https://www.infirmiere-canadienne.com/blogs/ic-contenu/2024/09/09/solutions-pour-la-prise-en-chargede-la-demence
How to elevate “person-centred care” from a buzzword to real action
By Shrinithi Subramanian & Sadaf Murad Kassam
September 9, 2024
istockphoto.com/SDI Productions
People who come to the hospital with pre-existing dementia often struggle with adapting to the change in environment because they may not be oriented to their setting and may even feel unsafe, which could lead to anxiety and agitation.
Globally, the increased number of older adults being diagnosed and living with dementia is alarming. According to the World Health Organization, more than 55 million people have dementia worldwide, which is expected to double in 20 years (WHO, 2023). This increases the risk of hospitalization and dementia-focused care in acute care hospital settings (Toubøl et al., 2020).
Dementia care in a busy surgical unit can be quite overwhelming for nurses as they struggle with a shortage of time and staff to provide person-centred care. Mundane hospital practices and a lack of dementia expertise create barriers for older adults living with dementia to access care in hospital settings. This leads to personal and professional dilemmas for nurses as they struggle to meet their work demands versus providing person-centred care to their patients. Patients with dementia need support and care from nurses to adjust to the hospital environment and require frequent reorientations, which at times can be cumbersome and provoke behavioural symptoms.
In this paper, we aim to share our professional and personal dilemmas in addressing the needs of older adults living with dementia in hospital settings.
Dementia in hospitals
Dementia can be a combination of various symptoms that cause memory loss, compromise cognitive skills, and impact the overall ability of the individual to carry out simple day-to-day tasks (Digby, Lee, & Williams, 2017; Zhao, Moyle, Wu, & Petsky, 2022). A common type of dementia in older adults is Alzheimer’s disease, which is a neurodegenerative disease (Alzheimer Society of Canada, 2021). The impact of increasing cases of dementia seen in acute care in the next decade will approximately double the annual health-care costs compared to the past two decades (Government of Canada, 2022).
So why is it a concern to see dementia in acute care hospitals? People who come to the hospital with pre-existing dementia often struggle with adapting to the change in environment because they may not be oriented to their setting and may even feel unsafe, which could lead to anxiety and agitation (Digby et al., 2017). Furthermore, health-care professionals who specialize in acute care settings may not have the expertise to provide dementia-focused care, which can further lead to negligence, longer hospital stays, aggravation of underlying conditions and even mortality (Digby et al., 2017).
“Person-centred care” in name only?
Through our experiences as registered nurses (RNs) working with people who have dementia and are admitted to surgical units in acute care hospital settings, we question if we are adhering to the Canadian Nurses Association’s Code of Ethics for Registered Nurses (CNA, 2017), which holds us responsible for representing the patient’s voice, addressing their challenges in receiving care, and providing them with equitable care. This question was a real-life struggle for us and gave us the feeling that, as RNs, we still need to achieve competency in providing dignified person-centred care to dementia patients in hospitals. Person-centred care is a significant phenomenon in nursing care (CNO, 2006). But in our practice as RNs in hospitals, we felt “person-centred care” was more a buzzword than the actual implementation of its principles.
We’re sharing two patient experience stories (see below) that we believe will resonate with readers and illustrate why we need to take impactful steps toward improving dementia care and forming meaningful nurse-patient relationships with those who have been long neglected in our health-care system.
- “As a newly graduated nurse, I started off my nursing career on a busy orthopedic unit at the University of Alberta Hospital. I had the opportunity to work with a woman, who had come to our unit from a dementia facility after she had a fall. During her time on the unit, I would often notice that she would become very agitated when she was left alone in her room. I struggled with understanding what I could do in my nursing role to comfort this patient. Due to how busy it was on the unit, I was constantly attending to different patients, and I did not feel I had sufficient time to sit and talk to the patient and get to know her interests. Eventually, we started playing her favourite songs while she sat by the nursing station, engaged her in conversations, and provided her pieces of paper and pencils to draw. I noticed that she responded well to music. She would sing along to the songs and also seemed calmer and more settled down. This was something that was meaningful to her and was a therapeutic way for her to manage her emotions.”
(Shrinithi Subramanian, RN, surgical unit)
- “A majority of patients who have pre-existing cognitive health issues struggle the most with rehabilitation and returning to the lifestyle they practised before their admission to the hospital, especially ethno-racial individuals. I worked with a patient who had mild cognitive impairment and had come into the acute care hospital for surgery for his knee fracture. Due to a major language barrier, he often did not receive dedicated time from the nurses and was labelled as an ‘agitated patient.’ Fortunately, I spoke his language [Gujarati, a dialect spoken in India] and was able to identify the cause of his agitation. He could not express his needs, such as wanting to be toileted, having his cultural foods, or asking his family to visit him. Having a one-on-one conversation with him allowed me to better understand his recovery process after his surgery, such as pain management and coping through social interactions. Even though his short-term memory was not intact, he remembered his past and could identify what was meaningful to him. And as an RN I felt connecting to his culture and his life course experiences in care may help him to recover and participate in his care.”
(Sadaf Murad Kassam, RN, surgical unit)
As direct-care workers, nurses in general spend the most time with patients, which provides them with the opportunity to advocate for patients’ rights to access quality care and build therapeutic nurse-patient relationships (Toubøl et al., 2020). Therefore, nurses are responsible for advocating for the needs of the patient and promoting essential changes that improve the quality of care. By taking such action, nurses can remove barriers and enhance the quality of dementia care in acute care hospital settings.
Recommendations
To overcome these challenges in the health-care system, it is necessary for nurses to recognize their existence and reflect on what they could do in their practice, both individually and collectively, to demonstrate their understanding of person-centred care. Applying effective strategies that can be evaluated in practice will ensure that nurses are going beyond their basic expectations to provide compassionate care that optimizes the quality of life of someone living with dementia.
Create better care plans
In acute care settings, there is a standardized plan of care that is meant to cater to the majority of patients. This includes how patients are admitted into the units, the schedule they follow for the day, the meals they are provided, and how they transition from hospital to home.
Having such a day-to-day task list with fixed goals developed for the care team undervalues the uniqueness of each patient and their needs. Often in fast-paced acute settings, dementia is considered a secondary concern, and not enough consideration is given to how an individual’s cognitive state goes hand in hand with the primary concern they present with (Digby et al., 2017). The mundaneness of the hospital diverts the focus to completing care tasks instead of building connections with patients and identifying their health requirements or goals.
To improve current practices, RNs should utilize their expertise in working closely with patients to propose initiatives that promote care plans that are tailored to those living with dementia. Care plans and coordination for dementia patients in acute care hospital settings can be improved by knowing the patients individually and allowing them to voice their likes and dislikes; using therapeutic communication with dementia patients and their families, and identifying their interests or cultural backgrounds (Pritchard et al., 2021; Toubøl et al., 2020).
Revamp education
For nurses to truly understand the needs of dementia patients in hospital and what it entails, nursing education and competencies must be enhanced to equip nurses with vital skills and knowledge that promote safe, efficient, and person-centred dementia care (Digby et al., 2017; Hung et al., 2017; Zhao et al., 2022). Nursing education must teach strategies that promote self-awareness, cultural sensitivity, patient advocacy, and leadership. Nurses and nursing students should be encouraged to reflect on personal and professional biases and stigmas against people living with dementia and implement strategies within their practice to mitigate stigmas. Organizing frequent workshops or educational sessions on dementia can benefit nurses in applying their learning to their practice.
Make better use of administrative staff
Nurses should also work closely with administrative staff in hospitals to discuss how additional resources can be implemented on the units to enhance dementia care. For example, many dementia patients from ethno-racial backgrounds struggle to have their needs expressed due to language barriers. These patients have unique cultures and traditions they follow in their regular lives that may not be continued in the hospital.
Increased integration of health-care members such as translators, care companions, recreational staff and volunteers into the health-care team can allow nurses to work hand in hand to provide comfort to patients and ensure that their needs are met (Pritchard et al., 2021). Making use of these underused services, such as volunteers, can have a significant impact on an individual’s life as they are given the opportunity for social interaction, have meaningful companionship, and are provided with sufficient time to recuperate in the new environment (Pritchard et al., 2021).
Focus on system-level change
Undoubtedly, acute care settings are fast-paced and workload heavy in nature, which can be quite stressful for nurses. Along with demonstrating proficiency in hands-on nursing skills, nurses are expected to be a voice for their patients. However, we see that in acute care settings, the workload of nurses can become demanding, which, unfortunately, causes them to lose the human touch to care. Insufficient time or skills can significantly compromise care; therefore, such issues must be dealt with on a systemic level.
Although nurses have a crucial role in representing patients’ voices, health-care leaders and hospital administrators also need to be involved in bringing more attention to dementia-focused care in hospital settings. Implementing changes is a shared responsibility that needs collaboration at the leadership level so that the concept of person-centred dementia care becomes a mandatory practice for health-care providers and leaders.
Conclusion
Instead of viewing dementia merely as a disease, nurses should strive to value the personhood of the patient and acknowledge their life experiences during care (Toubøl et al., 2020). Further education and research on the concept of dementia care in acute care hospital settings are warranted for nurses to improve dementia care.
Nurses and nursing students have the foundational knowledge for providing person-centred care, which takes into consideration not only physical health but also mental and spiritual needs. However, nurses and nursing students in clinical practice are not well equipped to apply this knowledge in real-life situations because they face the pressure of completing nursing tasks that primarily concern physical health (Zhao et al., 2022).
Utilizing the recommendations provided in this article, which has been based on the literature and our personal experiences, can be a meaningful first step toward improving dementia care in the hospital setting. Nurses and nursing students have the potential to create significant changes through their practice, so now is the time for them to demonstrate their leadership by expanding their knowledge and skills to integrate person-centred dementia care.
References
Alzheimer Society of Canada. (2021). What is dementia? Retrieved from https://alzheimer.ca/sites/default/files/documents/ASC_What-is-dementia-info-sheet_en.pdf
Canadian Nurses Association. (2017). Code of ethics for registered nurses. Retrieved from https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics
College of Nurses of Ontario (CNO). (2006). Therapeutic nurse-client relationship, revised 2006. Retrieved from https://www.cno.org/globalassets/docs/prac/41033_therapeutic.pdf
Digby, R., Lee, S., & Williams, A. (2017). The experience of people with dementia and nurses in hospital: An integrative review. Journal of Clinical Nursing, 26(9–10), 1152–1171. doi:10111/jocn.13429
Government of Canada. (2022, November 4). Dementia: Overview. Retrieved from https://www.canada.ca/en/public-health/services/diseases/dementia.html
Hung, L., Phinney, A., Chaudhury, H., Rodney, P., Tabamo, J., & Bohl, D. (2017). “Little things matter!” Exploring the perspectives of patients with dementia about the hospital environment. International Journal of Older People Nursing, 12(3), e12153. doi:10.1111/opn.12153
Pritchard, E., Soh, S.-E., Morello, R., Berkovic, D., Blair, A., Anderson, K., … Ayton, D. (2021). Volunteer programs supporting people with dementia/delirium in hospital: Systematic review and meta-analysis. Gerontologist, 61(8), e421–e434. doi:10.1093/geront/gnaa058
Toubøl, A., Moestrup, L., Ryg, J., Thomsen, K., & Nielsen, D. S. (2020). “Even though I have dementia, I prefer that they are personable”: A qualitative focused ethnography study in a Danish general hospital setting. Global Qualitative Nursing Research, 7, 2333393619899388.
World Health Organization. (2023, March 15). Dementia. Retrieved from https://www.who.int/news-room/fact-sheets/detail/dementia
Zhao, W., Moyle, W., Wu, M.-L. W., & Petsky, H. (2022). Hospital healthcare professionals’ knowledge of dementia and attitudes towards dementia care: A cross-sectional study. Journal of Clinical Nursing, 31(13–14), 1786–1799. doi:10.1111/jocn.15590
Shrinithi Subramanian, BScN, RN, is an RN at the University of Alberta Hospital.
Sadaf Murad Kassam, MN, BScN, GNC(C), RN, is a PhD student at the University of Alberta’s Faculty of Nursing and an RN at the University of Alberta Hospital.
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#dementia
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