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Changing practice

Designing a training programme to improve staff attitudes towards people with dementia

A training needs analysis identified a more positive approach to dementia patients was needed. This was addressed with interactive dementia awareness sessions.

Authors Julie Crabtree, BSc, DipHE, RMN, is Alzheimer Scotland Dementia Liaison Nurse; James Mack, MSc, PGCert TLHE, DipHE, RN, is Biggart Initiative Facilitator, Biggart Hospital; both at NHS Ayrshire and Arran, Scotland

Abstract Crabtree J, Mack, J (2010) Developing a nurse led initiative to improve approaches to dementia care in hospitals. Nursing Times; 106: early online publication.

Nurses in acute settings often lack the knowledge and experience to provide appropriate care for patients with dementia. Two specialist nurses at the Biggart Hospital in South Ayrshire, Scotland, used a questionnaire to determine staff attitudes to patients with dementia and designed a multidisciplinary training programme to improve practice in dementia care. This article describes the development, implementation and evaluation of the first stage of the programme.

Keywords: Dementia, Hospital, Education, Training

  • This article has been double-blind peer reviewed

Practice points

Benefits of a multidisciplinary approach to dementia care:

  • Dementia awareness is raised among all staff groups.
  • Relationships within staff groups are more supportive.
  • The patient journey and carer satisfaction is improved.
  • Staff are able to change the way they view people with dementia and to see them as individuals. 

 

Background

  • Mental disorder affecting older people is poorly detected and managed in general hospitals.
  • Between 30% and 40% of older people admitted to a general hospital will have a dementia type illness.
  • A 500 bed general hospital will have at least four times as many people with mental disorder than the local mental health services.
  • Older people with dementia are particularly vulnerable in acute settings. They are highly susceptible to environmental change and quickly suffer loss of independent function.
  • Dementia should be identified on admission to hospital. Care plans need to take account of the impact this will have for the older person’s management and discharge.

Source: Who Cares Wins, The Royal College of Psychiatrists, 2005

Introduction

Dementia is a complex condition that poses considerable challenges for nurses. It progressively destroys the brain cells, can affect every aspect of human thinking, feeling and behaviour and can last for many years (Murphy, 2000). Hospital wards can be frightening and stressful for people with dementia, adversely affecting their behaviour (Cunningham and Christie, 2009). A number of studies have shown that general ward staff lack dementia knowledge. Tolson et al (1999) found the care of patients with dementia on acute wards was ‘sub optimal’ due to a lack of knowledge and understanding of the condition among nursing staff.

More recently, The Scottish Parliament Cross Party Group on Alzheimer’s (2008) found all staff in accident and emergency departments and on acute hospital wards, including non clinical staff, needed dementia training. They identified a lack of leadership and ownership of dementia within NHS hospitals, as well as significant deficits in the knowledge and skills base of staff to deal with the condition.

Dementia in Scotland

  • Scotland has around 60,660 people with dementia. About a third are in the early stages of the illness and two thirds have moderate to severe dementia. Over 2000 are under age 65.
  • There will be an estimated 75% increase in the number of people with dementia by 2031
  • Around 10,000 to 12,000 people are diagnosed with dementia each year
  • Dementia affects about 5% of people aged 65, rising to 20% of those aged 80. Numbers will rise steadily as the population ages.
  • Over 36,000 (60%) of people with dementia live at home. A third live alone.
  • There are 29,000 unpaid carers who provide substantial home care to people with dementia.

Source: Alzheimers Scotland, 2007a  

The report Counting the Cost: caring for people with dementia on hospital wards(Alzheimer’s Society, 2009) found nurses did not understand what dementia was and identified a lack of person-centred care. In common with the general population, people with dementia can become physically unwell and require hospital care. Demographic changes and an ageing population mean there will be a disproportionate increase in the common conditions of old age, such as cancer, stroke and dementia (The Royal College of Psychiatrists, 2005). Dementia is also a major risk factor for developing delirium.

Lack of dementia knowledge from hospital staff, together with demanding work loads and pressure on beds, means people with dementia are often labeled “difficult” and staff are often requested to medicate them or transfer them to a psychiatric hospital (Moyle et al, 2008). In Scotland, people with dementia and their carers are further disadvantaged by the lack of availability of dementia services and poor service quality (Alzheimer Scotland, 2007a).

Dementia training

For several years there has been concern that dementia care has been inadequate in pre and post registration training (Kitwood, 1997; Fessey, 2007). Hospitals often fail to address the psychosocial aspects of care of people with dementia that can improve their quality of life and aid rehabilitation. This leaves ward nurses ill equipped to provide best practice to a client group they are increasingly required to nurse (Scottish Government, 2010).

Dementia was declared a national clinical priority by the Scottish Government in 2009 and it is now accepted that people with dementia should be recognised as individuals who have a wealth of life experience and values that can inform care (Cunningham and Archibald, 2006). This new culture of care seeks to challenge negative perceptions and attitudes towards people with dementia.

Attitudes towards dementia

Care givers attitudes towards people with dementia are often seen as more negative than positive (Fessey, 2007; Nolan, 2006).  People with dementia can be labelled “different” and can experience a loss of status. Recent findings suggest attitudes towards dementia can be improved through programmes designed to encourage person-centred communication and interaction (O’Connor and McFadden, 2010). A key aspect of Scotland’s new dementia strategy is the need for improved education and training to support hospital staff in meeting the needs of patients with dementia (The Scottish Government, 2010).  

The questionnaire

Biggart Hospital is a small general community hospital in South Ayrshire, Scotland, predominantly for patients aged 65 and over. It consists of a day hospital and 164 inpatient beds across six wards. There are two continuing care wards and four rehabilitation and assessment wards.

A training needs analysis was undertaken at Biggart Hospital in September 2009 using the Approaches to Dementia Questionnaire (Lintern et al, 2000). The 19-point questionnaire – which measures the attitudes of care givers towards patients with dementia - was circulated to all staff groups within the hospital.

A total of 102 questionnaires were returned (52%). Of the respondents, 52 were clinical staff, 21 were non-clinical staff and 29 questionnaires were unspecified.

Although many of the responses were positive, the questionnaire revealed a more positive approach to dementia patients would be beneficial in some areas (table 1).

More than one third of respondents agreed with the statement that “it is inevitable that once a person develops dementia they will go down hill”. Additionally, 41% of respondents agreed that “people with dementia are sick and need to be looked after”. However, it is now recognised that by focusing on the strengths and individuality of the person with dementia, rather than their deficits, they can live a positive life for a prolonged period of time with appropriate intervention and support (Burgess and Page, 2003).

 

QuestionAgree%Disagree%Neither agree or disagree%
It is important to have a very strict routine when working with dementia sufferers.545819211921
People with dementia are very much like children.252747512022
Dementia sufferers are sick and need to be looked after.384125272932
Once dementia develops in a person, it is inevitable that they will go down hill.303239432325

Dementia education and training model

The Dementia Manifesto (Alzheimer Scotland, 2007b) says it is best practice for people with dementia to be treated with dignity throughout their healthcare journey. To make this a reality in the clinical setting it is necessary to ensure all front line staff, such as nurses, healthcare assistants, porters, housekeepers and administration staff have some knowledge and understanding of dementia (The NHS Confederation 2010; Cheston and Bender, 1999).

The Biggart Initiative Dementia Sub-group used the results from the questionnaires to design and implement a “tiered approach” education and training programme to improve staff attitudes and values towards patients with dementia (figure 1). The Alzheimer Scotland leaflet What is Dementia? was distributed to all hospital staff and the first tier of the programme was piloted between November 2009 and June 2010.

Staff awareness sessions

A key message from Rights, Relationships, Recovery (The Scottish Executive, 2006) is the importance of promoting rights and values based care across a wide range of healthcare settings.

Borbasi et al (2006) have shown that acute care can negatively influence health outcomes for people with dementia, such as functional independence and quality of life.

All hospital staff who may come into contact with a person with dementia - from porters and domestic staff to advanced nurse practitioners – were invited to attend training.

A one-hour interactive dementia awareness session was designed by the authors. The aim was to raise awareness of the experience of someone with dementia in the hospital setting and to improve the patient journey. The sessions focused on fostering a person–centred approach to patients with dementia whilst highlighting the valuable contribution of family carers. A multidisciplinary approach was encouraged so that all staff could recognise the part they play in caring for patients with dementia.

Between 24 November 2009 and 7 June 2010 a total of 18 one-hour sessions were held, attended by 112 people (figure 2). All those who attended also received a booklet entitled What Everyone in Our Hospital Needs to Know about Dementia.

 

Evaluation

All staff who attended dementia awareness sessions were asked to complete an adapted version of the Harvard one-minute paper (Queen’s University, 2010). This enabled the authors to receive instant feedback and address any issues before the next session.

The sessions helped open up discussion between the staff groups in attendance, and increased understanding of their diverse roles and contribution to patient care.

The following themes emerged from the 110 returned evaluations: the patient experience, how the person with dementia feels, what staff can do in practice, and recognising people with dementia as individuals.

Comments included:

“Good quick overview. It highlights everyday situations on wards where patients often have dementia. Happy to hear it’s getting priority and changes are afoot.”

“Opened my eyes to how these patients are feeling. Learned a lot.”

“Being more aware of how I deal with dementia patients, such as the way I approach and speak to them.”

“Reminded me everyone is an individual.”

“Simple things that make a huge change to someone’s stay in hospital. Great.”

“Very interesting and could help a lot with my job as a housekeeper.”

Challenges

Although dementia care is considered a priority by the Scottish Government and a new dementia strategy was launched in June 2010, there are many obstacles to overcome when trying to implement a new initiative to change practice. These include competing demands on staff time, releasing staff from patient care and duties, lack of resources, coordinating various staff groups and support from managers.

An additional challenge for the authors was to coordinate their workload to free up time to design, implement, deliver and evaluate the training programme.

To address these challenges, the authors had to be flexible in the delivery of the sessions in order to target the various staff groups. Support from managers was instrumental in ensuring attendance. We found that anecdotal dialogue between staff resulted in others being keen to attend the training sessions.

Purpose built teaching accommodation is freely available within our hospital but we were unable to accept the offer of participation from university colleagues because of the cost of delivering the teaching sessions.

Conclusion

General nurses looking after people with dementia need more training and education. Ideally, this should be provided by RMNs who are experienced in caring for people with other psychiatric symptoms that co-exist with their dementia illness.

This hospital has recognised that addressing the needs of the person with dementia is imperative within a general hospital setting. As a result of this initiative, dementia awareness has now been raised among all staff groups - from identification of the condition to positive strategies on how best to improve the experience of the person with dementia in the acute setting.

To address tier two of the initiative, dementia champions have been identified. In partnership with mental health services the dementia champions undertook a more comprehensive development programme. This ran for 12 weeks from March 2010 and included clinical placements and support from RMN mentors within elderly mental health services. The dementia awareness sessions will be delivered in other community hospitals throughout NHS Ayrshire and Arran.

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