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Major report calls for better nurse training in dementia care


A “significant improvement” is needed in the way hospitals deliver care to people with dementia, according to a major national report.

While hospitals say they have policies in place, these are not always followed and simple steps are not taken that could lessen the distress to patients, most of whom are elderly.

The study said the encounter between staff and patients “is mainly task-related and delivered in a largely impersonal manner”, while the hospital environment is “often impersonal”.

Staff do not always greet or talk to patients during care, explaining what they were doing or offering choice. Sometimes they do not respond to patient requests for help.

The National Audit of Dementia, which covers England and Wales, found only 6% of people with dementia had their level of cognitive impairment measured on admission and discharge, while only 43% of case notes showed patients had a mental status test despite 75% of hospitals saying they had a procedure for it.

Only 9% of case notes showed patients being screened for delirium, despite 33% of hospitals saying they had policies in place.

People with dementia can become agitated, distressed or aggressive while in hospital due to the hospital environment, aspects of care, illness or injury, or their dementia getting worse.

NHS guidance says the use of antipsychotics to control these symptoms should be a last resort, but many hospitals still use them.

The audit found 28% of people with dementia received antipsychotic medication in the hospital, of which 12% were newly-prescribed the drugs while in there.

The reasons for these prescriptions were not recorded in 18% of these cases, while less than half of staff felt properly trained in dealing with challenging behaviour.

More than half (59%) of wards said personal items (such as family photographs or cards) were not put where dementia patients could see them for reassurance.

And only 26% of casenotes showed an assessment of functioning (such as basic activities of daily living, activity/exercise status, gait and balance), despite it being included in 84% of hospital procedures.

While 96% of hospital policies said they assessed nutritional status, only 70% of casenotes showed this had been done.

Furthermore, 19% of casenotes did not show the patient was asked about any continence needs and 24% did not show that the patient was asked about pain.

Only 74% of wards had a system to ensure enough staff to help dementia patients eat at mealtimes and only 5% of hospitals had mandatory training in awareness of dementia for all staff.

Overall, less than a third (32%) of staff said they had sufficient training or learning in dementia care.

Recommendations in the report include providing basic dementia training for all staff, with some ward staff receiving higher level training.

A senior clinical lead for dementia should also be in place in each hospital, with dementia champions in each department and at ward level.

Responding to the report, Royal College of Nursing chief executive and general secretary Peter Carter, said: “It is extremely worrying that two thirds of staff found that their training and development was not sufficient. It is essential that all staff are supported through training, education and leadership so that they able to provide skilled, knowledgeable care to people with dementia.

“Equally, each nurse is personally accountable for their own practice and must act promptly to raise concerns if staffing levels or other pressures are getting in the way of delivering good care,” he added.

Alzheimer’s Society chief executive Jeremy Hughes said: “Given that people with dementia occupy a quarter of hospital beds and that many leave in worse health than when they were admitted, it is unacceptable that training in dementia care is not the norm. Staff want to be empowered with the tools they need to deliver good quality care to people with dementia.

“Being in hospital is often confusing and frightening for people with dementia, but small changes can help make their stay more comfortable. We also need to invest in community care to support people with dementia to live at home and prevent them going into hospital unnecessarily.”



Readers' comments (14)

  • Dementia care: the inside story
    Dr Max Pemberton recalls the casual neglect – and moments of inspired nursing – he witnessed while working in care homes for the elderly.

    Dr Max Pemberton has witnessed dementia sufferers being abused but he has also seen nurses demonstrate great care and insight

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  • "That report also seemed to imply that even some nurses, somehow think that demented people 'are being deliberately awkward'."

    i am not sure whether you are referring to the article or my comment but I can assure you that in the clinic where I worked we adequatly trained in mental health to recognise and manage a wide range of psychopathologies and would never consider a patient with a MH disorder or any of the dementias as 'deliberately awkward'. It was just unfortunate that our ward was not suited to the needs and demands of the patient admitted to us. This was an error in the transferal process and agreement among doctors who probably never considered the level of staffing required for this unfortunate patient. I believe that if none of us had had any basic and post grad training in dementia the problematic of this patient for the 48 hours he was with us, before his transfer to more suitable facilities, would have been far greater. Ours was more a problem with staffing levels and the inability to provide the one to one care he required.

    also in response to you comment although I have an MSc in Healthcare Management my role and responsibility was to provide holistic and individualised nursing care to any patient admitted to the ward not to worry about whether or not it was affordable. Although we always had to be aware of and take responsibility for not wasting materials and ordering according to our needs our main duty was to see to it that patients had all they needed for optimal care to be given to them and if this was lacking to justify the necessity and request any extra materials we needed for any patient.

    Managers and administrators, departments of health, politicians, etc are engaged to worry about budgets and are paid a far higher salary than nurses for their efforts!

    I would also query the costs of continuing to include, if this is now lacking and which appears to be the case, basic training in care of the elderly, mental health and the dementias for nurses, medical practitioners and all other healthcare professionals in their training with postgraduate training for those who encounter patients with this disorders in their work.
    I fail to understand how nurses can be on the general register and accept or be accepted in posts in general nursing without this type of training.

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  • michael stone

    Anonymous | 19-Dec-2011 12:37 pm

    My comment was about the report, and its implication that non-specialist nurses might not properly understand dementia, and therefore are perhaps treating patients inappropriately. I was not criticising either you or Tinkerbell, or anyone else who has posted in this discussion - but however expert you are, it strikes me that it is fairly easy to be 'outnumbered' by demented but active patients, which isn't satisfactory but probbaly goes back to my 'it comes down to money' point.

    Some of these problems, do come down to the combination of different roles within the NHS, and the ultimate power of managers, as opposed to front-line staff, to decide about things like staffing numbers and training budgets. I tend to be with anyone who 'puts the patients first' in their mind, while they are thinking about any type of problem - but my instinct, is that a few 'pure pen-pushers' are present in some hospitals, etc.

    It is sheer madness to claim that a clearly inadequate number of nurses can 'cope with too many patients simply by organising their time/behaviour' better !

    But similarly, however many nurses and doctors are present, they do need to properly understand what they would need to do, to do their jobs well.

    Which is what I think tiritega mawaka | 18-Dec-2011 11:06 pm was saying with:

    'the facts are that traditional education alone will not lead to sustained changes in practice; a whole systems approach needs to be adopted in improving dementia care, from understanding organisational and team culture; to exploring environmental factors(such as noisy environments); unfortunately this means money...and who has the budget..???'

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  • dementia care is an important topic on everybody's lips but i do get fed up when nursing staff are blamed for everything that goes wrong these days, yes dementia patients do supply some challenging behaviour and very often we are so rushed off our feet just tagging them because they are not able to be left by themselves at any one time, Having more staff at these times would be an ideal and is not the norm especially because other areas may not be well staffed and these are taken away, so unfortunately it puts us back to square one. Most of the time the staff pull their hair out when we are not able to do our job properly and look after the groups of patients' we are allocated. Please don't put the nursing staff down give us encouragement and assistance to enable us to do our job properly and look after all groups of patients not just specific groups, after all we have a duty of care to all that are allocated to us.
    I've properly gone of the tack but although i know dementia patients are important i also recognise that so are all my other patients, being a nurse for the older adult there is a high percentage that my patients fall into this category but not all, but most need assistance with washing and dressing, feeding and assistance with walking, so give us a break from blame for five minutes. PLEASE

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