Effects of clinical supervision on nurse-patient cooperation quality: a controlled study in dementia care

Nursing interventions to improve care of people living with dementia in hospital: A mixed methods systematic review

BACKGROUND

There are growing numbers of people living with dementia being admitted to acute care hospitals. Hospitalization for people living with dementia can be difficult and is often associated with negative outcomes. Nurses play a significant role in shaping the hospital experience of people living with dementia, and there have been efforts to design, implement and evaluate interventions to improve nursing care of people living with dementia.

OBJECTIVE

To synthesize evidence on the effectiveness of, and experiences with, nursing interventions to improve care of hospitalized people living with dementia.

DESIGN

Mixed methods systematic review following the JBI convergent segregated approach to synthesis and integration of findings.

METHODS

The quantitative component considered studies that evaluated nursing interventions to improve the care of people living with dementia in hospital, comparing the intervention to usual care, other therapeutic modalities, or no comparator. The qualitative component considered studies that explored the experiences of nursing interventions from the perspectives of people living with dementia, caregivers, and nurses. A total of 8 databases were used to search for published and unpublished studies. Titles, abstracts, and full text selections were screened by two or more independent reviewers and assessed for methodological quality.

RESULTS

A total of 38 studies were included in the review, 24 quantitative, 9 qualitative and 5 mixed method designs. Critical appraisal scores were moderate. All studies regardless of methodological quality were included in the review. Interventions were grouped as principally related to (1) dementia education for nurses, (2) technology, (3) nursing skills, and (4) physical environment. Outcomes are presented related to health outcomes of people living with dementia; nurses' knowledge, confidence, and self-efficacy; and health system outcomes. As the interventions were heterogeneous, a meta-analysis of quantitative findings was not possible. The qualitative analysis incorporated 60 findings from 12 studies and led to nine categories and two synthesized findings recognizing external influences on nurses' practice with people living with dementia and the importance of interventions to humanize nurses' work with people living with dementia. Integration of the quantitative and qualitative results demonstrates the need to recognize the role of organization- and unit-level factors in the design and implementation of effective interventions.

CONCLUSIONS

There is limited high-quality evidence to demonstrate the effectiveness of interventions to improve nursing care of people living with dementia in hospital. Using approaches to intervention design and implementation that draw on models of behavior change and learning health systems may support effective change.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2021CRD42021230951.

A systematic review of the impact of person-centred care interventions on the behaviour of staff working in dementia care

AIM

To examine the content, focus, and effectiveness of person-centred care (PCC) interventions aimed at increasing staff PCC behaviour in health and social care settings for people with dementia.

DESIGN

Systematic search and narrative synthesis of quantitative data.

DATA SOURCES

PsychINFO, Medline, EMBASE, Web of knowledge, CINAHL, ASSIA, and BNI were searched from inception to 5 November 2016.

REVIEW METHODS

All records retrieved were screened using predetermined eligibility criteria. Quality assessment was performed with the Effective Public Health Practice Project tool (EPHPP).

RESULTS

A total of 4,367 records were screened and 33 studies examining the impact of PCC interventions were included. Eight different categories of PCC intervention were identified, with seven of these having at least some evidence to support their effectiveness in increasing staff PCC behaviour.

CONCLUSION

The range of interventions and outcome measures identified in this review highlight different ways PCC behaviour can be demonstrated by staff and the range of interventions that can be used to enhance PCC staff behaviour. In future, more rigorously controlled research comparing the relative effectiveness of these interventions will support nursing facilities and staff to choose appropriate interventions to support them in enhancing PCC.

IMPACT

This study addressed the health priority of increasing PCC for people with dementia. It found preliminary evidence that seven of the eight intervention types identified are effective at increasing staff PCC behaviour in health and social care settings for people with dementia.

How do inpatient psychiatric nurses make sense of and respond to behaviours in dementia? An Interpretative Phenomenological Analysis

Objectives: Existing literature demonstrates that nurses' understanding of behaviours in dementia influences their responses to persons with dementia. However, there is limited research on the psychological processes involved in how nurses make sense of the behaviours and how these impact on responding, and a dearth of such literature from inpatient acute dementia settings. This study explored how inpatient psychiatric nurses make sense of and respond to behaviours in dementia. Method: This study employed Interpretative Phenomenological Analysis (IPA), a qualitative method that explores in detail how participants make sense of their experiences. Eight inpatient psychiatric nurses were recruited from two inpatient services within a National Health Service Mental Health Trust. Semi-structured interviews were conducted to gain an in depth understanding of their experience. Transcripts of the interviews were then analysed using IPA. Results: Four interrelated themes were identified: 'Effort to sense make', 'Pressures of the organisation', 'Balancing personal and professional selves: The underlying emotional connection'; and '"Looking back on it…"'. Conclusions: The study highlighted that sense making is a dynamic process, which occurs through a range of psychological processes and can change moment by moment dependent on the influences on the nurse. It demonstrated that nurses need to be supported to move flexibly through a range of emotional connections, which were found to underlie the negotiations made at work and influence sense making and responding. Nurses may benefit from space to reflect and formulate their understanding of clients, but further research is required to determine the effectiveness of this.

Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: A systematic review

BACKGROUND

Poor oral health has been a persistent problem in nursing home residents for decades, with severe consequences for residents and the health care system. Two major barriers to providing appropriate oral care are residents' responsive behaviors to oral care and residents' lack of ability or motivation to perform oral care on their own.

OBJECTIVES

To evaluate the effectiveness of strategies that nursing home care providers can apply to either prevent/overcome residents' responsive behaviors to oral care, or enable/motivate residents to perform their own oral care.

MATERIALS AND METHODS

We searched the databases Medline, EMBASE, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science for intervention studies assessing the effectiveness of eligible strategies. Two reviewers independently (a) screened titles, abstracts and retrieved full-texts; (b) searched key journal contents, key author publications, and reference lists of all included studies; and (c) assessed methodological quality of included studies. Discrepancies at any stage were resolved by consensus. We conducted a narrative synthesis of study results.

RESULTS

We included three one-group pre-test, post-test studies, and one cross-sectional study. Methodological quality was low (n = 3) and low moderate (n = 1). Two studies assessed strategies to enable/motivate nursing home residents to perform their own oral care, and to studies assessed strategies to prevent or overcome responsive behaviors to oral care. All studies reported improvements of at least some of the outcomes measured, but interpretation is limited due to methodological problems.

CONCLUSIONS

Potentially promising strategies are available that nursing home care providers can apply to prevent/overcome residents' responsive behaviors to oral care or to enable/motivate residents to perform their own oral care. However, studies assessing these strategies have a high risk for bias. To overcome oral health problems in nursing homes, care providers will need practical strategies whose effectiveness was assessed in robust studies.

The experience of people with dementia and nurses in hospital: an integrative review

AIMS AND OBJECTIVES

To identify and examine existing research exploring how people with dementia and nurses view acute hospital care.

BACKGROUND

Admission to hospital can be traumatic for a person with dementia due to an inability to cope with unfamiliar environments, faces and routines. Adverse behavioural and health outcomes can result. Dementia adds complexity to patient care. Inability to deliver appropriate care is a source of stress and frustration for nurses.

METHODS

Integrative review of the literature 2005-2015 reporting the experience of people with dementia and nurses caring for them in an acute hospital setting (n = 24).

RESULTS

Hospitals focus on acute medical care; consequently people with dementia are considered low priority and a disruption to normal routine. Risk management often takes priority over patient dignity. People with dementia are stigmatised. Families have significant roles to play in the care of a person with dementia in hospital but are often excluded. Nurses struggle to complete even basic patient care, and focus on tasks often at the expense of specific patient needs. Support for nurses is lacking. The job satisfaction of nurses caring for people with dementia is poor.

CONCLUSIONS

Nurses require improved education and support to care for patients with dementia. Hospitals must focus on genuine caring concurrently with rapid discharge requirements, risk mitigation and fiscal restraint. More research is needed to inform the development of appropriate care for people with dementia in hospitals.

RELEVANCE TO CLINICAL PRACTICE

Nurses must understand the complex needs of people with dementia in hospital. Nurse education about dementia, practical support, strong clinical leadership and role-modelling is needed. Empathy for patients regardless of diagnosis must remain a core attribute of nurses. Current hospital culture requires wider system review to mitigate against stigmatisation of patients with dementia.

Everyday Ethics in the Care of Elderly People

This article analyses the general ethical milieu in a nursing home for elderly residents and provides a decision-making model for analysing the ethical situations that arise. It considers what it means for the residents to live together and for the staff to be in ethically problematic situations when caring for residents. An interpretative phenomenological approach and Sandman’s ethical model proved useful for this purpose. Systematic observations were carried out and interpretation of the general ethical milieu was summarized as ‘being in the same world without meeting’. Two themes and four subthemes emerged from the analysis. Three different ethical problems were analysed. The outcome of using the decision-making model highlighted the discrepancy between the solutions used and well-founded solutions to these problems. An important conclusion that emerged from this study was the need for a structured tool for reflection.

Clinical supervision: What is going on in West Wales? Results of a telephone survey

This research was designed to identify successful models of clinical supervisory practice and the problems encountered by practitioners following the incorporation of clinical supervision into their practice. The survey population of 35 was a self-selected sample out of 118 practitioners who had completed the Welsh National Board validated diploma level module in clinical supervision. These practitioners had completed the module organised by the School of Health Science at Swansea at eight sites across Mid and West Wales between February 1995 and June 1997. Work on the study began in March 1997 and was completed in March 1998.

The study employed semi-structured telephone interviews which sought information on practitioners' experiences, and how their clinical supervision was organised in practice. The data were analysed by quantification, and by description of the responses by repeated independent analyses. Finally, the key themes were organised into 'narrative types'.

The findings are presented in three parts relating to the three functions of supervision: support, learning, accountability. Key findings include:

•The method was suitable and effective •Community practitioners are generally better placed than their counterparts in acute hospitals to undertake effective supervision •Time and organizational support are crucial factors •The need for, and value of, clinical supervision was universally acknowledged by those interviewed.

Recommendations relating to the findings are included.

Counteracting Fragmentation in the Care of People With Moderate and Severe Dementia

Symptoms such as amnesia, agnosia, apraxia, and aphasia may lead to a fragmented experience and actions among people with moderate and severe dementia. The aim of this study was to explore the interactions where fragmentation occurred and how caregivers counteract fragmentation. The observation notes from participant observations were analyzed using interpretive content analysis. Fragmentation was noted if the patients showed that they did not recognize what was going on, the people involved, the things used in the action, or did not recognize themselves in the situation. Care providers could counteract fragmentation by a caring based on attentive interest in the interaction, valuing the person behind the dementia disease, using an individual perspective considering the impact of the dementia disease, and striving for mutual interpretation of the shared situation. Caring based on these assumptions could help the patients to keep their world together.

The Development of the strain in dementia care scale (SDCS)

BACKGROUND

Though many staff gain satisfaction from working with people with dementia in residential facilities, they also experience significant stress. This is a serious issue because this in turn can affect the quality of care. There is, however, a lack of instruments to measure staff strain in the dementia-specific residential care environment, and the aim of this study, accordingly, was to develop the "Strain in Dementia Care Scale."

METHODS

The instrument was developed in three steps. In the first step, items were derived from six focus group discussions with 35 nurses in the United Kingdom, Australia, and Sweden concerning their experience of strain. In the second step, a preliminary 64-item scale was distributed to 927 dementia care staff in Australia and Sweden, which, based on exploratory factor analysis, resulted in a 29-item scale. In the final step, the 29-item scale was distributed to a new sample of 346 staff in Sweden, and the results were subjected to confirmatory factor analysis.

RESULTS

The final scale comprised the following 27 items producing a five-factor solution: Frustrated empathy; difficulties understanding and interpreting; balancing competing needs; balancing emotional involvement; and lack of recognition.

CONCLUSIONS

The scale can be used (a) as an outcome measurement in residential care intervention studies; (b) to help residential facilities identify interventions needed to improve staff well-being, and, by extension, those they care for; and

Finding a way forward: a literature review on the current debates around clinical supervision

Nursing research increasingly calls for clinical supervision to support nurses and improve nursing practice. Despite this, clinical supervision is not well established in healthcare organisations. This paper employs a critical interpretive approach to review the clinical supervision literature. The review discusses the current debates and challenges exploring possible ways of moving beyond the current criticisms and limitations in the literature. The review concludes that despite some confusion about the quantifiable outcomes, clinical supervision presents a professionally enriching activity that provides a forum for sharing of knowledge and generation of shared understandings of health care. Through this shared experience it is possible that innovative and creative approaches to health care will be born.

Staff training to reduce behavioral and psychiatric symptoms of dementia in nursing home residents: a systematic review of intervention reproducibility

Staff training has been cited as an effective intervention to reduce behavioral and psychiatric symptoms of dementia (BPSD) in nursing home residents. However, the reproducibility of interventions can be a barrier to their dissemination. A systematic review of controlled clinical trials on the effectiveness of staff training for reducing BPSD, published between 1990 and 2013 on the EMBASE, PUBMED, LILACS, PSYCHINFO and CINAHL databases, was carried out to evaluate the reproducibility of these interventions by 3 independent raters. The presence of sufficient description of the intervention in each trial to allow its reproduction elsewhere was evaluated. Descriptive analyses were carried out. Despite reference to a detailed procedures manual in the majority of trials, these manuals were not easily accessible, limiting the replication of studies. The professional expertise requirement for training implementation was not clearly described, although most studies involved trainers with moderate to extensive expertise, further limiting training reproducibility.

Validation method training: nurses' experiences and ratings of work climate

BACKGROUND

Training nursing staff in communication skills can impact on the quality of care for residents with dementia and contributes to nurses' job satisfaction. Changing attitudes and practices takes time and energy and can affect the entire nursing staff, not just the nurses directly involved in a training programme. Therefore, it seems important to study nurses' experiences of a training programme and any influence of the programme on work climate among the entire nursing staff.

AIMS AND OBJECTIVES

To explore nurses' experiences of a 1-year validation method training programme conducted in a nursing home for residents with dementia and to describe ratings of work climate before and after the programme.

DESIGN

A mixed-methods approach.

METHODS

Twelve nurses participated in the training and were interviewed afterwards. These individual interviews were tape-recorded and transcribed, then analysed using qualitative content analysis. The Creative Climate Questionnaire was administered before (n = 53) and after (n = 56) the programme to the entire nursing staff in the participating nursing home wards and analysed with descriptive statistics.

RESULTS

Analysis of the interviews resulted in four categories: being under extra strain, sharing experiences, improving confidence in care situations and feeling uncertain about continuing the validation method. The results of the questionnaire on work climate showed higher mean values in the assessment after the programme had ended.

CONCLUSION

The training strengthened the participating nurses in caring for residents with dementia, but posed an extra strain on them. These nurses also described an extra strain on the entire nursing staff that was not reflected in the results from the questionnaire. The work climate at the nursing home wards might have made it easier to conduct this extensive training programme.

IMPLICATIONS FOR PRACTICE

Training in the validation method could develop nurses' communication skills and improve their handling of complex care situations.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of healthcare providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. However, the impact of these interventions directly on clinical encounters and indirectly on patient satisfaction, healthcare behaviour and health status has not been adequately evaluated.

OBJECTIVES

To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations.

SEARCH METHODS

For this update, we searched: MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), and CINAHL (EbscoHOST) from January 2000 to June 2010. The earlier version of this review searched MEDLINE (1966 to December 1999), EMBASE (1985 to December 1999), PsycLIT (1987 to December 1999), CINAHL (1982 to December 1999) and HEALTH STAR (1975 to December 1999). We searched the bibliographies of studies assessed for inclusion and contacted study authors to identify other relevant studies. Any study authors who were contacted for further information on their studies were also asked if they were aware of any other published or ongoing studies that would meet our inclusion criteria.

SELECTION CRITERIA

In the original review, study designs included randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for healthcare providers that promote patient-centred care in clinical consultations. In the present update, we were able to limit the studies to randomized controlled trials, thus limiting the likelihood of sampling error. This is especially important because the providers who volunteer for studies of PCC methods are likely to be different from the general population of providers. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). Within our definition, shared treatment decision-making was a sufficient indicator of PCC. The participants were healthcare providers, including those in training.

DATA COLLECTION AND ANALYSIS

We classified interventions by whether they focused only on training providers or on training providers and patients, with and without condition-specific educational materials. We grouped outcome data from the studies to evaluate both direct effects on patient encounters (consultation process variables) and effects on patient outcomes (satisfaction, healthcare behaviour change, health status). We pooled results of RCTs using standardized mean difference (SMD) and relative risks (RR) applying a fixed-effect model.

MAIN RESULTS

Forty-three randomized trials met the inclusion criteria, of which 29 are new in this update. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. Descriptive and pooled analyses showed generally positive effects on consultation processes on a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy; and patients' perception of providers' attentiveness to them and their concerns as well as their diseases. A new finding for this update is that short-term training (less than 10 hours) is as successful as longer training.The analyses showed mixed results on satisfaction, behaviour and health status. Studies using complex interventions that focused on providers and patients with condition-specific materials generally showed benefit in health behaviour and satisfaction, as well as consultation processes, with mixed effects on health status. Pooled analysis of the fewer than half of included studies with adequate data suggests moderate beneficial effects from interventions on the consultation process; and mixed effects on behaviour and patient satisfaction, with small positive effects on health status. Risk of bias varied across studies. Studies that focused only on provider behaviour frequently did not collect data on patient outcomes, limiting the conclusions that can be drawn about the relative effect of intervention focus on providers compared with providers and patients.

AUTHORS' CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behaviour and health status, outcomes not assessed in studies reviewed previously. The latter conclusion is tentative at this time and requires more data. The heterogeneity of outcomes, and the use of single item consultation and health behaviour measures limit the strength of the conclusions.

Case conferences as interventions dealing with the challenging behavior of people with dementia in nursing homes: a systematic review

BACKGROUND

Challenging behaviors such as aggression, screaming, and apathy are often encountered when caring for people with dementia in nursing homes. In this context, a case conference is often recommended for healthcare professionals as an effective instrument to improve the quality of care. However, the subject case conference has not had great consideration in scientific literature. The aim of this review is to describe the effects of case conferences on people with dementia and challenging behavior and the staff in nursing homes.

METHODS

A search of intervention studies in nursing homes in the German or English language was performed in the following databases: Medline, Cinahl, PsycINFO, Cochrane library, Embase, and Google Scholar. The selection and the methodological quality of the studies were assessed independently by two authors. The results were summarized and compared based on categories such as study quality or outcomes.

RESULTS

Seven of 432 studies were included in the review. A total of four of seven studies showed a reduction in the challenging behavior of people with dementia, and five showed an influence on the competence, attitudes, and job satisfaction of the staff. However, due to the middle-range quality of several studies, the methodological heterogeneity and differences in the interventions, the results must be interpreted with caution.

CONCLUSIONS

In summary, little evidence exists for the positive effects of case conferences in the care of people with dementia. This review highlights the need for methodologically well-designed intervention studies to provide conclusive evidence of the effects of case conferences.

Workplace aggression experienced by frontline staff in dementia care

AIM

To describe the frequency of aggressive acts experienced by frontline staff working in two models of dementia care: Residential Alzheimer's Care Centers and Secured Dementia Units and to explore the associations between aggressive acts experienced by frontline staff and factors related to the work context and care providers.

BACKGROUND

Aggression towards healthcare providers in residential long-term care settings is well documented. However, few studies have examined associations between aggressive behaviours towards care providers and organisational factors.

DESIGN

A cross-sectional survey.

METHOD

The survey included demographic items and questions about aggressive acts experienced by staff and contextual factors. Analyses included: (1) descriptive statistics, (2) tests of difference (i.e. Student's t-test, Mann-Whitney U-test, chi-squared test and anova), (3) bivariate associations (i.e. Pearson and Spearman rank order correlations) and (4) multivariate linear regression.

RESULTS

Ninety-one health care aides and licensed practical nurses working in four nursing units using two models of dementia care participated (response rate 81%). The most frequently reported types of aggression were physical assault (50% of staff, n = 45) and emotional abuse (48% of staff, n = 44). Aggressive acts were significantly associated with working in Secured Dementia Units rather than Residential Alzheimer's Care Centers.

CONCLUSIONS

Frontline staff working in Secured Dementia Units were exposed to higher frequencies of various types of aggressive acts mainly initiated by residents. Future research needs to explore modifiable workplace factors associated with aggressive acts in a larger sample across a variety of long-term care settings.

RELEVANCE TO CLINICAL PRACTICE

To prevent staff perceived aggressive acts, leaders and managers in dementia care need to acknowledge the complex topic of workplace aggression and encourage an open discussion among frontline staff without assigning blame. Care provider strategies for dealing with aggressive behaviour have to be implemented in policies and clinical practice.

Job satisfaction amongst aged care staff: exploring the influence of person-centered care provision

BACKGROUND

There are challenges in attracting and sustaining a competent and stable workforce in aged care, and key issues of concern such as low staff job satisfaction and feelings of not being able to provide high quality care have been described. This study aimed to explore the association between person-centered care provision and job satisfaction in aged care staff.

METHODS

Residential aged care staff (n = 297) in Australia completed the measure of job satisfaction and the person-centered care assessment tool. Univariate analyses examined relationships between variables, and multiple linear regression analysis explored the extent to whichperceived person-centredness could predict job satisfaction of staff.

RESULTS

Perceived person-centred care provision was significantly associated with job satisfaction, and person-centred care provision could explain nearly half of the variation in job satisfaction. The regression model with the three person-centered care subscales as predictor variables accounted for 40% of the variance in job satisfaction. Personalizing care had the largest independent influence on job satisfaction, followed by amount of organizational support and degree of environmental accessibility. Personalizing care and amount of organizational support had a statistically significant unique influence.

CONCLUSIONS

As person-centered care positively correlated with staff job satisfaction, supporting staff in providing person-centered care can enhance job satisfaction and might facilitate attracting and retaining staff in residential aged care. The findings reiterate a need to shift focus from merely completing care tasks and following organizational routines to providing high quality person-centered care that promotes the good life of residents in aged care.

Findings from a pilot investigation of the effectiveness of a snoezelen room in residential care: should we be engaging with our residents more?

There is increasing literature on multisensory therapy or Snoezelen, with some evidence suggesting it promotes positive mood and reduces maladaptive behavior in people with dementia. We undertook a pilot evaluation of a Snoezelen room in residential care and compared effects with a condition in which staff took residents out to a garden. This study was therefore a comparison between a Snoezelen room containing prescriptive, expensive equipment and a more everyday existing location that, inevitably, also contained several sensory stimuli. The study was difficult to implement, with low numbers because some staff failed to attend sessions, and the frequent although rarely reported difficulty of introducing psychosocial interventions and doing research in residential care is one of the main stories of this study. No staff member used the room outside of the study, and we found no significant difference between Snoezelen and garden conditions. Results, although highly equivocal because of low numbers, raised the issue of the implementation of standard therapies in dementia care outpacing the evidence, possibly at the expense of less elaborate practices.

Management of behavioral problems in Alzheimer's disease

Alzheimer's disease (AD) is a complex progressive brain degenerative disorder that has effects on multiple cerebral systems. In addition to cognitive and functional decline, diverse behavioral changes manifest with increasing severity over time, presenting significant management challenges for caregivers and health care professionals. Almost all patients with AD are affected by neuropsychiatric symptoms at some point during their illness; in some cases, symptoms occur prior to diagnosis of the dementia syndrome. Further, behavioral factors have been identified, which may have their origins in particular neurobiological processes, and respond to particular management strategies. Improved clarification of causes, triggers, and presentation of neuropsychiatric symptoms will guide both research and clinical decision-making. Measurement of neuropsychiatric symptoms in AD is most commonly by means of the Neuropsychiatric Inventory; its utility and future development are discussed, as are the limitations and difficulties encountered when quantifying behavioral responses in clinical trials. Evidence from clinical trials of both non-pharmacological and pharmacological treatments, and from neurobiological studies, provides a range of management options that can be tailored to individual needs. We suggest that non-pharmacological interventions (including psychosocial/psychological counseling, interpersonal management and environmental management) should be attempted first, followed by the least harmful medication for the shortest time possible. Pharmacological treatment options, such as antipsychotics, antidepressants, anticonvulsants, cholinesterase inhibitors and memantine, need careful consideration of the benefits and limitations of each drug class.

A systematic review of communication strategies for people with dementia in residential and nursing homes

BACKGROUND

The impairment of verbal skills of people with dementia challenges communication. The aim of this review was to study the effects of nonpharmacological interventions in residential and nursing homes on (1) communication between residents with dementia and care staff, and (2) the neuropsychiatric symptoms of residents with dementia.

METHOD

Pubmed, PsychInfo, Web of Science, the Cochrane Library, and reference lists from relevant publications were systematically searched to find articles about controlled interventions with communication strategies. The data collected were pooled and subjected to a meta-analysis.

RESULTS

Nineteen intervention studies were selected for this review. They included structured and communicative "sessions at set times" for residents (e.g. life review) and communication techniques in activities of "daily care" applied by care staff (e.g. sensitivity to nonverbal communication). A meta-analysis of five set-time interventions (communication) and another meta-analysis of four set-time interventions (neuropsychiatric outcomes) found no significant overall effects. Individual set-time intervention studies report positive effects on communication when interventions are single-task sessions, like life review or one-on-one conversation. Interventions around daily care activities had positive effects on communication outcomes. Effects of both types of interventions on neuropsychiatric symptoms were divergent.

CONCLUSION

This review indicates that care staff can improve their communication with residents with dementia when strategies are embedded in daily care activities or interventions are single-task sessions at set times. These results offer the possibility of improving the quality of care, but not of directly reducing neuropsychiatric symptoms. More research is needed to study the effect of communication interventions on neuropsychiatric symptoms.

Caregivers' attitudes to education and supervision in work with the older people in a nursing home

Community-based care in Sweden has problems recruiting and keeping staff with formal competence and education. Both the caregiver's well-being and the receiver's care improve when the personnel receive support in the form of continuing supervision and education. Yet the caregivers in this study did not participate in a training and supervision programme during working hours. The aim of this study was to describe the attitudes towards education, support and supervision in the care of older people in municipal care in Sweden. The study used a qualitative approach with a descriptive design. Twelve caregivers, nine enrolled nurses and three nurses' aides from four wards in a nursing home were interviewed. The interviews were analysed with qualitative content analysis. The main findings showed that all of the caregivers were positive towards the idea of participating in training and asked for education and supervision but felt that the management did not create conditions that made it possible to participate during working hours. According to the findings there is a need for developing new forms and methods for learning that can be integrated into working life.

Public nursing home staff's experience of participating in an intervention aimed at enhancing their self-esteem

AIM

The aim of the present study was to gain an understanding of how nursing staff experienced participating in a training programme aimed at strengthening their self-esteem and empowering them, to determine whether participation benefited them in any way, and to describe their opinions about possible benefits or disadvantages.

BACKGROUND

Staff working in institutions such as nursing homes have a low status in society. A training programme was introduced to staff in a public nursing home. It focused on helping them understand factors in the work situation that influence them and on empowering them.

METHOD

The study was explorative and qualitative in design.

FINDINGS

The participants in the programme were generally satisfied with it. Their opinions about the benefits they received from the programme can be described using three themes: 'improved communication skills', 'enhanced self-esteem' and 'sees work in a different light'.

CONCLUSIONS

The most important finding of the present study is that it was possible to strengthen and empower staff. Staff members were generally pleased and satisfied with the content/organization of the training programme. They felt the programme had been of value to them by improving their communication skills and increasing their self-esteem.

IMPLICATIONS FOR NURSING MANAGEMENT

The present result could be of value to managers and educators working in the area of nursing home care when planning education and development activities for staff. Learning to communicate better and understand the social structure at the workplace could improve staff members' self-esteem, thereby enhancing the work situation and atmosphere as well as empowering the individuals.

Empirical studies of clinical supervision in psychiatric nursing: A systematic literature review and methodological critique

The objective of this paper was to systematically review and critically evaluate all English language research papers reporting empirical studies of clinical supervision in psychiatric nursing. The first part of the search strategy was a combination of brief and building block strategies in the PubMed, CINAHL, and PsycINFO databases. The second part was a citation pearl growing strategy with reviews of 179 reference lists. In total, the search strategy demonstrated a low level of precision and a high level of recall. Thirty four articles met the criteria of the review and were systematically evaluated using three checklists. The findings were summarized by using a new checklist with nine overall questions regarding the studies' design, methods, findings, and limitations. The studies were categorized as: (i) effect studies; (ii) survey studies; (iii) interview studies; and (iv) case studies. In general, the studies were relatively small scale; they used relatively new and basic methods for data collection and analysis, and rarely included sufficient strategies for identifying confounding factors or how the researchers' preconceptions influenced the analyses. Empirical research of clinical supervision in psychiatric nursing was characterized by a basic lack of agreement about which models and instruments to use. Challenges and recommendations for future research are discussed. Clinical supervision in psychiatric nursing was commonly perceived as a good thing, but there was limited empirical evidence supporting this claim.

Nurses’ experience of collaboration with relatives of frail elderly patients in acute hospital wards: A qualitative study

BACKGROUND

Frail elderly people admitted to hospital often receive help from relatives in managing their daily lives. These relatives are likely to continue to feel responsible after admission, and to hold valuable knowledge, which may contribute to decision-making related to care and treatment.

OBJECTIVE

To illuminate nurses' experience of collaboration with relatives of frail elderly patients in acute hospital wards, and of the barriers and promoters for collaboration.

DESIGN AND SETTING

The design was descriptive. Three acute units in a large Danish university hospital participated.

PARTICIPANTS

Six registered nurses and two auxiliary nurses in charge of discharge planning for the patients were included.

METHOD

Open interviews using an interview guide. Manifest and latent content analysis was applied.

RESULT

The main theme Encountering relatives-to be caught between ideals and practice reflected the nurses' two sets of conflicting attitudes towards collaboration with relatives, one in accordance with professional nursing values, the other reflecting the values of every day practice. The dual attitudes were reflected in two themes The coincidental encounter-the collaboration and Relatives-a demanding resource, which appeared in the text along with a number of sub-themes. Ideally, collaboration was considered important and described as a planned process, but in practice encounters with relatives were coincidental. Relatives were ideally considered a resource but also experienced as demanding, and nurses sometimes even avoided them. The nurses seemed unaware of the conflict of values, and their response pattern of escape-avoidance and labelling of relatives as difficult may be an indication of counter transference as a reaction to moral conflict. Macro level factors, such as organisational and societal values, and micro level factors, such as organisation of care, nurse's competence and communication skills, seemingly governed nurses' collaboration with relatives.

CONCLUSION

Although the nurses could be seen as mere victims of conflicting values, there appeared to be potential for improving collaboration practice within the restrictions of macro level factors by interventions at the micro level.

Nursing care for people with frontal-lobe dementia - difficulties and possibilities

BACKGROUND

Nursing care for people with dementia diseases affecting the frontal lobes places special demands on staff, but there is little information available about how best to tailor nursing care. The aim of this study was to describe nurses' experience of difficulties and possibilities in caring for people with dementia diseases with frontal-lobe dysfunction.

METHOD

The study was carried out as a descriptive qualitative study. Data collected during interviews with nursing staff (n = 10) were analyzed using qualitative content analysis.

RESULTS

The difficulties experienced were related to the patients' lack of inhibition and judgment, anxiety, agitation, reduced ability to deal with physical needs, egocentricity, imbalance between rest and activity and depressed mood. The possibilities were seen in relation to the nursing staff's professional encounters, characterized as being clear and consistent, a step ahead, flexible, calm and creating a positive atmosphere, close and trusting and being and doing things together. Continuous feedback and support were prerequisites for the engagement of the staff.

CONCLUSION

Nursing care in this context involves ethical issues whereby the residents' integrity must be balanced against a safe and secure environment. Nursing care is a sensitive but also demanding task, where nurses' actions can reduce the negative effects of the disease. It is therefore important to support staff in nursing care so they are able to manage their work and reduce the risk of emotional exhaustion.

Strain in nursing care of people with dementia: nurses' experience in Australia, Sweden and United Kingdom

OBJECTIVES

The aim of this study was to explore nurses' experience of strain in dementia care.

METHOD

Focus groups were held with 35 nurses in Sweden, Australia and UK, who care for people with dementia. The discussions were tape-recorded and analysed using qualitative content analysis.

RESULTS

The nurses described the complexity of their situation and referred to environmental factors such as 'the system', community attitudes, other staff, residents' family members and also their own family. With regard to caring for people with dementia, three main sources of strain could be identified: Being unable to reach; Trying to protect; and Having to balance competing needs.

CONCLUSION

The nurses' experience could be understood as a desire to do the best for the people in their care by trying to alleviate their suffering and enhance their quality of life. When they did not have the resources, opportunity or ability to do this, it caused strain.

An investigation into the perceptions of clinical supervision experienced by learning disability nurses

This study explored perceptions of clinical supervision among community-based residential learning disability nurses in south-east England. A questionnaire generated a sample of 35, of whom 26 engaged regularly in clinical supervision. Respondents reported that supervision provided protected time to reflect on their skills and on their professional and personal development. They identified a need for greater clarity in the roles of supervisor and supervisee, and a clearer separation of managerial and developmental imperatives. They wanted support and preparation for supervision, and range of options for type of supervision and choice of supervisor. Thus supervision was found to be important for staff working in isolated community-based services for people with learning difficulties. However, little research has been carried out in this area. This study could help to shape and unify the future provision of clinical supervision.

Are supervisors using theoretical perspectives in their work? A descriptive survey among Swedish-approved clinical supervisors

AIM

The aim of the study was to explore the theoretical perspectives in use by approved clinical nursing supervisors in Sweden.

BACKGROUND

For the time being, we know little of the theoretical perspectives in use on a daily basis by the clinical nursing supervisors in Sweden.

METHODS

A questionnaire (n = 49) and follow-up telephone interviews (n = 14) were used. Data analysis was made by descriptive statistics and qualitative content analysis.

RESULTS

The result from the questionnaire showed that the supervisors often used and combined different theoretical perspectives with origins in nursing, education and psychology. Surprisingly, one-fourth of the respondents did not state any nursing theoretical perspective in use during clinical nursing supervision. The result from the interviews revealed that the theory of Katie Eriksson (1987) was the most commonly used nursing perspective.

CONCLUSION

As the overall aim for clinical nursing supervision is to improve nursing for the patient/family, the supervisor's competence in nursing is essential. Given this fact, and that only three-quarters of the approved clinical nursing supervisors stated a use of theoretical nursing perspective when supervising, there is obviously a need for further investigations in this area. In addition, there is also a need for approved Swedish clinical nursing supervisors, to further become aware of the theoretical perspective in use that supports their clinical nursing supervision. Clinical nursing supervision is a multifaceted activity that needs to be supported by different nursing theoretical perspectives including physical, emotional, intellectual, spiritual as well as socio-cultural aspects.

Despite shattered expectations a willingness to care for elders remains with education and clinical supervision

The aim was to describe nursing home (NH) caregivers' work experiences while receiving education and clinical supervision for 2 years. Working in elder care seems to be losing its attraction especially with organizational changes, cutbacks and changes in work place conditions. Clinical supervision has been reported to increase job satisfaction and creativity. Semi-structured interviews from caregivers working at an NH in Sweden were conducted, at the start and again at 12 and 24 months. At about 12 months the caregivers were informed of planned cutbacks. Content analysis was the method used to analyse the interviews from seven caregivers who participated throughout the entire period. Findings show that the value of a caring milieu was one category generated by the subcategories: experiences related to work activities and changes, and experiences related to relationships. The value of knowledge was the other category that was influenced by the experiences related to the different backgrounds and the experiences related to increased knowledge gained from the support through education and clinical supervision. The categories contained positive as well as negative influences on care. The initial focus on practical duties associated with the opening of the NH shifted towards caregiver activities with the elders they spoke warmly about. After 2 years the caregivers' willingness to care continued despite their disappointment in the worsened working conditions. The main theme that resulted was: Despite shattered expectations a willingness to care for elders remained. Continued education and clinical supervision seems to be one factor behind the retained willingness. These findings demonstrate that support and caregiver involvement in educational programmes are important during times of change and when disappointments arise in the workplace.

Inappropriate treatment of people with dementia in residential and day care

Dependence on the help provided by other people increases the risk of a person being inappropriately treated. Our objective was to investigate inappropriate treatment and its context in the care of people with dementia. Some 85 clients across eight care units providing dementia care were observed by means of a structured Dementia Care Mapping method (DCM). Of the 17 DCM categories for inappropriate treatment, withholding, invalidation, and objectification were the categories coded most frequently. Inappropriate treatment episodes were mostly associated with eating and situations in which a client had a need or request. Most episodes occurred accidentally. The results show that nurses involved in dementia care need more knowledge of how illnesses causing dementia change the way the affected person experiences reality, and of the ethical aspects of their work.

Efficacy of clinical supervision: influence on job satisfaction, burnout and quality of care

AIM

This paper reports a study to determine how supervisees' backgrounds and surrounding infrastructure predict the efficacy of clinical supervision among Finnish nursing staff, their job satisfaction, levels of burnout and perceptions of the quality of care.

BACKGROUND

Several studies have described the effects of clinical supervision, but few have focused on evaluating it. Until recently, no studies have examined how clinical supervision evaluations are related to supervisees' backgrounds, surrounding infrastructure or respondents' levels of burnout, job satisfaction and perceptions of the quality of care.

METHODS

The survey involved supervisees completing a range of standardized and validated evaluation measures. The respondents were identified from 12 regional, central and university hospitals across Finland (n = 799). The data collection took place from October 2000 to February 2001.

FINDINGS

The evaluations varied statistically significantly and were associated with statistically significant variations in the respondents' backgrounds. Clinical supervision infrastructure was also strongly related to evaluation scores. Supervisees' age, education, gender, employment status, area of specialty, working hours, work experience and experience as a supervisor were statistically significant predictors for evaluations of the efficacy of clinical supervision. These evaluations of clinical supervision were also found to predict the respondents' job satisfaction, levels of burnout and assessments of good nursing.

CONCLUSION

Nursing staff, especially those who have over 10 years' work experience, work in general care, have a nursing diploma, are non-tenured, work part-time and work 24-hour rotating shifts can benefit from clinical supervision. However, resources need to be invested in supervisor education and nursing staff need to be encouraged to start working in both supervisor and supervisee roles because of the positive effects on job satisfaction and quality of care.

Clinical supervision, burnout, and job satisfaction among mental health and psychiatric nurses in Finland

This paper presents the findings from a survey of Finnish mental health and psychiatric nurses. The aim of the study was to describe and evaluate the current state of clinical supervision, and ascertain the levels of burnout and job satisfaction experienced by these health care professionals. Clinical supervision was found beneficial for mental health and psychiatric health care professionals in terms of their job satisfaction and levels of stress. The findings seem to demonstrate that efficient clinical supervision is related to lower burnout, and inefficient supervision to increasing job dissatisfaction.

Work satisfaction and dissatisfaction--caregivers' experiences after a two-year intervention in a newly opened nursing home

AIMS AND OBJECTIVES

The aim of the study was to investigate, from the narratives of nine enrolled nurses and one nurses' aide directly involved in patient care, the deeper meaning of work satisfaction and dissatisfaction when working with the older people.

BACKGROUND

Both nationally and internationally, there is little research documented regarding the working situation of the enrolled nurses and nurses' aides who make up the majority of care for older people today. With this in mind, it is important to focus on how these occupational groups experience their work with the older residents in municipal care, following a two-year intervention.

DESIGN

The study is part of a larger longitudinal study, with a quasi-experimental design within the municipal system of care for older people in Sweden. The investigation was carried out following a two-year intervention, which included: education, support and clinical supervision.

METHOD

The interviews were performed 12 and 24 months after start of the intervention and were analysed with a phenomenological-hermeneutic method inspired by Ricoeur's philosophy.

RESULTS

The findings from these narratives illustrated a change compared with the findings from the first interviews, when the nursing home had just opened. There was a shift from a dominance of dissatisfaction with work, to a dominance of work satisfaction and this was expressed in the following themes: experience of a changed perspective, experience of open doors, and experience of closed doors. Each theme emerged from several different subthemes and each subtheme that had been expressed in the caregivers' narratives was interpreted.

CONCLUSIONS

The study shows that the caregivers' experience of work satisfaction in the workplace exceeded their experience of dissatisfaction and that the intervention, consisting of: education, support, and supervision might have facilitated this positive development where the older residents were prioritized. It also shows that communication and understanding between management and staff had increased as the nursing home had opened.

RELEVANCE TO CLINICAL PRACTICE

The findings can be used to help to prevent work dissatisfaction, and thereby increase work satisfaction for caregivers working in nursing homes.

Méthode de prise en charge globale non médicamenteuse des patients déments institutionnalisés

INTRODUCTION

Over the last decades many approaches have been developed to manage cognitive and behavioral disturbances in dementia. The present work describes a global intervention program carried out with moderately to severely demented institutionalized patients. The aims of the intervention program are to stimulate and maintain the preserved abilities of demented patients in a supportive context, to decrease the behavioral disturbance and to avoid burnout of care-unit staff.

METHODS

This intervention combines different means: psychosocial care (validation therapy, social interaction), cognitive stimulation (memory and verbal training), and motor and sensitive stimulation. The global intervention program requires a special trained team composed of a supervisor, six aid-nurses, an occupational therapist, a speech therapist, a psychomotor therapist and a psychologist. The team cared for the patients five days per week over a three-month period. Assessments were conducted before and after the intervention program to measure the benefit.

RESULTS

Positive effects were shown for cognitive abilities, nutritional problems and staff burnout. However, due to the small sample size for this study, more research is needed to verify the effectiveness of this global intervention program, particularly the implications for nutrition.

CONCLUSION

This global intervention combined with pharmacological treatment seems to be useful for managing psychological and behavioral disorders of institutionalized demented patients.

Observation of nurse-patient interaction in oncology: review of assessment instruments

The aim of this review is to identify assessment instruments that can be used for analyzing sequences and can be applied to research into nurse-patient communication in cancer care. A systematic search of the literature revealed a variety of methods and instruments applicable to studies recording nurse-patient interaction. The studies that were qualitative in nature offered valuable information on observational research in general, on procedures relating to informed consent and observational arrangements in nursing practice. The quantitative studies provided an insight into the content and structure of the interaction by describing communication concepts or by frequency counts of previously determined behaviours. Systematic research into interaction sequences was not found. However, some of the quantitative instruments identified could be adapted for this purpose. The complexity and time-consuming nature of observational research highlight the need for efficiency. For instance a combination of quantitative and qualitative instruments could be considered.

Dementia and aggressiveness: stimulated recall interviews with caregivers after video-recorded interactions

BACKGROUND

In a previous study, nine caregivers and two residents with dementia showing aggressive behaviour, were video recorded. Caregivers who reported problems when dealing with such behaviour and caregivers, who did not, were included in this study.

AIM

The aim of the present study was to obtain insight into the reasoning of the caregivers who had reported problems when dealing with older people with dementia and aggressiveness and those who did not relative to their respective video-recorded interactions with these residents. A further aim was to gain insight by discussing their reasoning in relation to each other.

METHOD

Stimulated recall interviews were carried out with all the caregivers who had been video taped in the previous study. The text was analysed by thematic content analysis.

FINDINGS

Two main ways of thinking and discussing the care situations emerged. The caregivers, who had reported problems in handling behavioural and psychiatric symptoms in dementia earlier, reasoned that they were more focused on their duties, this included being responsible for the resident receiving her weekly shower. For this group of caregivers, the well being of the resident was in focus, but their attention was concentrated on the resident's well being and comfort after their shower. However, these caregivers seemed therefore unwittingly to prevent a positive interaction with the resident. The other caregivers were able to reflect spontaneously and appeared to be self-critical. This caregiver group seemed to sustain a positive interaction with the resident both during and after the shower.

RELEVANCE TO CLINICAL PRACTICE

In this study a nurturing and supportive climate and competence seemed to be the conditions necessary to facilitate reflections and promote creativity in the caregivers such that they are able to develop possible ways of handling difficult situations like aggressiveness in residents with dementia.

Nursing home care: changes after supervision

BACKGROUND

An intervention project was conducted in three nursing home wards in Sweden. Most patients had severe dementia. The intervention consisted of supervision for individualized and documented nursing care, based on multidimensional assessment.

AIM

To illuminate changes in carers' approach after the intervention.

METHODS

Several data collections were conducted across the intervention and consisted of nursing documentation, patient life stories as told by carers, video recorded interactions, stimulated recall interviews and a questionnaire. Both quantitative and qualitative methods were used in the analyses.

FINDINGS

The findings from the different methods mirrored each other and added to the credibility of the intervention. Communicated knowledge about patients improved in nursing documentation and also as told by carers. Carers were differently skilled in managing the complexity of nursing care situations before as well as after the intervention, but the intervention contributed to developing carers in 'confirming nursing care'. They also improved in their ability to verbalize reflections about their everyday life with patients with dementia.

CONCLUSION

Supervision made it possible for carers to share their lived experiences about their day-to-day life with patients, which could promote personal and professional development and thus improve care quality. It also appeared that a detailed assessment tool used as part of the nursing process contributed to seeing a patient as a real person behind a dementia surface.

Dementia and aggressiveness: video recorded morning care from different care units

The aim of the study was to illuminate, from video recorded sequences, interactions between individuals with dementia and aggressive behaviour and caregivers who reported problems dealing with such behaviour and caregivers who did not. Nine caregivers and two residents participated. The video recordings were later transcribed into text and analysed by using a phenomenological hermeneutic approach, inspired by Ricoeur's philosophy. The main themes that emerged from the analysis were 'Being involved and developing a positive interaction' and 'Being confined to routines and remaining in negative interaction'. The findings indicated the interactions either to be in a positive or negative spiral. Caregivers who had reported problems dealing with behavioural and psychiatric symptoms in dementia focused on accomplishing the task, where the main focus was on 'the goal itself'. In other sequences with caregivers who had been satisfied with their capability the focus was placed on 'how' the caregivers could reach their goal. Power was central in the material, in different ways, either as a possible way to handle the situation or as a possible way of defending oneself. Parts of Kitwood's framework and Fromm's theory about power 'over' and power 'to', has been used in the comprehensive understanding. Our conclusion is that caregivers should use power 'to' when they have to help persons with dementia and aggressive behaviour, as a part of behavioural and psychiatric symptoms of dementia, for being able to give help in the best possible way. They should also act in a sensitive and reflective manner, with the individual in focus.

Exploring the meaning of everyday life, for those suffering from dementia

Living with dementia means struggling to preserve a sense of self, to retain (and reevaluate) one's values in a new situation, and to search for a new way of life. This study explored the meaning of everyday life as expressed by 11 people suffering from dementia. Data were collected through interviews with people in the early stage of a diagnosed dementia disease. The findings indicate that many people with dementia feel shame, sorrow, and sadness when their life with the disease begins but also indicate prospects of a more manageable life. Since the reaction and adjustment to dementia differs from person to person, professional caregivers need to use a case-specific approach in the provision of care.

Assessment by nurses of mood, general behaviour and functional ability in patients with dementia receiving nursing home care

The aim of this study was to investigate the reliability of the Patient Mood Assessment Scale (PMAS), the General Behaviour Assessment Scale (GBAS) and the Gottfries Bråne Steen scale and to investigate mood, general behaviour, degree of dementia and symptoms for patients with dementia living permanently in nursing home care (n = 75). Interviews were conducted with the contact nurses, focussing on their view of the patients during the preceding week, based on the above-mentioned assessment scales. In 29 cases a second interview was conducted with another nurse in order to investigate the inter-rater reliability. The inter-rater reliability was high for items associated with ADL and intellectual functions, but low for items associated with emotional aspects. The nurses' difficulties in assessing the patients' emotional state could arise because these matters are not regularly discussed among the staff or could reflect the nurse's inner state rather than that of the patient. The varying understanding that the nurses had of the patients raises the question of whether the care provided is based on the nurses' opinions rather than on the patients' needs. There is a need for continuous and reflective discussions in the staff group, focusing on the patients' physical as well as emotional needs.

Effects of an implemented care policy on patient and personnel experiences of care

A care policy was implemented within health care in the county of Västerbotten, Sweden. A questionnaire was administered before and after the implementation of the care policy to assess its effects. Patients within hospital care and primary health care described their experiences in a base-line study (n=3950) in 1994 and a follow-up study (n=2941) in 1996. On the same occasions personnel (n=2362 and 2310, respectively) answered the same questionnaire assessing what they thought their patients experienced. No significant positive effects of the implementation were seen by the patients. Fewer patients felt that they were understood when they talked about their problems, dared to express criticism or denied they were treated nonchalantly in the follow-up study. The experiences of the personnel were in line with those of the patients concerning nonchalant treatment in the follow-up study. Furthermore, fewer staff members thought that their patients felt they had adequate help with hygiene whilst more thought that their patients felt they were responded to in a loving way. One interpretation of the negative outcome is that organizational changes, strained resources and cuts in staffing during the 90s may have reduced the possibility of integrating the care policy in spite of an ambitious and extensive intervention.

Actions seen as demanding in patients with severe dementia during one year of intervention. Comparison with controls

Behaviours, viewed by nurses as demanding, performed by patients with severe dementia were investigated during one year of intervention. Supervised implementation of individually planned care and systematic clinical supervision were implemented on one experimental ward (EW) while another ward (CW) served as control. Each ward had 11 patients. At baseline and after 6 and 12 months of intervention structured interviews with the patients' assigned nurses were conducted based on the Demanding Behaviour Assessment Scale and Multi Dimensional Dementia Assessment Scale. At the EW there was a decreased frequency (p=0.000) and a reduced occurrence of physical behaviours (p=0.008), a decreased frequency (p=0.029) and a reduced occurrence of vocal behaviours (p=0.002). No significant changes were seen at the CW. Bearing the small sample size in mind, the findings indicate that individually planned care and systematic clinical supervision could be a means of reducing the frequency, and/or effect the nurses' attitude and interpretation of the patients' behaviour as demanding. The findings, however, can only be seen as indications for further research, but point to the importance of including effect variables related to patients when intervening in nursing care.