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IPA Bulletin: Featured Article

Examining nursing care practice for people living with dementia (Wendy Moyle) June 2014

Examining nursing care practice for people living with dementia

Wendy Moyle, RN, PhD is the Director of the Research Centre for Clinical and Community Practice Innovation, a research program in the Griffith Health Institute at Griffith University in Brisbane, Australia. 

Nurses have a clear role as both the provider of care as well as the facilitator of interdisciplinary care. Over the last two decades, nurses have spent more time on researching the effectiveness and efficacy of nursing approaches to these roles. Although the nurse’s role in providing care to people with dementia may vary across settings, it is generally accepted that their role includes the support of the client and their family, and the integration of the interdisciplinary team. The following two papers examine the role of the community health nurse in dementia management and the role of case conferencing in palliative care outcomes for older people living with dementia in nursing homes:

Huang, H.L. et al. Factors associated with dementia care practices among community health nurses: Results of a postal survey. International Journal of Nursing Studies. 2013; 50: 1219-1228.

Taiwan has a rapidly ageing population that has already surpassed that of Japan and other developed countries. Changes in healthcare and social security systems, like many other countries, have resulted in a shift of care to the community, and therefore a need to understand the practices within the community, and the influence of attitudes and knowledge on such practices.

The first study aimed to explore the factors related to dementia care practices of community health nurses in Taiwan. Community health nurses (n=238) working in health care centres (district nurses), long-term care centres (care managers), and home care institutions (home health care nurses) were approached to complete a postal survey.

The survey was made up of instruments developed and validated in Taiwan with the main variables being knowledge, attitude, and confidence in relation to dementia care. Demographic data was also collected. Of the participants approached, 195 returned the questionnaire (response rate 81.9%). The mean age of participants was 35.4 years; 98% were women and the mean number of years working in a clinical setting was 11.5; and 61.2% had a college or university level education. Of those who reported they were educated in dementia related care, only 67.9% reported dementia education in their nursing education and only 26.5% had enrolled in dementia related education in the last two years.

While the majority of participants were experienced in assessment of dementia (65.8%) a small number of participants (11.2%) reported challenges in using cognitive assessment tools. More than 60% of the participants reported they had provided a nursing intervention to a family caregiver of a person with dementia.

There were significant differences in practices among the district nurses, care managers, and home health care nurses. District nurses were significantly less able or interested in assessment of dementia compared to other participants (X2=26.99, p=0.000), and district nurses more often took no action after they found a case of suspected dementia (X2=10.80, p=0.005).

While the total knowledge scores were not different between the three groups of participants, the level of confidence was significantly lower in district nurses (X2=39.76, p=0.001), which may explain the district nurses limited action to a suspected case of dementia.

The authors concluded that community health nurses with a higher level of confidence conducted more case assessments and more often used a cognitive assessment tool to assist them in their work. They recommend that to assist nurses to feel more empowered in dementia management that they receive training in both the symptoms and treatment of dementia, as well as the social resources that are available so that they can assess, manage and provide advice to clients and families.

Phillips, J.L. et al. Does case conferencing for people with advanced dementia living in nursing homes improve care outcomes: Evidence from an integrative review? International Journal of Nursing Studies. 2013; 50: 1122-1135.

Although there is evidence to guide dementia specific palliative care, there is also evidence that demonstrates clinicians may not be aware when a palliative approach is needed and they may also have difficulty in integrating such an approach. Case conferencing may be one option of facilitating the delivery of interdisciplinary palliative care in long-term care.

The second study was an integrative review that aimed to appraise the evidence for case conferencing as an intervention to improve palliative care outcomes for older people living with advanced dementia in long-term care.  Searches of the following databases: CINHAL, MEDLINE, PSYCHINFO and CareSearch were undertaken. Two reviewers screened the 238 titles identified against two evidence evaluation tools developed by the Australian Palliative Residential Aged Care Project and the Australian National Health and Medical Research Council.

This resulted in 77 articles to review and nine studies (two quantitative studies, four qualitative studies, three mixed methods) that addressed the review questions. Seven of these studies were conducted in Australia, one in the United States, and one in Sweden. Two higher-order randomised controlled trials demonstrated enhanced medication management for people living with dementia in long-term care. Pre-post studies indicated care conferencing may enhance palliative symptom management and qualitative studies suggest that case conferencing is feasible and worthwhile.

The authors recommend case conferencing, as a means of facilitating communication and coordination of the complexity of managing care needs, as well as increasing the uptake of appropriate interventions for symptom management.

The authors suggest however, that more evidence is needed to determine the efficacy as well as a cost analysis of case conferencing in care of people with dementia living in long-term care. Furthermore, there is a need to overcome the barriers and to enhance the facilitators to establishing case conferencing in long-term care.

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