Promoting a good life among people with Alzheimer's disease

In constant search of the good: a qualitative study into insiders' perspectives on living well with dementia

Introduction

The new concept of 'living well with dementia' is currently gaining traction in practice, policy, and research. However, people with dementia and their carers' own understanding of this concept has not received much scholarly attention. This is because empirical studies into living well with dementia are predominantly quantitative; there are only a few qualitative studies on this topic. This study therefore sets out to investigate what living well means for 'insiders' in an everyday context.

Methods

To explore insiders' own perspectives on living well with dementia, we conducted interviews and focus group discussions with 21 dementia stakeholders. The study included ten individuals with mild-to-moderate dementia living at home, five family carers who are or have been involved in the care for a person with dementia, and six health and social care professionals.

Results

Living well with dementia, for our study participants, revolves around shaping their daily lives according to their values. In this sense, living well with dementia is no different than without. As it involves the values of the person with dementia and those of their social network, living well is both an individual and a collective concern. Having dementia undermines people with dementia's ability to substantiate their values, but it is still possible to live well. As they attempt to shape living well with dementia, respondents encounter tensions within the social network and within the person with dementia. To handle these tensions, they work for mutual attunement by using sensitivity and switching between leading and following in social interactions.

Discussion

Living well with dementia in a daily context is a dynamic process in which people with dementia, family carers, and professionals constantly seek the good together. This insight contributes to a better understanding of stakeholders' ongoing, invisible efforts to mutually attune. It may also help bypass dichotomizing approaches to dementia. Finally, it opens up new venues for research into reciprocity in the care collective. The article closes with recommendations to improve dementia care and support in light of these findings.

Do differences exist in cross-cultural caregivers' respect for the autonomy/dignity of people with dementia? Real-time field observations in nursing homes

BACKGROUND

Although published studies have examined the perceptions of caregivers who are attending to older adults with dementia concerning the values of human dignity and/or autonomy in institutional settings, none have explored the possible differences in actual behavior that relates to these values for caregivers from diverse ethno-cultural backgrounds.

AIMS

Explore how caregivers with varied cultural backgrounds may differ in their real-time behavior regarding the autonomy and dignity of older adults with dementia and thereby determine whether that real-time behavior reveals new aspects of respect and disrespect for both the autonomy and dignity of those older adults.

RESEARCH DESIGN AND METHODS

A qualitative research based on non-participatory observations, was meticulously recorded using a written journal and a rigorous microanalysis to analyze the collected data. We made 58 shift-based observations (morning and evening) of 29 caregivers from 3 ethno-cultural groups working in 3 nursing homes in Israel. These groups included Israeli-born Jews (Sabras), Israeli Arab-Muslims (Arabs), and immigrants from the Former Soviet Union (IFSU).

RESULTS

(1) IFSU caregivers demonstrated more respect for autonomy and dignity, but also demonstrated disrespect for these values. (2) the main difference between the IFSU caregivers and other caregiver groups pertained to respect for their autonomy. The main specific facets of autonomy where IFSU caregivers surpassed their colleagues were information provision and persuasion. (3) toward both autonomy and dignity of these older adults, previously unaccounted for in the models we used, were discovered among the varied groups of caregivers, with only minor gaps between these groups.

DISCUSSION AND IMPLICATIONS

This study-the first of its kind to focus on the real-time behaviors of caregivers from diverse ethno-cultural backgrounds-reveals the potential effects of culture on applying practices related to dignity and autonomy during daily care. The findings may have important implications for caregiver training in multicultural societies.

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.

Dementia and dignity of identity: A qualitative evidence synthesis

In the late stages of dementia, individuals rely on others for their wellbeing and this creates an ethical imperative for responsive dementia care. Through a qualitative evidence synthesis of literature on what constitutes responsive dementia care, we identified dignity of identity as a central theme. Dignity of identity is the status each of us holds in relation to others and reflects our past experiences and our aspirations for the future. We did a qualitative evidence synthesis of 10 qualitative studies conducted with a total of 149 research participants, 95 of whom had dementia, and 54 of whom were paid and family member caregivers to people with dementia. Using "new materialism disability studies" as our theoretical framework, we illustrate how environments, both material and discursive, shape the abilities of people with dementia in residential care settings (RSCs) to live well and we use our findings to point to ways forward in dignity of identity-enhancing dementia care practice. Echoing the literature, we observe that people with dementia have the virtual capacity to live with dignity of identity and illustrate how material conditions and discourse influence the transition of dignity of identity in people with dementia from a virtual capacity to an actual capacity and how demonstrated capacity in turn influences material conditions and discourse surrounding care for people with dementia in RSCs. We call for a greater acknowledgement within literature on dignity and dementia of structural barriers to dignity of identity-enhancing care. The COVID-19 pandemic has shown us the fatal consequences of insufficient material conditions in RCSs and we hope that on a societal level there is improvement to both the material conditions in RCSs as well as an improvement in discourse about those who live and work in RCSs.

Everyday life in a Swedish nursing home during the COVID-19 pandemic: a qualitative interview study with persons 85 to 100 years

OBJECTIVE

To understand and report on the impact of the COVID-19 pandemic on the everyday lives of frail older persons living in nursing homes by exploring their experiences of how the pandemic-related restrictions had influenced them and in what way.

DESIGN

Empirical qualitative interview study.

SETTING

A publicly run nursing home in an urban area in Sweden in June 2020. The nursing home had visitor restrictions, cancelled activities and physical distancing requirements since March 2020.

PARTICIPANTS

A total of 10 persons, 85-100 years, living in a Swedish nursing home during the COVID-19 pandemic, were recruited through nursing home management and interviewed in June 2020 using medically approved visors and physical distancing.

ANALYSIS

Interviews were analysed using thematic analysis, which involves familiarisation, coding and definition of themes. Transcripts were coded into data-driven categories before being organised into categories that described and explained the data.

RESULTS

The analysis resulted in the main theme 'It is like living in a bubble', that describes everyday life in the nursing home during the pandemic as a world of its own in which the older persons felt both protected and isolated. This is described in four subthemes: living 1 day at a time, without fear of the virus; feeling taken care of; having limited freedom and missing out on the little extras.

CONCLUSIONS

Contributing to the growing area of COVID-19-related research, our findings provide novel insights into how pandemic-related restrictions in nursing homes represent a risk of isolating older people from the outside world and diminishing their freedom. Put in relation to the previous research, these findings could be applied beyond the pandemic, to develop research and practice that puts focus on how to support older people to decide for themselves how to spend the rest of their lives.

Advancing Long-Term Care Science Through Using Common Data Elements: Candidate Measures for Care Outcomes of Personhood, Well-Being, and Quality of Life

To support the development of internationally comparable common data elements (CDEs) that can be used to measure essential aspects of long-term care (LTC) across low-, middle-, and high-income countries, a group of researchers in medicine, nursing, behavioral, and social sciences from 21 different countries have joined forces and launched the Worldwide Elements to Harmonize Research in LTC Living Environments (WE-THRIVE) initiative. This initiative aims to develop a common data infrastructure for international use across the domains of organizational context, workforce and staffing, person-centered care, and care outcomes, as these are critical to LTC quality, experiences, and outcomes. This article reports measurement recommendations for the care outcomes domain, focusing on previously prioritized care outcomes concepts of well-being, quality of life (QoL), and personhood for residents in LTC. Through literature review and expert ranking, we recommend nine measures of well-being, QoL, and personhood, as a basis for developing CDEs for long-term care outcomes across countries. Data in LTC have often included deficit-oriented measures; while important, reductions do not necessarily mean that residents are concurrently experiencing well-being. Enhancing measurement efforts with the inclusion of these positive LTC outcomes across countries would facilitate international LTC research and align with global shifts toward healthy aging and person-centered LTC models.

Dementia care model: Promoting personhood through co-production

BACKGROUND

Despite robust evidence on its effectiveness, current approaches that aspire to person-centred care (PCC) frequently locate people with dementia as passive recipients rather than as active agents in the care process. We define active involvement in care as 'co-production'. In order to investigate co-production, we set out to review the evidence concerning personhood and dignity in dementia care.

METHOD

We adopted a meta-ethnographic approach to synthesise the predominantly- qualitative literature on personhood and dignity in dementia care using EMBASE, PsycINFO, and ASSIA databases. We also included relevant policy documents. Members of Patient and Public Involvement (PPI) group were consulted throughout.

RESULTS

A total of 14 empirical studies were subjected to content analysis. Three themes were identified: dignity and personhood, coping with dementia, and barriers to dignity in care. The findings suggest that positive strategies and coping mechanisms are associated with superior outcomes in relation to: sense of self, dignity and quality of care. The 22 policy documents yielded six themes pertaining to co-production: the part played by the person with dementia, family, environment, behaviour, governance and law, and health care partnership.

CONCLUSION

Personhood in dementia care is enhanced through co-production, by actively participating in social, civic and political life. This is promoted through behavioural changes at the micro and macro levels of society, including providers of care being trained in co-producing care and policy makers creating opportunities with, rather than for people with dementia.

Person-Centered Primary Care Strategies for Assessment of and Intervention for Aggressive Behaviors in Dementia

With an increase in the number of individuals affected by dementia, it is imperative for health care providers to be well versed in the most effective ways to manage neuropsychiatric symptoms, such as aggression. Aggression can be particularly hard to manage because it creates risk of harm for formal and informal caregivers, and options for medical intervention are complex and situation dependent. Although multiple guidelines for management of aggression in dementia are available in the literature, their scope is widespread and suggested treatments often vary, making decision making difficult to navigate for busy clinicians. Using a composite case as a model, the current article provides guidelines that take outpatient providers through the steps needed to provide effective treatment for aggression in individuals with dementia. Shifting the current focal point of health care for aggressive dementia patients toward a more person-centered approach will have a positive impact on patient care. [Journal of Gerontological Nursing, 43(2), 9-17.].

Influencing everyday activities in a nursing home setting: A call for ethical and responsive engagement

This study focuses on influence that older adults, living in nursing homes, have over everyday activities. Everyday activities are key to sustain a sense of stability, predictability, and enjoyment in the local world of people's everyday and therefore a critical dimension of the person-centeredness framework applied within gerontology. This narrative ethnographic study aimed to shed light on how influence can be situated contextually, and how it can emerge through activities as well as how it is negotiated in everyday by frail older adults living in a nursing home. Residents, staff members, and significant others from one nursing home in an urban area of Sweden participated in this study. Data were gathered through fieldwork, including participant observation and formal and informal conversations during a period of 6 months. Data were analyzed through a narrative interpretative approach. The findings are presented in narrative form as exemplars. The exemplars-Craquelures as justification, Seeking a place for other life worlds and An almost perfect trip-reveal a gap between the client-centeredness framework and lived experiences regarding older adults' influence in everyday activities. The role of everyday activities in the context of frailty is discussed in terms of ethical and responsive engagement, and implications for health-care practices are considered.

The home as ethos of caring: A concept determination

BACKGROUND:

Within nursing, the concepts of home and homelike have been used indiscriminately to describe characteristics of healthcare settings that resemble a home more than an institution.

OBJECTIVES:

The aim of this study was to investigate the concept of home ( hem in Swedish). The main questions were as follows: What does the concept of home entail etymologically and semantically? Of what significance is the meaning of the concept to caring science and nursing?

DESIGN AND METHODS:

This study had a qualitative design with a hermeneutical approach guided by Gadamer. Eriksson's model of concept determination was partly used to determine the etymology and semantics, the essence and epistemic category of the concept of home. In this study, etymological dictionaries and 17 Swedish language dictionaries published between 1850 and 2001 were investigated.

ETHICAL CONSIDERATION:

In all parts of this study, ethical guidelines have been followed concerning both gathering data from dictionaries and other sources and during the interpretation of these sources.

FINDINGS:

The home, framed as the ethos of caring, can be drawn as a three-dimensional picture where the three dimensions have a common core, enclosed and inviolable. Symbolically, the picture of home can be seen as the ethos of the human being's innermost room, the human being's manner of being and the tone expressed in the external or abstract room where the human being lives and interacts with others.

CONCLUSION:

Based on the findings in this study, we conclude that home as ethos is an inner ethical dimension within the human being. Human beings who are in contact with their ethos, the self, feel at home and dare to follow the voice of their heart. Nurses who experience at-homeness have an ability to invite the patient into a caring relationship. The home and the feeling of being at home have significant meaning in terms of human beings' health and well-being.

Agency and Communion in People with Alzheimer’s Disease, as Described by Themselves and their Spousal Carers

Agency (individuality) and communion (togetherness) are vital to a positive sense of self. People with Alzheimer’s disease are at risk of experiencing diminished agency and decreased communion. Their family members’, especially their partner’s, view on their agency and communion is also likely to influence their sense of agency, communion, and self. In the present study, individual interviews with 10 people with Alzheimer’s disease and their spousal carers were qualitatively analysed to describe how in each couple the two spouses viewed the agency and communion of the person with Alzheimer’s disease from an individual perspective. The findings show that the carers generally described the agency of the person with Alzheimer’s disease as slightly weaker compared with the persons with Alzheimer’s disease themselves. The carers also appeared to have poor knowledge of what supported and threatened the sense of communion of the person with Alzheimer’s disease.

Residents' engagement in everyday activities and its association with thriving in nursing homes

AIM

To describe the prevalence of everyday activity engagement for older people in nursing homes and the extent to which engagement in everyday activities is associated with thriving.

BACKGROUND

Research into residents' engagement in everyday activities in nursing homes has focused primarily on associations with quality of life and prevention and management of neuropsychiatric symptoms. However, the mere absence of symptoms does not necessarily guarantee experiences of well-being. The concept of thriving encapsulates and explores experiences of well-being in relation to the place where a person lives.

DESIGN

A cross-sectional survey.

METHOD

A national survey of 172 Swedish nursing homes (2013-2014). Resident (n = 4831) symptoms, activities and thriving were assessed by staff using a study survey based on established questionnaires. Descriptive statistics, simple and multiple linear regression, and linear stepwise multiple regression were performed.

RESULTS

The most commonly occurring everyday activities were receiving hugs and physical touch, talking to relatives/friends and receiving visitors, having conversation with staff not related to care and grooming. The least commonly occurring everyday activities were going to the cinema, participating in an educational program, visiting a restaurant and doing everyday chores. Positive associations were found between activity engagement and thriving, where engagement in an activity program, dressing nicely and spending time with someone the resident likes had the strongest positive association with resident thriving.

CONCLUSIONS

Engagement in everyday activities can support personhood and thriving and can be conceptualized and implemented as nursing interventions to enable residents to thrive in nursing homes.

Video-phone communication with cognitively impaired elderly patients

We investigated the potential role of remote interactions via video-phone in the care of the elderly. Family members and nursing staff were interviewed about their experiences of communicating with elderly people via video-phone. Seven family members and seven nursing staff participated in the studies. The interviews were analysed using qualitative content analysis. The results showed that it was possible for elderly people with cognitive impairment to engage in remote communication when certain conditions were met. There were also indications that the video-phone interaction sometimes increased the attention and focus of the elderly subjects.

Views on Dignity of Elderly Nursing Home Residents

Discussion about a dignified death has almost exclusively been applied to palliative care and people dying of cancer. As populations are getting older in the western world and living with chronic illnesses affecting their everyday lives, it is relevant to broaden the definition of palliative care to include other groups of people. The aim of the study was to explore the views on dignity at the end of life of 12 elderly people living in two nursing homes in Sweden. A hermeneutic approach was used to interpret the material, which was gathered during semi-structured interviews. A total of 39 interviews were transcribed. The analysis revealed three themes: (1) the unrecognizable body; (2) fragility and dependency; and (3) inner strength and a sense of coherence.

Ideals Regarding a Good Life for Nursing Home Residents with Dementia: views of professional caregivers

This study investigates what professional caregivers working in nursing homes consider to be a good life for residents suffering from dementia. Ten caregivers were interviewed; special attention was paid to the way in which they deal with conflicting values. Transcripts of the interviews were analysed qualitatively according to the method of grounded theory. The results were compared with those from a similar, earlier study on ideals found in mission statements of nursing homes. The concepts that were mentioned by most interviewed participants as important for a good life were ‘peace and quiet’, ‘going along with subjective experience’ and ‘no enforcement: the way the resident wants it’. A considerable overlap was found between the interviews and the mission statements; however, when compared with the mission statements, the interviews put less emphasis on individuality and on giving meaning, and more on offering residents pleasant activities. When faced with conflicting values, caregivers tend to make pragmatic and more or less intuitive decisions. Although this has its merits, it may be desirable to stimulate conscious reflection regarding conflict between different values.

The effect of environmental change on residents with dementia

This qualitative study aimed to identify and describe the relatives' and staff's perceptions of environmental change on residents with dementia. Data were collected from audio-taped relative and staff focus group interviews at an aged care facility in Western Sydney. The transcribed data from the focus groups were thematically analysed and categorized. Three major categories emerged from the analysed data: the special care unit as a family home, therapeutic environment and work environment. Relatives and staff identified that the overall design of the unit impacted on the residents' functioning and quality of life, sense of freedom, level of agitation, sleeping patterns and weight. Relatives reported that the environment was conducive to visiting and to children, and staff reported that the working environment was improved because of its layout and equipment. This study has shown that special care units can make a difference to the quality of life of residents and improve conditions for relatives and staff.

Design Recommendations for Recreational Systems Involving Older Adults Living With Dementia

As the population ages, an increasing number of people will be diagnosed with dementia. Studies have found that insufficient activities are offered in memory care units to people with dementia, even though people benefit tremendously from participating in recreational activities. Information and communication technologies (ICT) can potentially facilitate activities in this setting, yet there is little guidance for designers to develop systems that can support people with dementia in engaging in recreational activities. To fill this gap, recommendations were generated through fieldwork and refined in two rounds of expert feedback. Areas covered include hardware, content, applications, and navigation. Systems should be usable by people with dementia, in addition to staff, to counter disempowerment by not enabling people to use their full abilities. In addition, a diversity of materials is needed to appeal to individuals with dementia who have widely varying backgrounds, abilities, interests, and preferences.

Ethical dilemmas concerning autonomy when persons with dementia wish to live at home: a qualitative, hermeneutic study

BACKGROUND

Caring for people with dementia living in their own homes is a challenging care issue that raises ethical dilemmas of how to balance autonomy with their safety and well-being. The theoretical framework for this study consisted of the concepts of autonomy, beneficence, non-maleficence, paternalism and from the ethics of care. The aim of this study was to explore ethical dilemmas concerning autonomy that were identified when persons with dementia wished to live at home.

METHODS

This Norwegian study had a qualitative, hermeneutic design and was based on nine cases. Each case consisted of of a triad: the person with dementia, the family carer and the professional caregiver. Inclusion criteria for the persons with dementia were: (1) 67 years or older (2) diagnosed with dementia (3) Clinical Dementia Rating score 2 i.e. dementia of moderate degree (4) able to communicate verbally and (5) expressed a wish to live at home. The family carers and professional caregivers registered in the patients' records were included in the study. An interview guide was used in interviews with family carers and professional caregivers. Field notes were written after participant observation of interactions between persons with dementia and professional caregivers during morning care or activities at a day care centre. By means of deductive analysis, autonomy-related ethical dilemmas were identified. The final interpretation was based on perspectives from the theoretical framework.

RESULTS

The analysis revealed three main ethical dilemmas: When the autonomy of the person with dementia conflicted with (1) the family carer's and professional caregiver's need to prevent harm (non-maleficence) (2) the beneficence of family carers and professional caregivers (3) the autonomy of the family carer.

CONCLUSIONS

In order to remain living in their own homes, people with dementia accepted their dependence on others in order to uphold their actual autonomy and live in accordance with their identified values. Paternalism could be justified in light of beneficence and non-maleficence and within an ethics of care.

Understanding the role of an educational model in developing knowledge of caring for older persons with dementia

BACKGROUND

Statistics show that the number of older people in need of care is increasing worldwide, especially those with dementia. This implies demands on knowledge and competence among health care staff to care for them. In Sweden, Silviahemmet offers dementia care units the opportunity to become certified according to a special certification educational model. Silviahemmet provides educational programs for staff in dementia care and day care for person with dementia. All staff undergoes a systematic training course in dementia care. The aim of the study was to gain an understanding of how an educational model developed the perceived knowledge of staff caring for older persons with dementia in a nursing home.

METHOD

A phenomenographical approach was used and qualitative interviews were carried out with 13 staff members in a nursing home.

FINDINGS

The main results show that staff perceives the importance of knowledge, working together and creating a sense of fellowship. The care of persons with dementia requires a special approach and adherence. Participating in the educational program made the staff realize and acknowledge their tacit knowledge and the importance of reflection-in-action together in the team.

CONCLUSION

The results indicate the need for a common theoretical knowledge base and value system to achieve coherence in daily work.

Moments of homecoming among people with advanced dementia disease in a residential care facility

This study concerns moments of homecoming among people with advanced dementia disease living in a residential care facility. Our main finding from participant observations with nine residents was that the residents showed moments of homecoming, i.e. they alternated between verbal and/or nonverbal expressions of feeling at home and of not feeling at home. If care providers understand that they can help people with advanced dementia disease experience moments of homecoming, they can focus on aspects of care that can promote these experiences.

Clear conscience grounded in relations: Expressions of Persian-speaking nurses in Sweden

Background:

Conscience is an important concept in ethics, having various meanings in different cultures. Because a growing number of healthcare professionals are of immigrant background, particularly within the care of older people, demanding multiple ethical positions, it is important to explore the meaning of conscience among care providers within different cultural contexts.

Research objective:

The study aimed to illuminate the meaning of conscience by enrolled nurses with an Iranian background working in residential care for Persian-speaking people with dementia.

Research design:

A phenomenological hermeneutical method guided the study.

Participants and research context:

A total of 10 enrolled nurses with Iranian background, aged 33–46 years, participated in the study. All worked full time in residential care settings for Persian-speaking people with dementia in a large city, in Sweden.

Ethical considerations:

The study was approved by the Regional Ethical Review Board for ethical vetting of research involving humans. Participants were given verbal and written study information and assured that their participation was voluntary and confidential.

Findings:

Three themes were constructed including perception of conscience, clear conscience grounded in relations and striving to keep a clear conscience. The conscience was perceived as an inner guide grounded in feelings, which is dynamic and subject to changes throughout life. Having a clear conscience meant being able to form a bond with others, to respect them and to get their confirmation that one does well. To have a clear conscience demanded listening to the voice of the conscience. The enrolled nurses strived to keep their conscience clear by being generous in helping others, accomplishing daily tasks well and behaving nicely in the hope of being treated the same way one day.

Conclusion:

Cultural frameworks and the context of practice needed to be considered in interpreting the meaning of conscience and clear conscience.

Continuity and Change in Life Engagement Among People With Dementia

The purpose of this study was to explore the change and continuity in the engagement in life of people with advanced dementia. The idea of meaningful activities is commonly used in nursing research, but few studies have been performed on what makes activities meaningful. This study aims to shed light on the meaning of activities in a life course context, changes in activity patterns due to dementia disease, and the significance of narratives told by close relatives. The 11 stories of activities were analyzed using thematic narrative analysis with Leontyev's activity theory as a theoretical framework. The findings revealed several types of changes: slow and abrupt changes in everyday and physical activities, changes in the person's level of awareness, and changes in habits in new care settings and environments. The meaningfulness of activities was connected to a person's background, his/her motives, lifestyle and identity, and the contextuality of activities. Through the narratives, nursing care personnel could acquire a nuanced picture of the person and his/her engagement in life. These narratives are vital to helping people who have dementia to keep up with meaningful activities and enhance their quality of life, especially when the person has deficiencies in communication.

Relatives’ participation in everyday care in special care units for persons with dementia

Background:

Research concerning relatives’ participation in the everyday care related to persons living in special care units for persons with dementia is limited.

Research questions:

To examine relatives’ participation in their near one’s everyday care, the level of burden experienced and important factors for participation, in this special context.

Design:

The study had a cross-sectional design, and data collection was carried out by means of a study-specific questionnaire.

Participants and context:

A total of 233 relatives from 23 different special care units participated.

Ethical consideration:

The study was approved by the Norwegian Social Science Data Services.

Results:

A great majority of relatives reported that they visited weekly and were the resident’s spokesperson, but seldom really participated in decisions concerning their everyday care. Participation was seldom reported as a burden.

Discussion:

This study indicated that relatives were able to make a difference to their near one’s everyday life and ensure quality of care based on their biographical expertise, intimate knowledge about and emotional bond with the resident. Since knowing the resident is a prerequisite for providing individualised care that is in line with the resident’s preferences, information concerning these issues is of utmost importance.

Conclusion:

This study prompts reflection about what it is to be a spokesperson and whether everyday care is neglected in this role. Even though relatives were satisfied with the care provided, half of them perceived their participation as crucial for the resident’s well-being. This indicated that relatives were able to offer important extras due to their biographical expertise, intimate knowledge about and emotional bond with the resident. Good routines securing that written information about the residents’ life history and preferences is available and used should be implemented in practice.

Expressed Sense of Self by People With Alzheimer’s Disease in a Support Group Interpreted in Terms of Agency and Communion

The self is constructed in cooperation with other people and social context influences how people perceive and express it. People with Alzheimer’s disease (AD) often receive insufficient support in constructing their preferred selves, but little is known about how they express themselves together with other people with AD. In accordance with Harré’s social constructionist theory of self, this study aimed to describe how five people with mild and moderate AD express their Self 2 (i.e., their personal attributes and life histories) in a support group with a facilitator experienced in communicating with people with AD. The participants’ expressions of their Self 2 were analyzed with qualitative abductive content analysis and interpreted in terms of agency and communion and a lack of agency and communion. The findings highlight the importance of supporting a sense of agency and communion when assisting people with AD in constructing their self.

NFC based provisioning of instructional videos to assist with instrumental activities of daily living

Existing assistive living and prompting based solutions have adopted a relatively complex approach to supporting individuals. These solutions have involved sensor based monitoring, activity recognition and assistance provisioning. Traditionally they have suffered from a number of issues rooted in scalability and performance levels associated with the activity recognition process. This paper introduces a simplistic approach to assistive living within a user's residence through the use of NFC tags and smart devices. The core concept of this approach is presented and is subsequently placed within the context of related work. A description of the architecture is provided and results following technical evaluation of the first system prototype are discussed.

Needs of people with dementia in long-term care: a systematic review

With the aging of the population and the projected increase of dementia in the coming years, it is crucial that we understand the needs of people with dementia (PWD) in order to provide appropriate care. The aim of this study is to determine, using the best evidence possible, the care needs of PWD living in long-term care (LTC). A total of 68 studies, published between January 2000 and September 2010, were identified from six databases. From the selected studies, 19 needs of PWD were identified. The existing evidence suggests that psychosocial needs such as the need to engage in daily individualized activities and care must not be ignored in LTC. This review aims to provide a clearer picture of the needs of this growing patient population.

Maximizing a nurturing care style for persons with dementia: a person-centered analysis

BACKGROUND

Our aim was to structure the configuration of family caregivers' management strategies for the person with dementia (PWD) and to examine factors differentiating caregiving styles.

METHODS

Using a latent class analysis on the data (N = 338) collected from an ambulatory dementia clinic of a tertiary hospital and the local Alzheimer association, we classified overall patterns of caregivers' dementia management strategies into three domains: criticism, encouragement, and active management. As determinants related to caregiving style, caregiver sociodemographics, caregiving experience, and health outcomes were tested while controlling for the PWD's characteristics.

RESULTS

A hierarchical structure of dementia caregiving style was classified into three groups: passive class (33.24%), authoritarian class (29.12%), and nurturing class (37.65%). Caregiver's marital status, employment, reaction to PWD's memory and behavior problems, sense of competence, and perceived gains from caregiving were significantly associated with the caregiving styles derived. In particular, the authoritarian class perceived higher burden whereas the nurturing class was associated with greater gains.

CONCLUSION

A better understanding of caregiver coping and caregiving style is critical to improving care for the PWD. Information on predictive factors related to more constructive coping strategies can be beneficial to design interventions for caregivers. Understanding caregiving styles may thus provide meaningful evidence for more efficient allocation of supportive resources to caregivers caring for the PWD.

The responses of healthcare professionals to the admission of people with cognitive impairment to acute hospital settings: an observational and interview study

AIMS AND OBJECTIVES

To explore the responses of healthcare professionals to the admission of people with cognitive impairment to the acute hospital setting.

BACKGROUND

While improving care for people with dementia has been identified as a national priority, providing appropriate care in acute hospitals for people with comorbid cognitive impairment presents challenges to healthcare professionals.

DESIGN

Based on the principles of ethnography, this was a qualitative interview and nonparticipation observational study.

METHODS

Seventy-two hours of nonparticipant observations of care together with semi-structured interviews with family carers of 34 older people who had been admitted to a UK general hospital and had a cognitive impairment. Interviews and observations were conducted in 2009 and 2010. Analysis was undertaken using Strauss and Corbin's framework.

RESULTS

The results identified a core problem, 'disruption', and a core process, 'gaining or giving a sense of control to cope with disruption'. Healthcare professionals respond to the disruption in three ways: by acting to preserve the personhood of the individual; by seeking to protect themselves from the stresses associated with caring for the person with cognitive impairment; and by suspending the personhood of the individual.

CONCLUSION

Where healthcare professionals acted to suspend the personhood of the patient, they appeared to be demonstrating signs of 'burnout'.

RELEVANCE TO CLINICAL PRACTICE

There is a need both to challenge poor practice and for positive development work with healthcare professionals who work in acute hospitals with people with dementia and cognitive impairment so that they are equipped with the skills, emotional resilience and organisational support to be effective in meeting the needs of people with dementia and cognitive impairment.

Dignity-preserving dementia care

Research indicates the essentiality of dignity as a vital component for quality of life, reconfirming the emphasis on dignity preservation in the international code of nursing ethics. Applying Noblit and Hare’s meta-ethnography, the aim of the study was to develop a theory model by synthesizing 10 qualitative articles from various cultural contexts, exploring nurse and allied healthcare professional perception/practice concerning dignity-preserving dementia care. “Advocating the person’s autonomy and integrity,” which involves “having compassion for the person,” “confirming the person’s worthiness and sense of self,” and “creating a humane and purposeful environment,” was identified as a primary foundation for dignity-preserving dementia care. “Balancing individual choices among persons no longer able to make sound decisions, against the duty of making choices on behalf of the person,” which involves “persuasion” and/or “mild restraint,” was considered a crucial aspect in certain situations. “Sheltering human worth—remembering those who forget” was identified as a comprehensive motive and core value within dignity-preserving dementia care.

Nursing Staff’s Understanding Expressions of People With Advanced Dementia Disease

People with advanced dementia disease (ADD) are known to have communication difficulties and thus it presents a challenge in understanding the expressions of these people. Because successful communication presupposes cooperation at least between 2 individuals, both individual’s actions must be acknowledged. The aim of this study is to describe nursing staff’s ways of understanding the expressions of people with ADD when communicating with them. Interviews from 8 nursing staff were analyzed using qualitative content analysis. Two themes were constructed: “Being in communication” and “Doing communication.” Being in communication means that nursing staff perceive people with ADD as being capable of communication. Doing communication means that nursing staff attempt different individualized strategies to understand what people with ADD communicate. Good care of people with ADD presupposes nursing staff that are willing and able to relate to other people and to maintain good care for people with ADD continuous education and supervision are needed.

Creating relationships with persons with moderate to severe dementia

The study describes how relationships are created with persons with moderate to severe dementia. The material comprises 24 video sequences of Relational Time (RT) sessions, 24 interviews with persons with dementia and eight interviews with professional caregivers. The study method was Constructivist Grounded Theory. The categories of 'Assigning time', 'Establishing security and trust' and 'Communicating equality' were strategies for arriving at the core category, 'Opening up', which was the process that led to creating relationships. Both parties had to contribute to create a relationship; the professional caregiver controlled the process, but the person with dementia permitted the caregiver's overtures and opened up, thus making the relationship possible. Interpersonal relationships are significant to enhancing the well-being of persons with dementia. Small measures like RT that do not require major resources can open paths to creating relationships.

Psychometric properties of the Norwegian Person-centred Climate Questionnaire from a nursing home context

BACKGROUND

The physical and psychosocial environments in nursing homes influence the residents' everyday life as well as their well-being and thriving. The staff's perceptions of and relationships with the residents are crucially important to quality care. Quality care is described often as person-centred. Few measurement tools exist that focus on person-centred care in nursing homes.

OBJECTIVE

The aim of this study was to evaluate the psychometric properties of the Norwegian version of the Person-centred Climate Questionnaire-Staff version (PCQ-S).

DESIGN

This study had a cross-sectional survey design.

PARTICIPANTS AND SETTINGS

Two hundred and nine healthcare and support staff in five nursing homes in the eastern part of Norway.

METHODS

The Swedish PCQ-S was translated into Norwegian with forward and backward translation. The relevance of the items included in the questionnaire was assessed by an expert panel of 10 nursing home care staff, because the questionnaire has not been used in this context previously. A psychometric evaluation using statistical estimates of validity and reliability was performed. The discriminatory capacity of the questionnaire was also tested.

RESULTS

The content validity index was satisfactory (0.78). The PCQ-S showed high internal consistency reliability in that Cronbach's α was satisfactory for the total scale (0.92) and the three subscales (0.81, 0.89 and 0.87). The test-retest reliability was also satisfactory as evident from a Spearman's correlation coefficient of 0.76 (p < 0.01) between the total PCQ scores at test and retest. The Norwegian version retained the original factor structure of the Swedish version.

CONCLUSION

As the psychometric evaluation showed satisfactory validity and reliability scores, this study supports the Norwegian version of the PCQ-S when applied to a sample of nursing home staff.

Good care in group home living for people with dementia. Experiences of residents, family and nursing staff

AIMS AND OBJECTIVES

To investigate experiences of residents, their family caregivers and nursing staff in group living homes for older people with dementia and their perception of the care process.

BACKGROUND

Traditional nursing homes for people with dementia have several shortcomings related to depersonalisation, passivity, loss of skills and use of physical restraints. Group living homes are seen as an alternative to regular nursing homes, but experiences with this new care setting have rarely been investigated.

DESIGN

The study followed a naturalistic design. Qualitative data were collected over a period of 6 months in two group living homes located in the southern part of the Netherlands.

METHODS

Systematic participatory observations were carried out during daily life, care and activities in both homes. In addition, semi-structured interviews were held with residents, their family and nursing staff. These data were inductively analysed and related to Tronto's care ethical framework.

RESULTS

According to all parties, group living homes create structural opportunities for individualised care and attention to the residents' personal needs. The increased attentiveness and responsiveness for residents' well-being was seen as a sign of good care and fits with the phases of caring about and receiving care of Tronto's care ethical model. However, tensions occurred relating to the phases of taking responsibility and carrying out care. Not all residents and family members want or are able to take responsibility and perform self-care.

CONCLUSIONS

Group living homes create conditions for good care and stimulate attentiveness and responsiveness. Tensions in these homes may relate to the new division of responsibilities and tasks.

RELEVANCE TO CLINICAL PRACTICE

  Values of attention to needs and responsiveness are of high importance for nursing staff to provide good care for people with dementia in a nursing home setting.

Lost in the present but confident of the past: experiences of being in a psycho-geriatric unit as narrated by persons with dementia

AIM

To illuminate meanings of being in a psycho-geriatric unit. Background. There are known risks associated with moving persons with dementia from home to an institution, but little is known about how they experience being in psycho-geriatric units.

METHOD

Using open-ended research interviews, six persons with mild to severe dementia were asked to narrate about their experiences in the hospital. The interviews were interpreted using a phenomenological hermeneutical method of analysis.

RESULTS

The comprehensive understanding of being in a psycho-geriatric unit points towards an understanding of being lost in the present but confident of the past. The analysis showed that the participants appeared lost as they could not narrate where they were and why, but that they became confident when narrating about their previous life. The analysis also showed that being in the hospital meant sharing living space with strangers, invasions of private space and establishing new acquaintances. Being in the unit could also mean boredom and devaluation for participants. The interviews were interpreted in the light of narrative theory of identity: persons with dementia narrating about previous life experiences as to make claims of how to be interpreted by others; as persons instead of merely as 'demented' patients.

CONCLUSIONS

Experiences of care narrated by persons with dementia present meaningful and useful information that can provide feedback to inform care practice.

RELEVANCE TO CLINICAL PRACTICE

Experiences of care from persons with dementia provide meaningful information about care and the doing and being of staff. Creating time for conversations with these persons may facilitate well-being.