Treatment of older people with dementia in surgical wards from the viewpoints of the patients and close relatives

Exploring nurses' difficulties and strategies when caring for patients with dementia in a neurological ward

Nurses in neurological wards face numerous challenges when caring for patients with dementia, particularly those who also present other acute illnesses. However, studies focusing on this area are limited. This study aimed to explore the difficulties and strategies in caring for patients with dementia among nurses working in a neurological ward. A qualitative descriptive design was adopted. Twelve nurses from a neurology ward participated in individual semi-structured interviews. The data collected through these interviews were subjected to qualitative content analysis. Two main themes emerged from the analysis: (i) various shortcomings and concerns, which include subthemes: insufficient support, worry about patient safety, inadequate care ability of the caregiver, and insufficient self-competence, and (ii) unique clinical strategies, which include subthemes: cooperate with the caregiver, improve self-competence in dementia care, and employ meticulous resorts. The findings highlighted the nurses' dedication to minimizing patient risks and utilizing available resources as well as stakeholders to provide optimal care. To enhance patient care quality, it is essential to support nurses by addressing care-related barriers, offering continuous education, and establishing care pathways.

Exploring the Difficulties and Strategies of Family Caregivers in Caring for Patients With Dementia in Acute Care Wards

BACKGROUND

Providing appropriate care to patients with dementia in acute care settings can be a challenge for healthcare professionals. A key factor is working closely with family caregivers.

PURPOSE

This study aims to explore the difficulties and strategies involved in caring for patients with dementia who have been admitted to an acute care ward from the perspective of family caregivers.

METHODS

Exploratory research was conducted using a qualitative data collection approach. Data were collected by means of in-depth interviews carried out with participants. Semistructured interviews were conducted with nine participants. Content analysis was performed to analyze the data.

RESULTS

A number of themes and subthemes were identified based on the primary research purposes. The first theme is "vicious cycle due to multiple factors," with the following subthemes: (a) communication disturbance, (b) endless worries, (c) inadequate care skills of paid caregivers, and (d) physical and psychological exhaustion. The second theme is "do everything," with the following subthemes: (a) management of the behavioral and psychological symptoms of dementia, (b) constant accompaniment of the patient, and (c) seeking sources of support.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The results may be used to help healthcare professionals better anticipate the difficulties faced by family caregivers while providing assistance to patients with dementia and understand the related strategies they use. Acute care wards should consider the specific needs of family caregivers to ensure patients with dementia receive adequate care from the relevant parties in the ecological care chain during the care process.

Emotional safety of people living with dementia: a systematic review

BACKGROUND

Emotional safety is particularly important for people living with dementia. Although there have been efforts to define this concept, no systematic review has been performed.

AIM

We aimed to identify and analyze the knowledge available over a 10-year period regarding the emotional safety of people living with dementia to concretize this phenomenon.

METHODS

Seven databases were searched. Qualitative, quantitative and mixed-methods studies published between November 2007 and October 2017 were included. Study selection and critical appraisal were performed by two reviewers. A content analysis of the qualitative data and a descriptive analysis of the quantitative data were performed.

RESULTS

In total, 27 publications (n = 26 studies) were included. The following five main categories were identified: (1) "emotional safety as a primary psychological need"; (2) "emotional safety in the context of disease-related, biographical, demographic and socioeconomic factors"; (3) "inner conditions and strategies"; (4) "outer conditions and strategies"; and (5) "emotional safety as a condition".

CONCLUSION

People living with dementia appear to be particularly vulnerable to decreased emotional safety. Research should focus on achieving a comprehensive understanding of their emotional safety needs.

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.

[Relatives of patients with dementia as a link and mediator in acute care hospitals]

BACKGROUND

The needs of patients with dementia can hardly be met in an organization- and process-oriented acute care hospital. In order to create a successful interaction between patients and hospital staff, the importance of relatives as a link and mediator is considered.

OBJECTIVE

From publications on similar topics, it is deduced which conditions relatives need in order to be able to act as a link and mediator.

MATERIAL AND METHODS

A systematic search was conducted in the databases of Medline (PubMed), Cochrane, CINAHL, and GeroLit.

RESULTS

From the available literature, the reasons for the accompaniment by relatives can be outlined, their activities in the acute care hospital can be described and hindering and supporting factors can be presented.

CONCLUSION

Relatives already act as a link and mediator between patients with dementia and hospital staff. In doing so they act as advocates for the patient and are available to the professionals as experts and advisors. To accomplish this task, there are conditions that support or hinder the mediation activity.

Experiences of informal caregivers of people with dementia with nursing care in acute hospitals: A descriptive mixed-methods study

Aims

To explore the experiences of informal caregivers of people with dementia with the hospitalization of their relative concerning patient care, interactions with nurses, caregivers’ situation and the acute hospital environment.

Design

Mixed‐methods design.

Methods

The data were collected using an online questionnaire among a panel of caregivers (n = 129), together with a focus group and individual interviews from February to November 2019. The data were triangulated and analysed using a conceptual framework.

Results

Almost half of the respondents were satisfied with the extent to which nurses considered the patient's dementia. Activities to prevent challenging behaviours and provide person‐centred care were rarely seen by the caregivers. Caregivers experienced strain, intensified by a perceived lack of adequate communication and did not feel like partners in care; they also expressed concern about environmental safety. A key suggestion of caregivers was to create a special department for people with dementia, with specialized nurses.

Conclusion

Positive experiences of caregivers are reported in relation to how nurses take dementia into account, involvement in care and shared decision making. Adverse experiences are described in relation to disease‐oriented care, ineffective communication and an unfamiliar environment. Caregivers expressed increased involvement when included in decisions and care when care was performed as described by the triangle of care model. Caregivers reported better care when a person‐centred approach was observed. Outcomes can be used in training to help nurses reflect and look for improvements.

Impact

This study confirms that caregivers perceive that when they are more involved in care, this can contribute to improving the care of patients with dementia. The study is relevant for nurses to reflect on their own experiences and become aware of patients’ caregivers’ perspectives. It also provides insights to improve nurses’ training and for organizations to make the care and environment more dementia‐friendly.

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.

Acute care delivery to persons with cognitive impairment: a mixed method study of health professionals' care provision and associated challenges

Objectives: Cognitive impairment is common among older persons admitted to hospital and associated with adverse outcomes. Inadequate care has been widely reported, with health professionals tending to be ill-equipped to meet the specific needs of this patient group. This study aimed to investigate health professionals' care provision to persons with cognitive impairment and associated challenges.Design and Setting: A concurrent, cross-sectional mixed method study was conducted at two university-affiliated hospitals.Participants: A total of 339 health professionals participated in the study.Measurements: An online survey (n = 312) determined the extent to which health professionals perceived their care provision to be person-centered and evidence-based (POPAC-R), and experience distress in looking after this patient group (NPI-D). Four focus group interviews (n = 27) explored health professionals' experience of care provision.Results: More than half of the health professionals reported to act always or very frequently in person-centered and evidence-based ways, and two third experienced challenging behaviors as moderately to very distressing. Health professionals working in acute geriatric wards demonstrated statistically significant higher levels of person-centered and evidence-based care provision, and lower distress. Their caring practices pertained to building a relationship, addressing specific needs, involving family members, and working collaboratively.Conclusions: Findings suggest that geriatric models of care delivery support staff in meeting the needs of persons with cognitive impairment. Health professionals require an acute care culture that values relational, collaborative and coordinated care as essential to patient safety and quality of care, and supports the consistent implementation of evidence-based practices for this patient group.

Cognitive impairment assessment and interventions to optimize surgical patient outcomes

For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.

Identifying features associated with higher-quality hospital care and shorter length of admission for people with dementia: a mixed-methods study

Background

Concerns have repeatedly been expressed about the quality of inpatient care that people with dementia receive. Policies and practices have been introduced that aim to improve this, but their impact is unclear.

Aims

To identify which aspects of the organisation and delivery of acute inpatient services for people with dementia are associated with higher-quality care and shorter length of stay.

Design

Mixed-methods study combining a secondary analysis of data from the third National Audit of Dementia (2016/17) and a nested qualitative exploration of the context, mechanism and outcomes of acute care for people with dementia.

Setting

Quantitative data from 200 general hospitals in England and Wales and qualitative data from six general hospitals in England that were purposively selected based on their performance in the audit.

Participants

Quantitative data from clinical records of 10,106 people with dementia who had an admission to hospital lasting ≥ 72 hours and 4688 carers who took part in a cross-sectional survey of carer experience. Qualitative data from interviews with 56 hospital staff and seven carers of people with dementia.

Main outcome measures

Length of stay, quality of assessment and carer-rated experience.

Results

People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission. This is a challenging task when patients have complex needs, and requires named staff to take responsibility for co-ordinating the discharge and effective systems for escalating concerns when obstacles arise. When trust boards review delayed discharges, they can identify recurring problems and work with local stakeholders to try to resolve them. Carers of people with dementia play an important role in helping to ensure that hospital staff are aware of patient needs. When carers are present on the ward, they can reassure patients and help make sure that they eat and drink well, and adhere to treatment and care plans. Clear communication between staff and family carers can help ensure that they have realistic expectations about what the hospital staff can and cannot provide. Dementia-specific training can promote the delivery of person-centred care when it is made available to a wide range of staff and accompanied by ‘hands-on’ support from senior staff.

Limitations

The quantitative component of this research relied on audit data of variable quality. We relied on carers of people with dementia to explore aspects of service quality, rather than directly interviewing people with dementia.

Conclusions

If effective support is provided by senior managers, appropriately trained staff can work with carers of people with dementia to help ensure that patients receive timely and person-centred treatment, and that the amount of time they spend in hospital is minimised.

Future work

Future research could examine new ways to work with carers to co-produce aspects of inpatient care, and to explore the relationship between ethnicity and quality of care in patients with dementia.

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. 22. See the NIHR Journals Library website for further project information.

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.

Care needs of people with dementia in the peri-operative environment: A systematic review

The care of people with dementia within the hospital setting is challenging for healthcare professionals. Hospital design and services are not optimized for people with dementia, owing to the lack of preparation of healthcare professionals and the busy environment of the acute hospital. The peri-operative environment may present particular difficulties but little is known about the experience and care of people with dementia in this setting. The aim of this review was to examine the care of surgical patients who have dementia and their family members in peri-operative environments and describe strategies adopted by healthcare professionals. A systematic search of the following databases was completed: BNI, CINAHL, PubMED and PsychINFO in accordance with PRISMA guidelines. Data were extracted and analysed within a thematic analysis framework as described by Braun and Clarke. Ten papers based on eight studies were included, five (n = 355,010 participants) containing quantitative data and five reporting qualitative data (n = 395 participants). People with dementia who go undergo surgery experienced higher adverse post-operative outcomes such as respiratory problems or urinary tract infections. The key elements in surgical care for people with dementia included: health assessment throughout the surgical trajectory (pre-, intra- and post-operative) and the resources used by healthcare professionals in the peri-operative care. Healthcare professionals reported difficulties in the completion of health assessments due to the cognitive status of people with dementia and a lack of skills in dementia management. The use of restraints was still a common practice and a source of conflict. Dementia-specific training and guidelines focused on the care of surgical patients who have dementia in peri-operative environments are required to improve care and post-operative outcomes. More research is required to develop effective interventions to improve care and decrease the risk of complications for people with dementia in the peri-operative care environment.

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.

Person-centred care: experiences of older people with dementia

AIM

To explore the views, perceptions and experiences of older people with dementia of person-centred care, and how these might affect practice.

METHOD

This was a qualitative literature review. A literature search was undertaken, which involved searching databases, reference-checking, and hand-searching of academic journals, national policies and nursing organisation websites, from 1999 to 2017. The author undertook data extraction and a meta-synthesis independently to identify themes from the articles.

FINDINGS

A total of 12 articles were included in the literature review. Few articles pertaining to the views, perceptions and experiences of older people with dementia receiving person-centred care were identified, with most of the literature based in settings outside the UK. Four main themes were identified: shared decision-making; promoting individuality, independence and autonomy; person-centred care; and communication and giving voice to people with dementia.

CONCLUSION

Knowledge of the lived experience of people with dementia is important to ensure they receive care that enhances their quality of life. It is essential to consider the views and experiences of older people with dementia to provide effective person-centred care and undertake appropriate research. Further research is required to evaluate the experiences of older people with dementia receiving care to inform practice.

Care practices of older people with dementia in the surgical ward: A questionnaire survey

OBJECTIVES

The objective of this study was to describe the care practices of nursing staff caring older people with dementia in a surgical ward.

METHODS

The data were collected from nursing staff (n = 191) working in surgical wards in one district area in Finland during October to November 2015. Data were collected using a structured questionnaire and analyzed statistically. The instrument consists of a total number of 141 items and four dimensions. The dimensions were as follows: background information (12 of items), specific characteristics of older people with dementia in a surgical ward (24 of items), specific characteristics of their care in a surgical ward (66 of items) and use of physical restraints and alternative models for use of restraints for people with dementia (39 of items).

RESULTS

The questions which measure the nursing staff's own assessment of care practices when caring for people with dementia in surgical wards were selected: counseling people with dementia, reaction when a surgical patient with dementia displays challenging behavior and use of alternative approach instead of physical restraints. Most commonly the nursing staff pay attention to patient's state of alertness before counseling older people with dementia. Instead of using restraints, nursing staff gave painkillers for the patient and tried to draw patients' attention elsewhere. The nursing staff with longer work experience estimate that they can handle the patients' challenging behavior. They react by doing nothing more often than others. They pretend not to hear, see or notice anything.

CONCLUSION

The findings of this study can be applied in nursing practice and in future studies focusing on the care practices among older people with dementia in acute care environment. The results can be used while developing patient treatments process in surgical ward to meet future needs.