Healthcare professionals' perceptions of P.I.E.C.E.S. education in supporting care delivery for older adults with responsive behaviours of dementia in acute care

Barriers and facilitators to care for agitation and/or aggression among persons living with dementia in long-term care

BACKGROUND

Agitation and/or aggression affect up to 60% of persons living with dementia in long-term care (LTC). It can be treated via non-pharmacological and pharmacological interventions, but the former are underused in clinical practice. In the literature, there is currently a lack of understanding of the challenges to caring for agitation and/or aggression among persons living with dementia in LTC. This study assesses what barriers and facilitators across the spectrum of care exist for agitation and/or aggression among people with dementia in LTC across stakeholder groups.

METHODS

This was a qualitative study that used semi-structured interviews among persons involved in the care and/or planning of care for people with dementia in LTC. Participants were recruited via purposive and snowball sampling, with the assistance of four owner-operator models. Interviews were guided by the Theoretical Domains Framework and transcribed and analyzed using Framework Analysis.

RESULTS

Eighteen interviews were conducted across 5 stakeholder groups. Key identified barriers were a lack of agitation and/or aggression diagnostic measures, limited training for managing agitation and/or aggression in LTC, an overuse of physical and chemical restraints, and an underuse of non-pharmacological interventions. Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions.

CONCLUSIONS

This study advances care for persons living with dementia in LTC by drawing attention to unique and systemic barriers present across local and national Canadian LTC facilities. Findings will support future implementation research endeavours to eliminate these identified barriers across the spectrum of care, thus improving care outcomes among people with dementia in LTC.

Supporting person-centred dementia care following the COVID-19 pandemic

In recent years, nurses have experienced increased workplace pressures in part due to the coronavirus disease 2019 (COVID-19) pandemic, which exacerbated challenges in the delivery of person-centred dementia care. This article examines how people with dementia were affected by the COVID-19 pandemic, as well as exploring the ongoing effects on nurses and the care they provide for people with dementia. The author discusses the importance of dementia awareness and education for nurses that supports them to promote the needs of people with the condition. The article also outlines how nurse leaders can promote person-centred care for people with dementia through reflection and clinical supervision.

Nurse-Led Virtual Delivery of PIECES in Canadian Long-Term Care Homes to Support the Care of Older Adults Experiencing Responsive Behaviors During COVID-19: Qualitative Descriptive Study

BACKGROUND

Worldwide, the COVID-19 pandemic has resulted in profound loss of life among older adults living in long-term care (LTC) homes. As a pandemic response, LTC homes enforced infection control processes, including isolating older adults in their rooms, canceling therapeutic programs, and restricting family member visits. Social isolation negatively impacts older adults in LTC, which may result in increased rates of anxiety, depression, physical and cognitive decline, disorientation, fear, apathy, and premature death. Isolation of older adults can also cause an increase in responsive behaviors (eg, yelling, hitting, calling out) to express frustration, fear, restricted movement, and boredom. To respond to the challenges in LTC and support frontline staff, older adults, and family members, a novel registered practical nurse (RPN)-led delivery of the PIECES approach for addressing responsive behaviors among older adults with dementia using virtual training/mentoring was implemented in Canadian LTC homes. PIECES employs a person- and family/care partner-centered collaborative team-based approach to provide education and capacity-building for nurses; engages families as active participants in care; and embeds evidence-informed practices to provide person- and family-centered care to older adults with complex needs, including dementia.

OBJECTIVE

The aim of this study was to describe the experiences of LTC staff, family/care partners, and older adult research partners with implementation of a novel RPN-led virtual adaptation of the PIECES care-planning approach for responsive behaviors in two Canadian LTC homes during the COVID-19 pandemic.

METHODS

Using a qualitative descriptive design, two focus groups were held with three to four staff members (eg, RPNs, managers) per LTC home in Ontario. A third focus group was held with three PIECES mentors. Individual semistructured interviews were conducted with RPN champions, family/care partners, and older adult research partners. Research team meeting notes provided an additional source of data. Content analysis was performed.

RESULTS

A total of 22 participants took part in a focus group (n=11) or an in-depth individual interview (n=11). Participant experiences suggest that implementation of RPN-led virtual PIECES fostered individualized care, included family as partners in care, increased interdisciplinary collaboration, and improved staff practices. However, virtual PIECES, as delivered, lacked opportunities for family member feedback on older adult outcomes. Implementation facilitators included the provision of mentorship and leadership at all levels of implementation and suitable technological infrastructure. Barriers were related to availability and use of virtual communication technology (family members) and older adults became upset due to lack of comprehension during virtual care conferences.

CONCLUSIONS

These findings offer promising support to adopting virtual PIECES, a team approach to gather valuable family input and engagement to address residents' unmet needs and responsive behaviors in LTC. Future research should investigate a hybridized communication format to foster sustainable person- and family-centered care-planning practices to include active collaboration of families in individualized care plans.

A Novel Instrument for Caregivers in Managing Neuropsychiatric Symptoms of Dementia: Baycrest Quick-Response Caregiver ToolTM

Background

Family caregivers can experience significant stress related to behaviour changes in persons with dementia (PWD). Approaches to support caregivers with stress management when responding to changes in behaviours are needed. The Baycrest Quick-Response Caregiver Tool^TM (BQRCT) was developed to provide caregivers with an online tool that can be used in real time to recognize and manage their emotions when managing neuropsychiatric symptoms of dementia.

Methods

A mixed-methods approach was used to evaluate the feasibility of this new tool. Family caregivers of persons with dementia received education about managing neuropsychiatric symptoms of dementia through the online tool. Caregiver demographic information and feedback about the tool was obtained through telephone and online surveys. Health-care providers accessed the tool and also provided feedback.

Results

The 21 caregivers who completed the study found the tool helpful and reported high feasibility that included being able to access, complete, and implement the strategies presented in the tool. The 18 health-care providers found the tool useful and most would recommend it to peers and clients. Participants also provided specific suggestions for improvement, such as including more examples of complex behaviours.

Conclusions

This tool adds to and complements existing strategies for managing neuropsychiatric symptoms of dementia. Its accessibility through the online platform is especially useful for caregivers who are unable to seek help in person, and for health-care providers and caregivers seeking additional resources.

Italian Dementia-Friendly Hospital Trial (IDENTITÀ): efficacy of a dementia care intervention for hospital staff

This study investigated the short-term impact and the retention of a dementia care intervention for healthcare staff working in an Italian acute hospital setting. Additionally, we identified the predictors of improvement across the intervention. Sixty-two healthcare staff from an Italian public hospital participated in a dementia care intervention consisting of 5 modules delivered in a 5-hour training program focusing on dementia management, knowledge, and care. A pre-test/post-test and six-months follow-up design was used to evaluate participants' changes in knowledge, attitudes, and confidence in dementia. The intervention significantly improved healthcare staff's dementia knowledge and confidence immediately after the end of the intervention. No significant changes were observed from post-test to follow-up, indicating retention of these outcomes over six months. Regarding attitude to dementia, we found an immediate improvement only in the Recognition of Personhood scale. Looking at the predictors of improvement, healthcare staff with lower levels of knowledge, attitudes, and confidence in dementia at pre-test were those who improved more following the intervention. These findings provide further evidence that dementia care interventions are suitable initiatives to promote knowledge and skills required to manage the needs of people with dementia in an acute hospital setting.

Dementia-related continuing education for rural interprofessional primary health care in Saskatchewan, Canada: perceptions and needs of webinar participants

Dementia-related continuing education opportunities are important for rural primary health care (PHC) professionals given scarce specialized resources. This report explores the initial perceptions and continuing education needs of rural interprofessional memory clinic team members and other PHC professionals related to a short series of dementia-related education webinars. Three webinars on separate topics were delivered over an 8-month period in 2020 in Saskatchewan, Canada. The research design involved analysis of webinar comments and post-webinar survey data. Sixty-eight individuals participated in at least one webinar, and 46 surveys were completed. Rural memory clinic team members accounted for a minority of webinar participants and a majority of survey respondents. Initial perceptions were positive, with webinar topics and interactivity identified as the most effective aspects. Continuing education needs were mainly aligned with professional roles; however, some overlap of interests occurred. Future webinars will further explore learning needs within an interprofessional environment.

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

OBJECTIVE

This review will focus on the effectiveness of, and experience with, nursing interventions to improve the care of people with dementia in hospital.

INTRODUCTION

Acute care for people with dementia has been identified as an area for improvement. Admission to hospital can be upsetting and difficult for people with dementia and can be associated with negative outcomes. Nurses play a significant role in shaping the experience of hospitalization and are the focus of many related interventions.

INCLUSION CRITERIA

This mixed methods review will examine literature on improving acute care for people with dementia. The quantitative component will consider studies that evaluate nursing interventions to improve care of people with dementia, comparing the intervention with usual care, other therapies, or no comparator. Outcomes will include behavioral, health, and health system indicators. The qualitative component will consider studies that explore the experience of nursing interventions from the perspective of people with dementia, their family- or friend-caregivers, and nurses.

METHODS

This review will be conducted in accordance with JBI methodology for mixed methods systematic reviews. Twelve databases and gray literature sources will be searched for published and unpublished studies. Titles, abstracts, and full-text selections will be screened by two or more independent reviewers and assessed for methodological validity using the standard JBI critical assessment tools. This review will follow a convergent segregated approach to data synthesis and integration.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021230951.

The Rationale and Design of Behavioral Interventions for Management of Agitation in Dementia in a Multi-Site Clinical Trial

BACKGROUND

Agitation and aggression are common in patients with Alzheimer's disease and related dementias and pose a significant burden on patients, caregivers, and the healthcare systems. Guidelines recommend personalized behavioral interventions as the first-line treatment; however, these interventions are often underutilized. The Standardizing Care for Neuropsychiatric Symptoms and Quality of Life in Dementia (StaN) study (ClinicalTrials.gov Identifier # NCT0367220) is a multisite randomized controlled trial comparing an Integrated Care Pathway, that includes a sequential pharmacological algorithm and structured behavioral interventions, with treatment-as-usual to treat agitation in dementia in long-term care and inpatient settings.

OBJECTIVE

To describe the rationale and design of structured behavioral interventions in the StaN study.

METHODS

Structured behavioral interventions are designed and implemented based on the following considerations: 1) personalization, 2) evidence base, 3) dose and duration, 4) measurement-based care, and 5) environmental factors and feasibility.

RESULTS

The process to design behavioral interventions for each individual starts with a comprehensive assessment, followed by personalized, evidence-based interventions delivered in a standardized manner with ongoing monitoring of global clinical status. Measurement-based care is used to tailor the interventions and to integrate them with pharmacotherapy.

CONCLUSION

Individualized behavioral interventions in patients with dementia may be challenging to design and implement. Here we describe a process to design and implement individualized and structured behavioral interventions in the context of a multisite trial in long-term care and inpatient settings. This process can inform the design of behavioral interventions in future trials and in clinical settings for the treatment of agitation in dementia.

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

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

Behaviour assessment tools in long-term care homes in Canada: a survey

OBJECTIVE

Many people living in long-term care homes (LTCH) experience changes in behaviour termed the behavioural and psychological symptoms of dementia (BPSD). The valid and reliable assessment of BPSD is essential to guide treatment and monitor the effect of interventions. The aim of this study was to identify behavioural assessment tools implemented in LTCH and factors that impact on their use in clinical care.

METHODS

We completed an online mixed-design survey of 300 randomly selected Canadian LTCH between September and November 2018. Respondents were asked to report tools used, reasons for use, methods of administration, training/supports available, confidence in use and challenges faced. Survey results were summarized descriptively and the correlation between implementation supports and confidence examined. Free-text responses were analysed qualitatively.

RESULTS

Of 300 LTCH invited to participate, 103 completed the survey. Homes reported using a mean 2.2 ± 1.1 (range 0-7) different tools. The two most commonly used tools were the Dementia Observation System (DOS) and Cohen-Mansfield Agitation Inventory (CMAI). Overall confidence in most aspects of tool use was reported to be high, with workload identified as the greatest challenge. Training and supports correlated with confidence in tool use. Qualitative findings indicate tools provide valuable data to understand behaviours, facilitate team communication, target interventions and track outcomes.

CONCLUSIONS

Behavioural assessment tools, in particular a direct observation tool, are widely used in clinical care in Canadian LTCH. Education, enhanced resources, leadership support and applications of technology represent opportunities to improve their use.

Facilitating Staff Adoption of New Policies and Procedures in Aged Care Through Training for Readiness for Change

This study examined whether training staff in preparation for organizational changes, such as the implementation of new practices, can increase levels of change readiness in residential aged care. Four aspects of organizational readiness were compared across time and between training and control conditions. Participants (n = 129) were employed in eight residential aged care facilities in Australia. Survey data were collected at four time-points: preintervention and three postintervention time-points. The two conditions (training and control) differed significantly from one another on the subscales of appropriateness, personal valence, and efficacy postintervention but not at preintervention. The finding of support diminishing at 6 month and 12 months following the intervention for the training group was unexpected. The findings suggest that within aged care facilities, training in change processes may enhance an organization's readiness for change, and booster training may be needed to help to sustain all aspects of change readiness over time.

Is feyerabendian philosophy relevant for scientific knowledge development in nursing?

To revitalize nursing science, there is a need for a new approach to guide nurse scientists in addressing complex problems in health care. By applying theoretical concepts from a revolutionary philosopher of science, Paul K. Feyerabend, new nursing knowledge can be produced using creativity and pluralistic approaches. Feyerabend proposed that methods within and outside of science can produce knowledge. Despite the recognition of Feyerabendian philosophy within science, there is currently a lack of literature regarding the relevance of Feyerabendian philosophy for nursing science. We aim to (a) describe and critique Feyerabendian concepts, (b) discuss the potential application of Feyerabendian philosophy for knowledge production within gerontological nursing and (c) describe theoretical possibilities for nurse scientists in using Feyerabendian philosophy to guide nursing knowledge development. We begin by introducing Feyerabend's life and his inspirations for his theoretical concepts, epistemological anarchism, theoretical pluralism and humanitarianism, and conclude by offering suggestions of how to apply Feyerabendian philosophy in nursing research.

Nurses' Experiences in Caring for Older Adults With Responsive Behaviors of Dementia in Acute Care

Introduction: Approximately 56,000 individuals with dementia were admitted to Canadian hospitals in 2016, and 75% of them experience responsive behaviors. Responsive behaviors are words or actions used to express one's needs (e.g., wandering, yelling, hitting, and restlessness). Health-care professionals perceive these behaviors to be a challenging aspect in providing care for persons with dementia.

Aims: This study explores the perceptions of nurses about (a) caring for older adults with dementia experiencing responsive behaviors in acute medical settings and (b) recommendations to improve dementia care.

Methods: Thorne's interpretive description approach was used. In-person, semistructured interviews were conducted with 10 nurses and 5 allied health professionals from acute medical settings in an urban hospital in Ontario. Interviews were conducted with allied health professionals to understand their perspectives regarding care delivery for persons with responsive behaviors of dementia. Data were analyzed using Braun and Clarke's experiential thematic analysis.

Findings: Themes related to caring for individuals with responsive behaviors included (a) delivering care is a complex experience, (b) using pharmacological strategies and low investment nonpharmacological strategies to support older adults with responsive behaviors, (c) acute medical settings conflicted with principles of dementia care due to a focus on acute care priorities and limited time, and (d) strong interprofessional collaboration and good continuity of care were facilitators for care.

Conclusions: Findings provide guidance for improved support for nurses who provide care for individuals experiencing responsive behaviors in acute medical settings such as increasing staffing and providing educational reinforcements (e.g., annual review of dementia care education and in-services).