The Impact of Challenges Faced by Nurses in Working With Alzheimer’s Disease Patients. A Case Study of Neuropsychiatric Hospital Aro Abeokuta
CHAPTER ONE
Objectives of Study
- To identify and analyze the specific challenges encountered by nurses working with Alzheimer’s disease patients at Neuropsychiatric Hospital Aro Abeokuta.
- To explore potential strategies and interventions for mitigating the identified challenges and improving patient care outcomes.
- To assess the impact of addressing these challenges on nurses’ job satisfaction, well-being, and the overall quality of care provided to Alzheimer’s patients.
CHAPTER TWO
LITERATURE REVIEW
Dementia
The World Health Organization (WHO) defines dementia as “a syndrome due to disease of the brain – usually of chronic or progressive nature – in which there is disturbance of multiple higher cortical functions including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement” (WHO, 2012, p. 7). Dementia is also seen as a term used to describe a range of cognitive and behavioral symptoms that can include memory loss, problems with reasoning and communication and change in personality and a reduction in a person’s ability to carry out daily activities, such as shopping, washing dressing and cooking (NCE guidelines, 2018). Dementia UK further notes that dementia is an umbrella term for a range of progressive conditions which are all associated with an ongoing decline of brain functioning. This may include problems with memory loss, thinking speed, mental sharpness and quickness, language, understanding, judgement, mood movement, and difficulty in carrying out daily activities (Alladi , Mekala, Chadalawada, Jala, Mridula & Kaul, 2011).
There are several subtypes of dementia, but dementia is not a disease of its own, but a syndrome that have several causes (Alladi et al., 2011). It is the result of different diseases. It is a clinical syndrome – that is, a collection of symptoms and other features that exist together and form a recognized pattern (Sandilyan & Dening, 2015, p. 39).
The common forms of dementia are;
Alzheimer’s Disease
Alzheimer’s disease is the most common form of dementia and is responsible for about 75% of cases, either on its own or with other forms of pathology (in which cases we refer to mixed dementia). Alzheimer’s disease is thought to be caused by an abnormal build up of proteins in the brain (Alladi et al., 2011).
In the early stages of Alzheimer’s disease, memory loss in relation to recent events and words finding difficulties are the most common features (Jellinger, 2013). As the diseases progresses, greater memory loss and language difficulties become apparent. This causes difficulty in everyday activities such as shopping, handling money, and navigating routes. There may be other symptoms like anxiety and lack of motivation (Jellinger, 2013).
There are certain brain changes caused by Alzheimer’s disease. There is abnormal disposition of insoluble ‘plagues” of fibrous protein called amyloid and twisted fibres called neurofibrillary tangles in the brain (Jellinger, 2013). These abnormal plagues and tangles interfere with normal functioning of brain cells (Sandilyan & Dening, 2015).
CHAPTER THREE
METHODOLOGY
Design
A cross-sectional survey study design was applied. During June 2021 and July 2022, data collection took place in seven acute care hospitals in the northern region of the Netherlands: one university hospital, three non-university teaching hospitals, and three general hospitals. The hospitals’ size varied from 263 beds to 542 beds, and the university hospital had 1300 beds. An online questionnaire, including all relevant information, was distributed through contact persons who sent this questionnaire to department managers. The survey was also nationally distributed through Facebook because of its widespread use among nurses. We did a call on a national private nursing group for questionnaires of a professional nursing magazine and on an open group for nurses in general. After three weeks, a reminder was sent. On Facebook, a request was performed and repeated once after one week. Because the hospitals participated at different times, nurses had the opportunity to participate throughout the entire investigation period. The hospital sampling was based on convenience, and social media sampling was based on self-selection.
We included all nurses directly caring for patients with alzheimer disease in a hospital, with at least three months of experience as a nurse, and a willingness to participate. All types of wards were included, except for paediatrics and obstetrics. QualtricsXM (version 2018, Prove, UT USA) was used as an online survey tool for distribution. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement has been applied for the current article (von Elm et al., 2008).
CHAPTER FOUR
RESULTS
Participants and descriptive data
We received 429 questionnaires from hospital nurses and 113 from nurses through social media (total n=542). Of this, 229 nurses (=42%) completed the questionnaire. The average time to complete the questionnaires was 15 minutes. The response rate based over five hospitals is 29%, for the two other hospitals, it was not clear how many nurses received the survey. The length of the questionnaire and the lack of affinity with the target group were the main reasons for not completing it. The distribution of nurses between the university hospital, non-university teaching hospitals, and general hospitals was evenly spread. Some ward managers sent it to all the nurses, and some decided to send it to a few nurses in their ward. The participating number of wards per hospital varied from one to four.
An overview of the characteristics of the nurses is presented in Table 1. A small percentage of nurses work in other hospitals types, e.g. private hospitals. In practice, most nurses work on combined wards such as medical-geriatric, medical-surgical, or intensive care. For this reason, this ward variable was an unsuitable background variable in the analyses. Almost half of the nurses were educated at a secondary vocational level, and a similar portion had a bachelor’s degree. However, in the Netherlands, nurses are educated on two different levels, vocational level and on bachelor level. In practice, they perform the same tasks. Although we report the highest completed education, the respondents were able to fill in all completed education in the questionnaire. This shows that some nurses worked with older people as a care assistant before they became a nurse. The experience of nurses was evenly spread between the groups. In all, 61.1% of the nurses worked more than 24 hours per week, of which only 9% of the nurses worked more than 33 hours per week. The group of nurses who participated via social media is comparable to the group from the northern hospitals. The nurses graded their skills in caring for patients with alzheimer disease at on average 7.2 on a scale from 1 to 10, with a range of 3 to 10. In all, 62.5% of the participating nurses completed a course on caring for patients with alzheimer disease the past year.
CHAPTER FIVE
DISCUSSION, CONCLUSION AND RECOMMENDATIONS
Discussion
This study focused on the nursing care for patients with alzheimer disease in Dutch acute hospital settings and the nurses’ attitudes toward and perceptions of this care, to gain additional insights into how nurses manage challenging behaviour, and finally, which variables influence the nursing care of patients with alzheimer disease.
Although it is not precisely known how many patients with alzheimer disease are on average in a ward, the perceptions seem to be in line with estimates of 25-40 per cent (Brooker et al., 2014; Feast et al., 2020).
The findings of nursing care show that participating nurses often perform general preventive interventions. However, they perform fewer interventions related to alzheimer disease care, such as organising activities, to prevent delirium. Previous research has shown that when preventive interventions are carried out from person-centred care, this can prevent complications (Feast et al., 2020). The literature has demonstrated that day structure, and activities are essential for patients with alzheimer disease and play a role in preventing delirium (Handley, Bunn, & Goodman, 2017; Prato, Lindley, Boyles, Robinson, & Abley, 2018). Additionally, the use of urinary catheters, of which half of the nurses in our study state to use often or always, is a possible cause of agitation and increases the risk of infections and delirium as a result (Janice L. Palmer et al., 2014). In addition, the literature has demonstrated that the use of urinary catheters influences the length of hospital stay of elderly patients because their recovery is delayed by their limited ability to mobilise (Surkan & Gibson, 2018). A possible explanation for this is that nurses have a basic knowledge of care, but no specific knowledge of interventions related to the care for patients with alzheimer disease. The low score concerning the use of tube feeding seems appropriate, regarding international guidelines, where the use of tube feeding in a temporary crisis is described as a possibility (Volkert et al., 2015). The participating nurses indicate that they often use medical and physical restrictive measures. The use of medical restraints leads to a higher risk of complications. Therefore, patients’ mobility, the situation before admission, and the perspective from the view of the person with alzheimer disease must be considered (Featherstone, Northcott, Harden, et al., 2019). The choice of medical restraints is often used by nurses as a last resort for managing challenging behaviour, because of insufficient time, to increase safety or insufficient knowledge of alternatives to restraint, but this choice is also influenced by a negative attitude and nurses’ insufficient knowledge (Hynninen, Saarnio, & Isola, 2015; Moyle, Borbasi, Wallis, Olorenshaw, & Gracia, 2011). However, our findings show that participating nurses say that they mostly ‘react with care’ as a reaction to challenging behaviour and that they use ‘professional knowledge’ as an alternative approach. These desirable reactions seem to contradict the frequent use of freedom- restricting measures. Follow-up research is needed to gain more insight into the situations that lead to the use of these restrictive measures. In addition, more research is necessary to investigate the possible preventive role of activities during admission in relation to challenging behaviour.
The nurses report various aspects related to the alzheimer disease-sensitiveness of care in their department that could be improved. The care activities could be more adapted to the needs and pace of patients with alzheimer disease. Internationally, personal care is described as the gold standard for the care of people with alzheimer disease (The American Geriatrics Society Expert Panel on Person-Centered Care, 2016). The basic principles of person-centred care are based on approaching the person as an individual from the perspective of the person with alzheimer disease (Brooker, 2004). Person-centred care is not only about the level of care providers but is also essential at other organisational levels. This means that people with alzheimer disease are also taken into account in the planning of shifts, whereby the complexity of care at the psychosocial level is higher. However, in acute hospitals, the complexity of care is determined mainly by physical aspects related to the cause of admission and are therefore not considered in the planning of shifts (Dewing & Dijk, 2016; Handley et al., 2017). Ward managers also relate planning problems to the insufficient number of nursing staff on duty (Timmons et al., 2016).
The nurses participating in our study are insufficiently aware of specific alzheimer disease-related care aspects, such as the prevention of delirium and challenging behaviour and regular use of urinary catheters. Medical and physical restrictive measures are frequently applied as an intervention in the care for patients with alzheimer disease. This seems inconsistent with how nurses indicate that they react to challenging behaviour.
Nurses express a positive attitude toward caring for patients with alzheimer disease and strive to provide adequate care. Although nurses have a strong sense of responsibility in preventing delirium, it is not clear whether they have sufficient knowledge about delirium in patients with alzheimer disease to succeed in this. In addition, nurses do not always experience the care for patients with alzheimer disease as satisfying but regularly as demanding. This phenomenon is due mostly to alzheimer disease-related aspects and particularly challenging behaviour such as restless behaviour, aggression, wandering, and disorientation.
The participating nurses feel proficient and use different approaches in managing challenging behaviour. However, they still use medical and physical restraints as necessary, despite the professional standards focusing on alternative psychosocial interventions. The nurses indicate that the training of nurses could be improved, even though this study shows a positive relation between completed a course on alzheimer disease in the last year and attitudes and perceptions. Among the research population, the given care is influenced by the hoiaspital type, level of education, and the number of hours that nurses work in the ward. Research on alzheimer disease care on the level of ward managers and directors could provide additional insights into the awareness of the importance of alzheimer disease-friendly nursing care. Finally, more research is necessary on sufficient forms of education and training, during formal education and on the job, because nurses indicate that they want to provide proper care but are insufficiently equipped to do so.
Relevance to clinical practice
In order to improve care for patients with alzheimer disease in the hospital, nurses must become aware of their ability to influence the behaviour of patients with alzheimer disease through the use of alzheimer disease-related preventive interventions. Awareness can be stimulated by deploying alzheimer disease nurses in each department, who act as role models and for teaching on the job. This requires a positive learning climate and a policy aimed at quality improvement and person-centred care. In addition, patients’ stories can be used. In future training and education, more emphasis should be put on nurses’ awareness of their skills and abilities.
What does the paper contribute to the global clinical community?
- This quantitative study confirms results from earlier qualitative studies, namely, nurses striveto provide proper care but have insufficient knowledge about caring for patients with alzheimer disease. The attitudes toward and perceptions of caring for patients with alzheimer disease in acute hospitals can be
- Aquantitative approach to a relevant topic makes international comparisons
- The attitudes and perceptions of nurses are influenced by the type of hospital where nurseswork, the level of education, the number of hours nurses, work in the ward, and if they completed a course on alzheimer disease in the last
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