Programme. Framework synthesis, incorporating thematic synthesis, was conducted and the confidence in findings was assessed using GRADE CERQual.

DATA SOURCES

Seven qualitative studies that explored care in acute hospitals as experienced or perceived by the person living with dementia.

RESULTS

The VIPS framework helped to capture views of care. Patients often experienced rushed and task- based approaches, poor communication, and exclusion in some cases. The environments were clearly unsuitable, sometimes exacerbating behaviours of concern, thus leading to unnecessary restraint due to an inability to protect this group.

CONCLUSIONS

Further research needs to be conducted in testing existing or developing new interventions to improve the physical environment, the systems of care and to provide more person-centred approaches to care. Organisational structures must ensure patients are cared for in a dementia friendly environment by a dementia trained workforce. At local level, involving support workers, eliminating unnecessary care practices, and facilitating individual choices of patients are recommended.

The awareness of healthcare staff towards post-stroke cognitive impairment: a cross sectional study

[Purpose] This study aimed to determine the awareness amongst healthcare staff of post-stroke cognitive impairment in a university teaching hospital and supporting stroke rehabilitation unit. [Subjects and Methods] A cross sectional study was employed to collect data from 20 healthcare staff about post-stroke cognitive impairment. This study was conducted in Ireland at two sites, the Acute Stroke unit in Cork University Hospital, and the Stroke Rehabilitation unit and Assessment and Treatment Centre in St. Finbarr’s Hospital. [Results] Approximately 75% of participants felt that they had knowledge about post-stroke cognitive deficits, with around 50% of them having patients with persistent cognitive decline between 40% and 60%. Most participants (70%) agreed that cognitive function should be routinely assessed and the majority (85%) discussed the potential impact of post-stroke cognitive deficits with patients and their families. However, some participants need to be aware of post-stroke cognitive deterioration. [Conclusion] Although there was evidence of good practice, a small number of healthcare staff felt that they did not have sufficient knowledge about post-stroke cognitive deficits. Thus, further professional education should be provided to improve the knowledge of healthcare staff about potential cognitive impairments after stroke.

Quality of acute care for persons with cognitive impairment and their families: A scoping review

BACKGROUND

An increasing number of older persons with cognitive impairment use inpatient services for co-occurring acute illness. Research has demonstrated that persons with cognitive impairment face more adverse health outcomes during hospitalization than their age counterparts without cognitive impairment. As hospitals tend to be ill equipped to meet the complex care needs of this population, various initiatives underscore the need to better utilize existing evidence to improve quality of care.

OBJECTIVES

To map the extent of knowledge about quality of acute care in inpatient settings, and to synthesize knowledge on strategies to improve quality care for persons with cognitive impairment and their families.

DESIGN

A scoping review using Arksey and O'Malley's methodological framework.

DATA SOURCES

CINAHL and Medline were searched and reference lists of pertinent articles screened to identify publications regarding acute care for persons with cognitive impairment.

REVIEW METHODS

Two reviewers independently screened and identified publications based on eligibility criteria. Publications were included if they targeted acute care issues relating to persons with cognitive impairment 65 years or older, their family members, or health professionals caring for them, and were published after 2000 in English or German. Publications were read and data were extracted using a predefined template. Thematic analysis was conducted by two reviewers.

RESULTS

Of the 1445 identified publications, 66 were included. Quality of acute inpatient services pertained to structural (such as staff capacity and knowledge) and process dimensions (such as forming a caring relationship, assessing and intervening). Strategies identified to improve care quality included interventions at the point of care, such as specific tools and specialist roles to improve patient outcomes, as well as educational and training interventions to enable staff to care for this patient group.

CONCLUSIONS

There is a discrepancy between clearly defined best practice for persons with cognitive impairment utilising inpatient services, and the quality of care actually experienced by patients, family members, and staff. Research reveals a sobering picture of inadequate care and manifold challenges encountered by this patient group, family members and staff alike. Promising strategies to improve care quality target health professionals' knowledge and capacity to work with this group and include specific tools and models of care, such as specialist roles and units. Organisation-wide efforts to ensure quality care for this patient group are needed, as is further research to determine which implementation and intervention strategies achieve the most beneficial outcomes for all involved.

A dementia communication training intervention based on the VERA framework for pre-registration nurses: Part I developing and testing an implementation strategy

BACKGROUND

People living with dementia experience progressive difficulty in expressing physical and emotional needs. Health care staff including student nurses require training to develop compensatory communication strategies. However, there is no standardised foundation level dementia communication training within pre-registration curricula.

AIM

This article describes the theoretical underpinnings and development of a foundation level dementia communication skills training based on the VERA (Validation, Emotion, Reassurance, Activity) framework.

METHOD

The training strategies drew on behavioural change theory using the COM-B model and Gagné's 9 Events of Instruction. The VERA framework was operationalised using a multicomponent teaching strategy. The intervention was refined based on quality improvement Plan-Do-Study-Act cycles with feedback from people living with dementia, facilitators and student nurses. Data collection used semi-structured questionnaires (n = 51) and four focus group (n = 19) interviews with students. Data analysis involved descriptive statistics and thematic analysis.

RESULTS

The intervention was a 2.5-hour face-to-face training session delivered at the start of students' older adult unit placement with follow-up reflection sessions during placement. Training was delivered to 51 students, all students described the training as useful and would recommend it to their peers. Elements of the training that were highly valued were: opportunities to express concerns in caring for people with dementia, applying the VERA framework using role play and outlining realistic expectations of VERA. Students recognised the need for on-going training especially for more complex patients.

CONCLUSION

Combining behaviour change and education theory with stakeholder feedback strengthened the development of VERA as a foundation level dementia communication training for pre-registration nurses.

Dementia Care Content in Prelicensure Nursing Curricula: A Pilot Mixed-Methods Study

BACKGROUND

Having a nursing workforce equipped to provide quality care for patients living with dementia is essential. The purpose of this study was to investigate how undergraduate nursing programs integration of dementia care content into their curricula.

METHOD

Using sequential explanatory mixed methods, a stratified sample of 137 representatives of programs in 11 states with dense elderly populations completed a quantitative survey. A subsample (n = 8) completed qualitative e-mail interviews.

RESULTS

Most respondents indicated dementia care content was integrated into their curricula (n = 103, 92.8%). Clinical partnership with dementia care centers was associated with a greater proportion of students interacting with individuals having dementia (p = .02). Curriculum overload was the most significant challenge to integrating dementia content (n = 61, 43.9%). Qualitative themes supported the quantitative results.

CONCLUSION

Future research is needed to identify best practices to ensure that nursing curricula provide essential content to meet the care needs of the growing population of individuals with dementia. [J Nurs Educ. 2018;57(2):88-95.].

Lessons learned from narrative feedback of students on a geriatric training program

Geriatrics continues to draw insufficient numbers of medical students today. Currently, little is known regarding how education can motivate students to choose geriatrics. The authors' aim was to examine geriatrics from the students' perspective to identify elements that can be useful in education and improving attitudes toward, interest in, and knowledge about geriatrics. The authors analyzed narrative reflection essays of 36 students and clarified the themes from the essays during focus group sessions. Four overarching themes that influenced students' perspective on geriatrics were identified: professional identity, perception of geriatrics, geriatric-specific problems, and learning environment. Students have an inaccurate image of clinical practice and the medical professional identity, which has a negative impact on their attitude toward, interest in, and knowledge of geriatrics. Furthermore, this study yielded the important role of the hidden curriculum on professional identity, the novelty of geriatric-specific problems to students, and the importance of educational approach and good role models.

Multidisciplinary attitudes to people with dementia; training and environmental factors play a role in caring for people with dementia in a Cardiac Catheterisation Laboratory

Purpose

The purpose of this paper is to explore multidisciplinary attitudes and environmental factors affecting dementia care in the Cardiac Catheter Laboratory (CCL).

Design/methodology/approach

Questionnaires (n=87) were distributed in a hospital CCL in the North of England. The authors utilised the Dementia Attitudes Scale which incorporates two subscales: Social Comfort and Dementia Knowledge. In addition, a newly devised questionnaire asking about perceptions of how the CCL environment affected care of patients with dementia was added.

Findings

The response rate was 71 per cent (n=62). Years’ experience in the CCL was associated with lower Social Comfort scores (p=0.026). Dementia training was associated with higher mean Dementia Attitudes Scale and Social Comfort scores (p=0.021, p=0.007). Participants who had undertaken “Professional studies” had higher Dementia Attitudes Scale and Dementia Knowledge mean scores (p=0.038, p=0.046) but “On-the-job” training was perceived as most beneficial (32 per cent, n=20). Unit co-ordinators and nurses felt the CCL was an unfavourable environment for patients with dementia. Care was perceived to be impaired by environmental functionality, equipment and the presence of ionising radiation.

Research limitations/implications

The small sample limits generalisability. Although the Dementia Attitudes Scale is a validated questionnaire it has not been widely used so reliability of these results is unclear.

Practical implications

Caring for patients with dementia has unique challenges especially in areas like the CCL. These results suggest that practical experience and training can affect the perception of staff to patients with dementia hence there may be a need to assess what would be the most appropriate training to give health professionals in the future.

Originality/value

The authors believe this to be the first multi-professional research study into care of patients with dementia in a specialised acute unit. This was the most diverse sample known to have attitudes to dementia measured quantitatively in an acute hospital department and the results need to be replicated before practice should be changed.

Reconciling conceptualizations of ethical conduct and person-centred care of older people with cognitive impairment in acute care settings

Key commentators on person-centred care have described it as a "new ethic of care" which they link inextricably to notions of individual autonomy, action, change and improvement. Two key points are addressed in this article. The first is that few discussions about ethics and person-centred are underscored by any particular ethical theory. The second point is that despite the espoused benefits of person-centred care, delivery within the acute care setting remains largely aspirational. Choices nurses make about their practice tend to comply more often with prevailing norms than those championed by person-centred care. We draw on elements of work by moral philosopher Løgstrup and Foucault to provide insight into nurses' ethical conduct and ask why nurses would want to act otherwise, when what they think and do is viewed as normal, or think and act otherwise if doing so is seen within the organization as transgressive? To address these more specific questions, we discuss them in relation to the following constructs: the ethical demand, sovereign expressions of life and parrhêsia. We conclude by arguing that a ethical theoretical framework enables nurses to increase their perceptibility and appreciation of the ethical demand particularly those emanating from incommensurability between organizational norms and the norms invoked by person-centred care. We argue that nurses' responses to the ethical demand by way of parrhêsia can be an important feature of intra-organizational reflexivity and its transformation towards the delivery care that is more person-centred, particularly for older people with cognitive impairment. We conclude the article by highlighting the implications of this for nursing education and research.

Elements of a sustainable, competent, and empathetic workforce to support patients with dementia during an acute hospital stay: A comprehensive literature review

Internationally, there has been a focus on the development of acute hospital workforces to support and care for people with dementia. Recommendations and initiatives to improve person-centred care in acute hospitals have included: education and training, dementia-specific roles, clinical leads, and environment changes. The aim of this literature review is to understand the elements of a sustainable, competent, and empathetic acute hospital workforce providing person-centred care for patients with dementia. The following databases were searched for literature published in English from January 1, 2006, to August 1, 2016: CINHAL, MEDLINE, PsychINFO, PubMed, and Science Direct. A thematic analysis was applied to develop a meta-synthesis of the data. A total of 12 papers with a range of methodological approaches from various countries were included. Emergent themes were as follows: understanding the current workforce, implementation and evaluation of training, and exploration of new and existing roles. An important element was the sustainability of acute hospital workforces competent in dementia care, as studies highlighted an ageing nursing population and a high turnover of staff. Dementia awareness training was sustainable, although there was a lack of consistency in the length, content, and delivery, which had a viable impact on the provision of empathetic and person-centred care. The lack of consistency of training and specialist dementia roles restricts recommendations from a robust evidence base.

Reconciling conceptualizations of relationships and person-centred care for older people with cognitive impairment in acute care settings

Relationships are central to enacting person-centred care of the older person with cognitive impairment. A fuller understanding of relationships and the role they play facilitating wellness and preserving personhood is critical if we are to unleash the productive potential of nursing research and person-centred care. In this article, we target the acute care setting because much of the work about relationships and older people with cognitive impairment has tended to focus on relationships in long-term care. The acute care setting is characterized by archetypal constraints which differentiate it from long-term care, in terms of acuity and haste, task-orientated work patterns and influence from "the rule of medicine," all of which can privilege particular types of relating. In this article, we drew on existing conceptualizations of relationships from theory and practice by tapping in to the intellectual resources provided by nurse researchers, the philosophy of Martin Buber and ANT scholars. This involved recounting two examples of dyadic and networked relationships which were re-interpreted using two complementary theoretical approaches to provide deeper and more comprehensive conceptualizations of these relationships. By re-presenting key tenets from the work of key scholars on the topic relationships, we hope to hasten socialization of these ideas into nursing into the acute care setting. First, by enabling nurses to reflect on how they might work toward cultivating relationships that are more salutogenic and consistent with the preservation of personhood. Second, by stimulating two distinct but related lines of research enquiry which focus on dyadic and networked relationships with the older person with cognitive impairment in the acute care setting. We also hope to reconcile the schism that has emerged in the literature between preferred approaches to care of the older person with cognitive impairment, that is person-centred care versus relationship-centred care by arguing that these are complementary rather than mutually exclusive and can be brought together in one theoretical framework acknowledging personhood as relational in essence.

An Education Intervention to Enhance Staff Self-Efficacy to Provide Dementia Care in an Acute Care Hospital in Canada: A Nonrandomized Controlled Study

Education is needed for enhanced capacity of acute hospitals to provide dementia care. A nonrandomized controlled, repeated-measures design was used to evaluate a dementia education program delivered to an intervention group (IG, n = 468), compared to a wait-listed group (n = 277), representing separate sites of a multisite hospital. Participants completed self-efficacy for dementia and satisfaction measures and provided written descriptions of dementia care collected at baseline, postintervention (IG only), and at 8-week follow-up. Oral narratives were gathered from IG participants 8 weeks postintervention. The IG demonstrated significant improvement in self-efficacy scores from baseline to immediately postintervention (P < .001), sustained at 8 weeks. There were no changes from baseline to 8 weeks postintervention evident in the wait-listed group (P = .21). Intervention group participants described positive impacts including implementation of person-centered care approaches. Implementation of dementia care education programs throughout hospital settings is promising for the enhancement of dementia care.

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

BACKGROUND

People 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.

OBJECTIVES

This 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.

DESIGN

A 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).

SETTING

One NHS Trust in the North of England, UK.

PARTICIPANTS

40 acute hospital staff working in clinical roles, the majority of whom (90%) were nurses.

METHODS

All 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).

RESULTS

The 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.

CONCLUSIONS

Training 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.

Teaching geriatrics using an innovative, individual-centered educational game: students and educators win. A proof-of-concept study

Given the increasingly aging population, nearly every doctor will encounter elderly adults who present with multiple complex comorbidities that can challenge even experienced physicians. This may explain why many medical students do not have a positive attitude toward elderly adults and find the complexity of their problems overwhelming. It was hypothesized that a recently developed medical school geriatrics course, based on the game GeriatriX and designed specifically to address the complexities associated with decision-making in geriatrics, can have a positive effect on attitudes toward geriatrics and on perceived knowledge of geriatrics. The effects of this game-based course were evaluated as a proof of concept. The assessment was based on the Aging Semantic Differential (ASD) and a validated self-perceived knowledge scale of geriatric topics. The usability of (and satisfaction with) GeriatriX was also assessed using a 5-point Likert scale. After completion of the course, the ASD changed significantly in the geriatrics course group (n = 29; P = .02) but not in a control group that took a neuroscience course (n = 24; P = .30). Moreover, the geriatrics course group had a significant increase in self-perceived knowledge for 12 of the 18 topics (P = .002), whereas in the control group self-perceived knowledge increased significantly for one topic only (sensory impairment) (P = .04). Finally, the geriatrics students reported enjoying GeriatriX. This proof-of-concept study clearly supports the hypothesis that a 4-week course using a modern educational approach such as GeriatriX can improve students' self-perceived knowledge of geriatrics and their attitudes toward elderly adults.

What is the current state of care for older people with dementia in general hospitals? A literature review

This paper summarises a literature review focusing on the literature directly pertaining to the acute care of older people with dementia in general hospitals from 2007 onwards. Following thematic analysis, one overarching theme emerged: the consequences of being in hospital with seven related subthemes. Significantly, this review highlights that overall there remains mostly negative consequences and outcomes for people with dementia when they go into general hospitals. Although not admitted to hospital directly due to dementia, there are usually negative effects on the dementia condition from hospitalisation. The review suggests this is primarily because there is a tension between prioritisation of acute care for existing co-morbidities and person-centred dementia care. This is complicated by insufficient understanding of what constitutes person-centred care in an acute care context and a lack of the requisite knowledge and skills set in health care practitioners. The review also reveals a worrying lack of evidence for the effectiveness of mental health liaison posts and dementia care specialist posts in nursing. Finally, although specialist posts such as liaison and clinical nurse specialists and specialist units/shared care wards can enhance quality of care and reduce adverse consequences of hospitalisation (they do not significantly) impact on reducing length of stay or the cost of care.

Falling behind: a substantive theory of care for older people with cognitive impairment in acute settings

AIMS AND OBJECTIVES

To develop a theoretical understanding of the processes hindering person-centred care of older people with cognitive impairment in acute care settings.

BACKGROUND

Although person-centred care with its holistic focus on the biopsychosocial needs of patients is commonly considered the gold standard care for older people with cognitive impairment, the extent to which care is person-centred can increase in acute care settings generally.

DESIGN

Grounded theory inspired by Strauss and Corbin.

METHOD

The study used a grounded theory approach to generate and analyse data from a Swedish sample of acute care staff, patients and family members.

RESULTS

The substantive theory postulates that staff risks 'falling behind' in meeting the needs of older patients with cognitive impairment if working without consensus about the care of these patients, if the organisation is disease-oriented and efficiency-driven, and if the environment is busy and inflexible. This facilitated 'falling behind' in relation to meeting the multifaceted needs of older patients with cognitive impairment and contributed to patient suffering, family exclusion and staff frustration.

CONCLUSIONS

The theory highlights aspects of importance in the provision of person-centred care of older people with cognitive impairment in acute settings and suggests areas to consider in the development of caring environments in which the place, pace and space can meet the needs of the older person.

RELEVANCE TO CLINICAL PRACTICE

The proposed substantive theory can be used to critically examine current ward practices and routines, and the extent to which these support or inhibit high-quality person-centred care for older patients with known or unknown cognitive impairments.