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Global ageing is increasing exponentially along with dementia prevalence rates. The demographic trends show that dementia along with other comorbidities has a serious effect on prolonged hospitalisation than people without dementia, with a huge impact on health services and the national economy .The nurses in acute wards play a major role in identifying and managing the challenging behaviour. The interventions seems to be inconsistent due to the busy context of the acute wards and lack of guidance on care of dementia patients with challenging behaviour, which again has a detrimental effect on dementia patients. Upon reviewing the literature, a gap is identified about experiences of nurses caring for dementia patients with challenging behaviour . Hence the writer plans to explore the experiences of nurses in dementia with challenging behaviours using a Husserlian phenomenological approach with the hope that it can contribute to the nursing practices.
Dementia is a progressive degenerative disease of the brain, and the fourth leading cause of death for the age group of 65 and above (O’Callaghan 2008, cited by Jean and Murphy, 2011). Currently there are about 41,470 people with dementia live in Ireland as per EuroCoDe age/gender specific dementia prevalence rates (2006 census of population). Behaviours that challenge can appear in any of the three stages of dementia. Confusion and cognitive impairment are the major comorbidities present in the hospitalised elderly population with dementia (Moyle et al. 2008).
Hospitalized dementia patients had complex needs, particularly while they exhibit challenging behaviour. Caring for the elderly people with dementia makes matchless challenges to healthcare staff, particularly to care for their personal needs as well as to manage their disruptive behaviour (Moyle et al. 2008). While attending the heavy work load along with high emotional involvement can produce stress on nursing staff which could lead to frustration and dissatisfaction (Chou et al. 2012). Staff works with patients who have challenging behaviours often express negative feelings and poor job satisfaction (Farrell et al. 2010). Even though there were many studies conducted in the area of dementia and associated behaviours , few studies done about nurses’ experiences in caring for dementia patients with challenging behaviour. Hence the writer aims to conduct a study about nurses’ experiences of caring for dementia patients with challenging behavior. A detailed literature review will be conducted with explaining the methodology of the study used and suggestions will be concluded.
1.2 Search strategy
A literature search using electronic databases: Cinahl, Medline, Pub Med,Cochrane and Google scholar. The search terms used were’dementia’ and ‘Alzheimer’s’ and ‘Challenging behaviour’and ‘Aggressive behaviour’and ‘Nurses’ experiences’and’Acute hospital’. Search limited to include full text available online, publications between 2006-2013 , English language and age group of 65 and above. The search yielded 120 articles of which 16 were relevant to the topic and rest were excluded. Out of 16 studies 7 were dealing with dementia patients in acute hospitals and 6 were about challenging behaviour in dementia patients and 3 were dealing with nurses’ stress and job satisfaction. Reference list was also reviewed from the articles used to review. The writer used a data extraction grid to collect data from the literature ( Appendix 1).
1.3 Review of Literature
1.3.1 Caring for older people with dementia
The National Dementia Strategy in England identifies dementia as a fatal illness with a life expectancy of 4.5 years from diagnosis to death (Xie et al.2008). Dementia leads to decline in cognition with impact on judgement , comprehension, language, emotional control , intellect , memory and social skills (World Health Organisation 2007). Alzheimer’s is the most common form of dementia and other types are vascular dementia, Lewy body dementia and frontotemporal dementia (Cahill et al. 2012). Dementia has three stages; early, moderate and severe (http://www.dementia.ie).
In a qualitative study by Nolan (2007) using a purposive sample of seven nurses with the thematic approach reported that the physical layout of the acute ward as inappropriate to care for older people with dementia and the highlighted alarm is the safety of the patient. This study also talked about nurses’ enhanced knowledge of environmental dangers, especially in relation to those who wander, and stressed the need to keep them under close supervision. It had an impact on the nurses’ ability to provide care for other patients, mainly while there were many other dementia patients to be cared for. Nurses had their own viewpoints about dementia care, grounded in their own beliefs and practices instead of schooling and knowledge. Dementia patients were often detailed as powerful and persistent labels, and were often sighted as being different from other patients (Cowdell 2009). This study, using an ethnographic approach suggested that instead of meeting the needs of the clients , care mainly focussed on completing the physical needs and provision of care included less amount of good communication.
Due to functional deficits, dementia patients were unable to complete their activities of daily living and due to the time constraints nurses had to take over such activities (Nolan 2006). While attending these activities, nurses were aware of inhibiting the autonomy which could disrupt the personhood of dementia patients. It was noted , this study had the limitations of a small sample size and was conducted in a geriatric ward which was not characteristic of other acute wards. Similar results were found out by a study of Edberg et al. (2008). A qualitative study by Edvardsson et al. (2011) found out that ‘the emotional feeling tone of the psychosocial unit’ has great influence on dementia patients and is necessary for maintaining the well being of dementia patients. Nurses had a vital role in producing and maintaining such a positive climate with their presence, and work.
1.3.2 Challenging behaviour in dementia
Challenging behaviour has been defined as ‘an active attempt by the person to express an unmet need, which could be physiological and psychological’ (Stokes G 2000, cited by Andrews 2006 ) or ‘can be a sign of pain or suffering , or a reaction to carer’s torment, which consecutively increases the behavioural problems’ (Bird et al. 2007). A quantitative study by Pulsford (2011) using the Management of Aggression in People with Dementia Attitude Questionnaire (MAPDAQ) to assess the behaviour, the result shows that staff finds the aggressive behaviour mainly as circumstantial, could be from an interaction with staff or from the nature of care providing. Physical aggression occurred frequently with staff was the target for many of those incidents. This study was limited by less response from staff.
Moyle et al. (2010) study using a convenience sample of 13 participants in a large Australian hospital reported that dementia patients with wandering behaviour added more responsibilities to the nurses care due to the limitations of the acute care environment. So they had an attitude to devalue such patients which led to nurses managing the safety issues of the patient, and less intervention were used to meet the physical, social and emotional needs of persons with dementia. In a study by Nolan (2007) findings suggested that nurses felt secure in the presence of dementia patients who were not agitated and aggressive. A cross sectional survey by Cubit et al. (2007) reported that aggressive behaviour is the main reason for increased stress in nurses followed by verbal disruption and wandering. Moyle et al. (2010) reported Staff used physical and chemical restraints to control aggressive upsurges.
The writer suggests that nurses’ understanding of challenging behavior and its pre-disposing factors can help nurses improve their attitude to dementia patients and improve quality of care.
1.3.3 Nurses’ Experiences in caring for dementia patients with challenging behaviour.
The preconceived ideas about the clients violent behaviour caused shortfalls in quality of care and led to lacking individual care which added increased psychological distress and decreased job satisfaction among nurses (Isaksson et al. 2009). This study had limitations of a small sample size and conscious biases present, but the trustworthiness is proved by discussing the findings with other research groups and by seminars with other researchers. Nurses described caring for older people with dementia in an acute hospital as reaching to feelings of incompetence and job dissatisfaction , and tended to focus their efforts on physical care due to lack of confidence (Cowdell 2009). Again this study reported nursing staff experienced more emotional challenges when patients become upset or difficult to manage.
Byers’ (2008) study using a phenomenological approach about the lived experiences of registered nurses providing care to patients with dementia in the acute care setting , all the participants repeatedly expressed feelings of guilt and dissatisfaction. Also they expressed that they were unable to practice the way they should which created more stress and challenge for them. Similar results were found out by Edberg et al.’s (2008) study using a combined approach of qualitative and quantitative methods
Nurses who work in dementia special care units for long term experienced less distress from disruptive behaviour which was in contrast to previous studies where residential care staff with more experience suffered more strain (Cubit et al. 2007), but this study had used the convenience sample for cross sectional survey and the survey tool was limited by asking to recall events from the past week, thus reliability can be questioned. Edvardsson et al. (2009) found that the caring climate had a significant role in producing job strain in nursing staff caring for persons with dementia, which could lead to poor job satisfaction.
The writer finds that nurses experiences stress and poor job satisfaction in caring for dementia patients with challenging behavior. So the writer aims to explore the experiences of nurses to understand how the nursing care can be improved
1.4 Methodological issues in the literature:
Upon reviewing the literature, the studies which gave information about the experiences of nurses about dementia care where qualitative studies and had rich descriptions about the topic but as the samples were small in size in qualitative research and the studies conducted in single sites, the results cannot be generalised. Edberg et al.’s (2008) study used a focus group and participants were recruited through the personal awareness of moderators and reliability can be varied, but trustworthiness and transferability of the findings evidenced by the uniqueness of results and is reinforced by agreement of the findings between nurses in different groups and across the countries. Ethical approval was obtained from relevant sources for all studies.
Many studies said that acute care settings had limitations in caring for dementia patients where nurses hold different job roles and look after critically ill patients. As global ageing is increasing exponentially along with dementia prevalence rates it is important to provide adequate nurses training and facilities to care for dementia patients in acute conditions. Hence the writer aims to explore the experiences of nurses in caring for dementia patients with challenging behaviour and to contribute findings to improve quality care .
Chapter 2: Methodological issues in research
In reviewing the literature related to nurses’ experiences of caring for dementia patients with challenging behaviour, three main themes were emerging. It has been identified that nurses are the frontline workers in the acute hospital with dementia patients and there were not much study done about the experiences of nurses in relation to caring and their knowledge of dementia care. Therefore a gap has been identified in the literature. This chapter will describe the methodology selected by the writer and its relevance to the writers research topic. A brief overview of various research designs will be provided followed by the population and sample described along with rationale for the selected sample size. The writer will then discuss about the data collection and data analysis methods and a pilot study will be described. Ethical considerations will be addressed and at the end, trustworthiness and the strengths and limitations will be explained
2:2 Aim of the study:
The proposed research aims to explore the experiences of nurses in caring for dementia patients with challenging behaviour to find out about the barriers and to improve care standards for dementia patients.
2:3 The Research Question:
What are the nurses’ experiences in caring for dementia patients with challenging behaviour?
2:4 Research Methodology
Nursing research is a systematic inquiry structured to build trustworthy evidence to important issues of nurses and their clients and research methods are the techniques used by researchers to collect and scrutinize the information relevant to the question (Polit & Beck 2014). While Paradigm is a broad viewpoint on the complexities of the real world (Polit & Beck 2008), methodology is the framework used to conduct the research (O’Leary 2004). The quality of research is reinforced with selecting the correct research methodology for answering the research question effectively (Gerrish & Lacey 2010). Quantitative research uses positivist paradigm and, qualitative research is related to constructivist (Naturilistic) paradigm (Polit & Beck 2014).
Quantitative research seeks to present a world view which is objective and involves variables which can be quantified and manipulated whereas qualitative research looks to get the opinions, experiences of participants and the meanings of their perspective on the research topic is looking for (Watson et al. 2008). Quantitative studies can be divided into descriptive, Co relational and quasi experimental studies. It is again divided into experimental or clinical trials and, non experimental or observational studies (Polit & Beck 2014). Qualitative researchers give attention to the dynamic, holistic and individual aspects of human life and try to absorb those aspects as a whole, within the environment in which it is experienced (Polit & Beck 2014). Qualitative study can be divided into three categories: grounded theory, which describe the key social and psychological processes which occur in the social setting wherein ethnography learn from members of the cultural groups, to realise their world view and, describes their customs and norms. Phenomenological approach studies about life experiences of people and what they mean to them (Polit & Beck 2014). Parahoo (2006) says that phenomenology is based on the philosophy of Husserl (descriptive), in contrast Heideggerian phenomenology looks into the individual personal history and psychological make up to understand the way in which how they experiences phenomena (interpretive). The aim of the proposed research is to explore the experiences of nurses caring for dementia patients with challenging behaviour, therefore the writer finds qualitative research method using the Husserlian phenomenological approach as appropriate to the study. Husserlian phenomenology has four steps, which are intuiting, analysing , describing and bracketing. By using ‘bracketing ‘which leaves writer’s perceptions, prejudices and beliefs away to get the description of respondents’ experiences in pure form (Polit & Beck 2014)
The research will be undertaken as part of a PG diploma in Nursing and the time scale will be over 9 months.( Appendix 2 )
2.5 Population, sample and sampling
A target population is the total population and study population is a subset of the target population (Gerrish &Lacey 2010) while the sample is a subset of the population being Studied (Polit & Beck 2008). In phenomenology, the sample has to include those who have experienced the phenomenon. So the writer plans to use nurses who care for dementia patients. Sampling is the process of selecting a portion of the population to represent the entire population (Polit & Beck 2008). Qualitative researchers look to identify the key individuals, events or settings that provide a rich source of data and are not so concerned about identifying the total population in developing the sample frame (Gerrish & Lacey 2010). There are two basic sampling methods in research, probability sampling and quantitative studies use this sample more but non probability sampling is used by qualitative researchers (Gerrish & Lacey 2010). The writer has chosen a purposive sample for this study, which is a form of non probability sampling and researchers’ knowledge of the population employed to select the sample (Polit & Beck 2008). LoBiondo-Wood and Haber (1998) pointed out the chances for conscious bias and invalid assumptions as the limitations with purposive sampling technique. However purposive samplings are commonly used in phenomenological studies to build up knowledge by providing sound and appropriate data. A sample of 10 nurses working in an acute geriatric ward in an academic teaching hospital in Ireland and regularly caring for dementia patients with challenging behaviour deemed appropriate for the study.
2.6 Inclusion and Exclusion Criteria
Registered nurses with minimum one year working experience and care for dementia patients with challenging behaviour on a regular basis are included. Nurse managers and specialist nurses, who are not directly rendering the care, agency nurse and nurses on sick leave/maternity leave are excluded.
2.7 Study Setting
The participants will be more relaxed and relieved if they are in a comfortable setting , and will be more open with the researcher (Langford 2001). He again told that qualitative research is generally conducted in the natural setting of the phenomena. Hence the investigator aims to carry out the study in a private room in the hospital which is away from the ward.
2.8 Data Collection
Data is the information collected during the course of a study and it can be in the form of numerical values in quantitative study whereas narrative information on a qualitative study (Polit & Beck 2014). Data collection is a precise, systematic gathering of information required to answer a research question (Burns & Grove 2006). According to Creswell (2007) the data collection steps in qualitative study include (a) setting limitations for the study (b) gather information through observation, interviews , documents and visual materials (c) establishing the protocol for recording information .Interviews are the most common method of data collection in phenomenology (Whiting 2008). Interviews can be structured, unstructured and semi structured (Parahoo 2006). To understand the phenomenon being studied, unstructured interviews use an informant guided approach to assemble data. (Watson et al. 2012). Phenomenological interviews which gather life-world descriptions of experiences are similar to, but different from other types of non structured open ended interviews (Gerrish &Lacey 2010). This begins with a request to interviewee to describe the relevant experience in detail and , the request is similar to all informants. Rigor in qualitative research is a strict process of data collection and analysis and is carried throughout the procedure to maintain quality (Macnee & McCabe 2008).
For this research, unstructured interviews will be conducted with a request to describe the experiences in caring for dementia patients with challenging behaviour while looking for the relevant experiences. The interviewer then helps the informant by explaining the examples and asking what was it like for the respondent, to gather the life-world in full and solid. The interviews are open ended and the interviewer may focus on trying to clarify in the depth of the nature of the phenomenon being studied (Gerrish & Lacey 2010). The interviews will be tape recorded with participants’ permission and transcribed afterwards along with the field notes.
2.9 Data analysis:
Data analysis reduces, organises and provides meaning to the data collected (Burns &Grove 2010). In qualitative research, analysis of data is hooked on to the methodological aspect used to guide the study process (Watson et al. 2012). Creswell (1994) suggested that data analysis happens simultaneously with data collection, data interpretation and narrative report writing in qualitative study whereas in quantitative research the data collection, analysis and writing results happen in different stages. At the end of the interviews the recorded materials of data collection have to be transcribed for data analysis, where data are searched, coded, and formed into patterns that adhere to the rules of the guiding methodology (Watson et al. 2012). For the transcription of data to shape the responses of informants in phenomenological research where the data collected through unstructured interviews, Tesch (1990) has developed an eight step approach (Creswell 1994). In this research, all the interviews will be audio taped and transcribed for transcript verbatim, uses handwritten field notes to narrate the participants mannerisms during the interview and the researchers’ impressions after each interview (Parahoo 2006). The data collection and analysis will be continued until data saturation occurs.
2.10 Pilot Interview:
A pilot study is the smaller version of a proposed study and the researcher usually carries out these to process the methodology (Burns & Grove 2010). A pilot interview will be carried out in the proposed setting with one nurse to assess feasibility of the study, the effectiveness of sample, familiarise the writer with the interview process, tape recording equipment and it will allow any other issues that arise to be dealt with by the researcher. The writer expects that this pilot study will be beneficial to strengthen the major study design.
For the research results to be accurate and valid, quantitative researchers collect high quality data by the use of measuring instruments, whereas in qualitative research, the trustworthiness of data is established by confirming the findings with informants which exactly display the viewpoints and experiences of them instead of researchers’ perceptions (Polit & Beck 2008). Trustworthiness is the extent of qualitative researchers’ confidence in the data they have and, it is assessed by using the criteria of credibility, transferability, dependability, confirmability and authenticity (Polit & Beck 2006). Credibility refers to the findings being typical of the participants’ experiences which will be established in this study by validating the results with participants . While transferability is the scope of the findings to be applicable to other settings (Polit & Beck 2006) and is obtained by detailed description of setting and audit trail. Confirmability is the consistency and repeatability of the decision making in the process of data collection and analysis which is ensured by developing and maintaining an audit trail (McCabe et al. 2008). Dependability of qualitative data focuses on the stability of information across individuals or over time and will be gained by achieving saturation, audit trail and member checking and in the current study the writer plans to collect data until saturation occurs (Houser 2012). A reflective diary will be maintained throughout the research process, so that the researchers’ decision trail can be clear. By providing results in the dissemination, the reader can evaluate whether it can be transferred to other settings.
2.12 Ethical Consideration
A code of ethics has been developed to guide the researchers to deal with the ethical dilemmas while drawing up the studies which are rigorous and ethical (Polit & Beck 2014). Ethical principles hold up each stage of the research process. There are three ethical principles underpinning the research conducted on human subjects according to Belmont report and which are (A) respect for human dignity which stands for Participants right to self determination and to participate in the study or not, (B) beneficience is to do some benefit and to avoid physical and psychological harm and (C) justice is the right to better treatment and privacy (Polit & Beck 2014). Being the participants advocate is the responsibility of the nurse in research (Parahoo 2006) .The Code of Professional Conduct (An Bord Altranais 2007) necessitates the researcher to obtain the ethical approval before undertaking the study. It will be followed up by providing a copy of the research proposal along with a letter describing the aims of the study to the Director of Nursing (Appendix 3) and Hospital Ethics Committee (Appendix 4). Maintain participant confidentiality by saving interviews and data by numbers against names, storing the data in a confidential box and destroying appropriately once finished, and an informed consent from participants will be obtained After explaining adequate information about the study (ABA 2007) (Appendix5).
2.13 Limitations of the Study:
The sample collected from a single setting may influence the transferability of the results in other settings and non ‘generalaisability of the results which is the nature of qualitative studies using a phenomenological approach (Gerrish & Lacey 2006). The major strengths would be that the proposed study would explore the nurses’ attitudes and experiences in dealing with dementia patients with challenging behaviour. The writer found very few articles about the current topic while reviewing the literature and aims that this study will provide a limelight into a vital aspect of nursing care of dementia patients with challenging behaviour.
2.14 Dissemination of findings:
A research cannot add on to nursing practice unless the results are not published and frequently it is the end job of the researcher to prepare a research report and share it with others ( Polit & Beck 2014). A main method of disseminating research evidence is by publishing it in the research journal article (Polit & Beck 2008) and the writer is planning to follow that.
2.15 Chapter Conclusion:
The proposed research aims to explore the experiences of nurses caring for dementia patients with challenging behaviour. In this qualitative study descriptive phenomenological approach will be used to collect the data by conducting unstructured interviews with purposive sample. A pilot interview to be carried out. Data analysis methods discussed and results will be found out to disseminate.
3.1 Summary and conclusion.
From the literature reviewed in this study the writer recognised that along with the ageing population of Ireland the dementia cases are increasing dramatically. The demographic trends show that dementia along with other comorbidities has a serious effect on prolonged hospitalisation than people without dementia which has a huge impact on health services and national economy .The nurses in acute wards play a major role in identifying and managing the challenging behaviour but the interventions seems to be inconsistent due to the busy context of the acute wards and lack of guidance on care of dementia patients with challenging behaviour which again has a detrimental effect on dementia patients’ care. The writer wishes to look into the arena of nurses’ experiences of caring for dementia patients with challenging behaviour. The aim of the study is to provide an in-depth knowledge of nurses’ experiences and it is hoped that the findings will broaden the knowledge of issues underlying the behaviour and nurses experiences and attitude towards it. The writer strongly believes that the study will provide clinically significant findings which can be incorporated in the nursing practice which will improve patients’ outcome and reduce length of hospital stay. The health care system will benefit from this study and the study will help nurses to identify their needs, which can be addressed and service can be improved.
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