Caring for older people with dementia in the emergency department.

BACKGROUND: Admission to an emergency department (ED) may expose the older person with dementia to a range of negative consequences, including a deterioration in their behavioural symptoms. The authors conducted a review of primary research relating to the experiences of older people with dementia, their carers and ED nurses, to understand how these experiences might inform nursing practice. METHODS: Integrative review with a search of the electronic databases of Medline, CINAHL and PSYCHINFO using specified inclusion and exclusion criteria. RESULTS: Three themes were identified: carers and older people with dementia-waiting and worrying; nurses juggling priorities; and strategies for improvement-taking a partnership approach. CONCLUSION: Older people with dementia may be exposed to disparities in treatment in the ED. A practice partnership between carers and ED nurses may help to prevent this. ED nurses need support to blend technical- and relationship-centred care. Participatory research exploring the experiences of older people with dementia, their carers and ED nurses is needed.

Caring for an older person with dementia in the Emergency Department (ED): An Appreciative Inquiry exploring family member and ED nurse experiences.

AIMS AND OBJECTIVES: To generate insights about what matters and is valued by family members of older people with dementia in the emergency department. To explore the experiences of emergency nurses looking after older people with dementia in an episode of care. BACKGROUND: In the emergency department, older people with dementia are at risk of suboptimal care. Little is known of the experiences of family members of being with an older person with dementia in the emergency department or the experiences of emergency nurses looking after older people with dementia in this environment. DESIGN AND METHODS: Phase 1 Data Analysis of the Discovery Phase of an Appreciative Inquiry study. Study participants were family members of older people with dementia and emergency nurses. Data collection methods included interviews with family members of older people with dementia and 30 hr of participant observation working alongside emergency nurses. This study was guided by the Standards for Reporting Qualitative Research. RESULTS: Two themes emerged from the analysis: What matters to family members with four subthemes and challenges for family members and nurses in the emergency department with two subthemes. CONCLUSION: This study demonstrates that some emergency nurses are connecting with family members even in the briefest of clinical encounters. It is feasible for more emergency nurses to do the same more of the time. RELEVANCE TO CLINICAL PRACTICE: The older person with dementia must be given a triage category of no less than 3 (to be seen by the doctor within the hour) on arrival in the department. Further education is needed to assist emergency nurses to establish rapport and incorporate family member insights as part of care planning and assessment of the needs of the older person with dementia.

Nurse's perceptions of organisational barriers to delivering compassionate care: A qualitative study.

BACKGROUND: Compassionate care is an international priority of healthcare professionals. There is little understanding about how workplace issues impact provision of compassionate care in nursing practice. Therefore, it is important to address the workplace issues and organizational factors which may hinder compassionate care delivery within nursing practice. OBJECTIVE: The aim of this study was to explore workplace and organizational barriers to compassionate care from the nurses' perspective. RESEARCH DESIGN: The study used a qualitative exploratory design, and data were analyzed by conventional content analysis. Participants and research context: A total of 15 nurses working in different fields of nursing were recruited from four hospitals at northwest of Iran. Participants were selected by purposive sampling. Semistructured interviews were conducted for data collection. Ethical consideration: Ethical approval of this study was gained from the Ethical Review Board of Tabriz University of Medical Sciences. FINDINGS: The main theme which emerged from data analysis was "unsupportive organizational culture." This theme had two main categories including "excessive workload alongside inadequate staffing" and "the lack of value on compassionate care." DISCUSSION: Organizational barriers to development of compassionate in clinical practice were identified in this study. A closer examination of these barriers is required to move compassionate practice from an individual responsibility to a collective responsibility that is owned and shared by organizations. CONCLUSION: For compassionate care to flourish, policy makers, managers, and healthcare providers must foster an organizational atmosphere conducive to compassionate care.

Clarifying misconceptions about compassionate care.

AIM: To discuss the meaning of compassionate care as it applies to staff, patients and families in health and social care settings, its application to practice and how organizational infrastructures affect the delivery of care. BACKGROUND: The term compassion has assumed headline status and inclusion in current health and social care policy. Clarity of what the term means in practice is needed and may help to promote delivery of compassionate care consistently across health and social care settings. DESIGN: Discussion paper. DATA SOURCES: This article draws on data from an action research programme (Leadership in Compassionate Care Programme, 2007-2011) that focused on embedding compassionate care into practice and education and related literature focused on compassionate person-centred care. A literature search was conducted and articles published in English relating to the terms compassionate, person-centred care between 1999-2011 were included. DISCUSSION: Perceptions of compassion, practising compassion and the infrastructure to support compassion are discussed. IMPLICATIONS FOR NURSING: It is anticipated that this discussion will prompt further debate, raise awareness and help to clarify the meaning of compassion in everyday practice with patients, relatives and staff, so that it can be more clearly named, valued and defended. CONCLUSION: This article challenges some of the beliefs and values that underpin the meaning of compassionate care and its application to practice. It brings greater clarity to the meaning of compassion, which could be used to form the basis of shared visions of caring, both strategic and operational, across organizations.

Cultivating compassionate care. .are.

The term compassion is at the forefront of current healthcare policy, yet its meaning and how it can be realised in practice is far from clear. This article debates the meaning of compassion in the context of practice and argues that it essentially involves how people relate to each other. It highlights key processes to enhance compassion with self, patients and their families, healthcare professionals and the organisation.

A qualitative study of organisational resilience in care homes in Scotland.

Providing care for the dependent older person is complex and there have been persistent concerns about care quality as well as a growing recognition of the need for systems approaches to improvement. The I-SCOPE (Improving Systems of Care for the Older person) project employed Resilient Healthcare (RHC) theory and the CARE (Concepts for Applying Resilience) Model to study how care organisations adapt to complexity in everyday work, with the aim of exploring how to support resilient performance. The project was an in-depth qualitative study across multiple sites over 24 months. There were: 68 hours of non-participant observation, shadowing care staff at work and starting broad before narrowing to observe care domains of interest; n = 33 recorded one-to-one interviews (32 care staff and one senior inspector); three focus groups (n = 19; two with inspectors and one multi-disciplinary group); and five round table discussions on emergent results at a final project workshop (n = 31). All interviews and discussion groups were recorded and transcribed verbatim. Resident and family interviews (n = 8) were facilitated through use of emotional touchpoints. Analysis using QSR NVivo 12.0 focused on a) capturing everyday work in terms of the interplay between demand and capacity, adaptations and intended and unintended outcomes and b) a higher-level thematic description (care planning and use of information; coordination of everyday care activity; providing person-centred care) which gives an overview of resilient performance and how it might be enhanced. This gives important new insight for improvement. Conclusions are that resilience can be supported through more efficient use of information, supporting flexible adaptation, coordination across care domains, design of the physical environment, and family involvement based on realistic conversations about quality of life.

Valuing compassion through definition and measurement.

The Leadership in Compassionate Care programme aims to embed compassionate care in practice and education. This article describes a project within the programme that explores with staff, patients and families the meaning of compassion and how this can be measured. The project has involved developing practice statements from noticing the aspects of compassionate care that work well. Staff were provided with support to consider, develop and implement actions that would help ensure consistency in developing compassionate care.

Exploring and developing student midwives' experiences (ESME)-An appreciative inquiry study.

BACKGROUND: There is increased focus on investing in midwifery students as our future workforce. Inquiring into what helps to support an enriched learning experience for student midwives in clinical placements is timely. AIM: To work collaboratively with key stakeholders (student midwives, midwives) in clinical placements to generate an experience-based understanding of what works well in relation to the student midwife experience and from this understanding, co-create ways to enhance students' experiences. DESIGN: An appreciative inquiry approach was used to discover what matters and what works well at present in the student midwife experience from the perspective of student midwives, midwives, and midwifery managers and to use this knowledge to create enhanced experiences in the future. Data were generated across four local health districts in New South Wales, Australia. Data were analysed using immersion crystallisation and then mapped to the 'Senses Framework'. SETTING: Four midwifery units in tertiary teaching public hospitals in NSW. PARTICIPANTS: There were 124 participants in this study: 45 midwifery students and 76 employed midwives. MEASUREMENTS AND FINDINGS: The data culminated in the refinement of the 'Senses Framework' for use in the midwifery learning context. Student midwives and midwives valued experiences that helped them to feel safe, to feel that they belong, to experience continuity in their learning and work, to have a sense of purpose, to have their achievements and their contributions to be recognised and to feel that they matter. Furthermore, the midwives themselves valued the experience of these senses in supporting them to be facilitators of learning in the workplace. The relational framework for learning together in the workplace has the potential to support achievement of the sense of security, belonging, continuity, purpose, achievement and significance for all involved. KEY CONCLUSIONS: There is much to celebrate in what is being achieved currently in promoting excellence in learning experiences in the midwifery context. In particular this study has made conscious the contribution that student midwives and midwives can and do make to enable the positive and reciprocal relationships that develop in the student midwife experience that support the nurturing of enriched learning environments. This study emphasised that learning in the workplace is a relational endeavour, rooted in the day to day engagement between student midwives, midwives and others. By mapping these positive processes to the senses framework these processes are made more explicit and provide guidance for enhancing the learning experience in the midwifery context. IMPLICATIONS FOR PRACTICE: The framework and related inquiry tools developed from the study may be useful in other settings to further test out the impact of this relational approach to learning for student midwives.

Implementation of a Complex Intervention to Support Leadership Development in Nursing Homes: A Multimethod Participatory Study.

Leadership is key to quality improvement in nursing homes. This article reports on the initial analysis of the transformational My Home Life Leadership Support program for nursing home managers being implemented in Scotland. It analyses learning from a multimethod participatory descriptive study. Contribution analysis theory informed the evaluation. Evidence-Based Practice, Relationship-Centered Care, Appreciative Inquiry, and Caring Conversations informed the intervention to develop transformational leadership. Data generation methods included baseline and postintervention questionnaires to describe culture change within the study population, together with more in-depth qualitative data generated from group discussions throughout the leadership support program. Qualitative data analysis was an iterative collaborative process with participants to generate themes about the impact of the program on themselves and their practice. Data showed positive changes in managers' perceptions of their self-awareness, leadership communication and relationship skills, and development of positive cultures. This model offers lessons for those interested in ways to approach the emotional, educational, and cultural dynamics of change in other human service contexts.

Developing Caring Conversations in care homes: an appreciative inquiry.

Relationship-centred practice is key to delivering quality care in care homes. Evidence is strong about the centrality of human interaction in developing relationships that promote dignity and compassion. The Caring Conversations framework is a framework for delivering compassionate care based on human interactions that was developed in the acute healthcare setting. The key attributes are: be courageous, connect emotionally, be curious, consider other perspectives, collaborate, compromise and celebrate. This paper reports on a study to explore its relevance to the care home setting and the development of an educational intervention, based on the framework, to enhance development of human interaction. The study used the approach of appreciative inquiry to develop Caring Conversations in the care home setting. Appreciative inquiry has a unique focus on what is working well, understanding why these aspects work well and co-creating strategies to help these good practices happen more of the time. The aim of the study was to celebrate and develop excellent human interaction that promotes dignity between staff, residents and families in care homes. The study took place in 2013-2014 in one care home in Scotland, over 10 months. Participants included staff (n = 37), residents (n = 20) and relatives (n = 18). Data generation methods involving residents, relatives and staff included observation and interviews about experiences of interaction. An iterative process of data analysis involved mapping core themes to the Caring Conversations framework with findings showing how people communicated correlated well with the Caring Conversations framework. Building on knowledge of what works well, staff developed small 'tests of change' that enabled these good practices to happen more of the time. Appreciative inquiry proved a valuable approach to exploring Caring Conversations, developing practice and developing an educational intervention that could be shared across other care settings.

Barriers to implementing an integrated care pathway for the last days of life in nursing homes.

AIM: this paper explores the barriers that needed to be overcome during the process of implementing an integrated care pathway for the last days of life as a way of developing quality end-of-life care in nursing homes. METHODS: an action research methodology underpinned the study. Qualitative and quantitative data were collected in eight nursing homes before, during and after the implementation of the care pathway. FINDINGS: six main barriers were identified: a lack of knowledge of palliative care drugs and control of symptoms at the end of life; lack of preparation for approaching death; not knowing when someone is dying or understanding the dying process; lack of multidisciplinary team working in nursing homes; lack of confidence in communicating about dying; some nursing homes are not ready or able to change. These findings highlight a functional 'rehabilitative' culture that may not be so appropriate in the current context of nursing home care, and one that makes implementing an integrated care pathway for the last days of life less straightforward than in other settings. CONCLUSION: it cannot be presumed that the implementation of a care pathway for the last days of life in nursing homes is straightforward. This study suggests that an action research framework was extremely useful in highlighting and overcoming some obstacles when developing evidence-based practice. Action at both local and public policy level is required to fully address barriers that prevent quality end-of-life care in nursing homes.

Strategies for Enhancing "Person Knowledge" in an Older People Care Setting.

This article presents findings from a study about compassionate care-the development of person knowledge in a medical ward caring for older people. Appreciative inquiry, an approach to research that focuses on discovering what works well and implementing strategies to help these aspects happen most of the time, was used. Staff, patients, and families participated in this study, which used a range of methods to generate data including interviews and observations. Immersion/crystallization was used to analyze these data using a reflexive and continuous approach to extracting and validating data. Findings uncovered that knowledge of the person and ways of promoting this were key dimensions of compassionate caring. The attributes of "caring conversations" emerged through the analysis process, which we suggest are crucial to developing person knowledge. The political and public focus on compassionate care makes it opportune to raise discussion around this form of knowledge in academic and practice debates.

Appreciative Inquiry as an intervention to change nursing practice in in-patient settings: An integrative review.

BACKGROUND: High profile accounts of failures in patient care reflect an urgent need for transformational development in healthcare. Appreciative Inquiry is promoted as an approach to exploring and bringing about change in social systems. Appreciative Inquiry has been used extensively in North American business since the late 1980s. The application of Appreciative Inquiry may have merit in the complex world of human health experiences. OBJECTIVES: To identify, evaluate and synthesise the evidence about the impact of Appreciative Inquiry on changing clinical nursing practice in in-patient settings. DESIGN: An integrative review and narrative synthesis. SETTING: In-patient settings including paediatrics, maternity and mental health. PARTICIPANTS: Nurses of all grades, patients, carers, relatives, other healthcare professionals including allied healthcare staff, management and students. DATA SOURCES: An electronic search of the following electronic databases was performed in January 2015 and updated in July 2015: MEDLINE, EMBASE, Cochrane Library (Cochrane database of systematic reviews), Cumulative Index of Nursing and Allied Health Literature, PsychINFO, PsychARTICLES, Amed, Assia, Scopus and Web of Science. Hand searching of reference lists of included studies was undertaken. Limits were set to include literature published in English only and publications from 1990 to July 2015. REVIEW METHODS: Three reviewers independently assessed eligibility for inclusion and extracted data. Full text articles were systematically appraised using a standardised data extraction instrument in conjunction with criteria to assess whether change using Appreciative Inquiry is transformational. RESULTS: Eight studies (reported in 11 papers) met the inclusion criteria. Overall, these studies demonstrate poor application of Appreciative Inquiry criteria in a nursing context. This makes judgement of the impact difficult. One study achieved transformation against agreed criteria for Appreciative Inquiry. Other included studies demonstrated that Appreciative Inquiry is being perceived as a gateway to knowledge translation rather than transformative change in practice. CONCLUSIONS: Appreciative Inquiry offers potential for nurse practice development and change but not without cognisance of the pivotal components. If Appreciative Inquiry is to be perceived as a legitimate research endeavour, there must be engagement and attention to rigour. Findings suggest caution is required against the choreography of Appreciative Inquiry where participant experiences are moulded to fit a previously drafted master plan. Further research is needed to explore the role of expert facilitation in securing and sustaining successful outcomes of Appreciative Inquiry.

Beyond tokenistic involvement of older people in research - a framework for future development and understanding.

Research and development work in health and social care are increasingly required to involve users at all stages of the research process yet there is scant empirical evidence to support the justification of this laudable aim. Evidence does suggest that at present efforts to achieve this are primarily tokenistic and that more work is needed, both to examine what user involvement in research activity actually means, and how this can best be supported. This paper sets out to describe developments to support involvement of older people through work at the Royal Bank of Scotland Centre for the Older Person's Agenda and to identify a number of challenges that this has raised for researchers. These challenges have arisen out of a number of assumptions that underpin the process of user involvement. The paper discusses some of the benefits of working in partnership with older people and identifies strategic issues for consideration in order to promote future partnership working.

Compassionate Care: Student nurses' learning through reflection and the use of story.

INTRODUCTION: Current concern in health care about delivering care that is compassionate has important implications for how compassion is taught and made explicit in nurse education curricula. This paper will describe the use of stories within the curricula to enhance knowledge and skills in compassionate caring. METHODOLOGY: The Leadership in Compassionate Care Programme (LCCP) was a 3-year action research project that sought to capture what compassionate care means within practice and utilise this learning within education. Stories gathered within clinical practice were used to stimulate reflective learning as part of a nursing module that teaches recognition of acute illness and deterioration at Edinburgh Napier University. Students listened to stories which included experiences of staff, students, patients and relatives and related these to their own experiences in practice. In this paper, examples from the online discussions are discussed with reference to one of six themes that emerged from the LCCP, that of caring conversations. FINDINGS: The discussions suggest that reflective learning and the use of stories about the experience of giving and receiving care can contribute to the development of the knowledge, skill and confidence that enable student nurses to provide compassionate relationship centred care within practice. CONCLUSIONS: Reflective learning can be a valuable strategy for students to ponder new knowledge and allow predetermined ideas to be challenged. Stories can initiate this process and help student nurses to understand not only the needs of others, but their own expectations and values, which in turn can inform how they plan and deliver person centred compassionate care.

Newly qualified Project 2000 staff nurses in Scottish nursing homes: issues for education.

The contribution of nursing homes to nurse education in the UK is growing. This article presents educational issues raised by nine senior Nurse Managers from nursing homes in one Scottish health board. The Managers were interviewed as part of a larger Scottish study of employers' views of the skills of newly qualified Project 2000 staff nurses. Perceptions of the adequacy of the skills of newly qualified diplomates in first staff nurse posts in nursing homes following registration were explored. Impressions were mixed but generally favourable. The perceived strengths - confidence, knowledge and a questioning approach, and perceived limitations - in practical and organisational skills, matched closely those of senior Nurse Managers in the NHS sector. Managers noted the significance for learning of the business and customer care ethos of nursing home care and of the exacting skill requirements of specialist and increasingly acute care demands within this sector. There was uncertainty about and concern to strengthen preceptorship support. Matters for debate include the adequacy of telephone support versus in person on-site support for newly qualified nurses, whether expectations of initial performance are realistic and whether skill requirements differ between independent and NHS sectors. The potential value of NHS and independent health care inter-sectoral dialogue and networking is suggested.

Enhancing partnerships with relatives in care settings.

AIM: The aims of this project were to implement guidance that sought to involve carers of older people in decision-making processes, and to promote practice development through work-based learning. METHOD: Data were collected and analysed to examine how carer involvement was being managed on the wards. The data were then fed back to staff in each area and meetings were held to discuss which aspects of carer involvement were priorities for them. These were then matched with the four markers of satisfactory involvement identified in a previous study (Walker et al 1999). RESULTS: Several strategies were implemented to enhance carer involvement, including life story work, written communication books and a newsletter. Early feedback from the project highlighted benefits for staff and relatives, which included greater confidence in negotiating care and closer relationships between relatives and staff. CONCLUSION: If carer involvement in care is to become a reality, staff need support and encouragement to develop meaningful relationships with relatives and to value their expert opinions.

Developing compassion through a relationship centred appreciative leadership programme.

BACKGROUND: Recent attention in health care focuses on how to develop effective leaders for the future. Effective leadership is embodied in relationships and should be developed in and with staff and patients. This paper describes development, implementation and evaluation of an appreciative and relationship centred leadership programme carried out with 86 nursing staff covering 24 in-patient areas within one acute NHS Board in Scotland. AIM OF LEADERSHIP PROGRAMME: The aim of the programme was to support staff to work together to develop a culture of inquiry that would enhance delivery of compassionate care. THEORETICAL UNDERPINNINGS: The 12 month Leadership Programme used the principles of appreciative relationship centred leadership. Within this framework participants were supported to explore relationships with self, patients and families, and with teams and the wider organisation using caring conversations. STRUCTURE OF PROGRAMME: Participants worked within communities of practice and action learning sets. They were supported to use a range of structured tools to learn about the experience of others and to identify caring practices that worked well and then explore ways in which these could happen more of the time. METHODS: A range of methods were used to evaluate impact of the programme including a culture questionnaire and semi structured interviews. Immersion crystallisation technique and descriptive statistics were used to analyse the data. FINDINGS: Key themes included; enhanced self-awareness, better relationships, greater ability to reflect on practice, different conversations in the workplace that were more compassionate and respectful, and an ethos of continuing learning and improvement. CONCLUSIONS: The programme supported participants to think in different ways and to be reflective and engaged participants rather than passive actors in shaping the cultural climate in which compassionate relationship centred care can flourish. Multidisciplinary programmes where the process and outcomes are explicitly linked to organisational objectives need to be considered in future programmes.

Supporting the development of interpersonal skills in nursing, in an undergraduate mental health curriculum: reaching the parts other strategies do not reach through action learning.

The centrality of therapeutic relationships is considered to be the cornerstone of effective mental health nursing practice. Strategies that support the development of these skills and the emotional aspects of learning need to be developed. Action learning is one such strategy. This article reports on a qualitative research study on the introduction of Action Learning Sets (ALS) into a Pre-registration Mental Health Nursing Programme. This teaching and learning methodology was chosen to support the emotional aspects of learning and mental health nursing skills. Four themes were identified: developing skills of listening and questioning in 'real time', enhanced self-awareness, being with someone in the moment--there is no rehearsal and doing things differently in practice. Students and lecturers found the experience positive and advocate for other Pre-registration Mental Health Nursing Programmes to consider the use of ALS within the curriculum.

Caring about caring: developing a model to implement compassionate relationship centred care in an older people care setting.

AIM: This study actively involved older people, staff and relatives in agreeing a definition of compassionate relationship-centred care and identifying strategies to promote such care in acute hospital settings for older people. It was a major component of a three year programme (the Leadership in Compassionate Care Programme, LCCP) seeking to integrate compassionate care across practice and educational environments. BACKGROUND: Compassionate caring and promoting dignity are key priorities for policy, practice and research worldwide, being central to the quality of care for patients and families, and job satisfaction for staff. Therapeutic relationships are essential to achieving excellence in care but little is known about how to develop and sustain such relationships in a culture that increasingly focuses on throughput and rapid turnover. APPROACH AND METHODS: The study used appreciative inquiry and a range of methods including participant observation, interviews, story telling and group discussions to actively engage older people, relatives and staff. A process of immersion crystallization was used to analyze data with staff as co-analysts. FINDINGS: The study adds considerably to the conceptualization of compassionate, relationship-centred care and provides a model to aid staff deliver such care in practice, based on 'appreciative caring conversations' that enable all parties to gain two forms of 'person and relational knowledge' about 'who people are and what matters to them' and 'how people feel about their experience'. Such knowledge enables staff, patients and carers to 'work together to shape the way things are done'. The study generated a model called the 7 'C's that captures in detail the factors necessary to promote 'appreciative caring conversations'. CONCLUSIONS AND IMPLICATIONS: The study demonstrates that engaging in 'appreciative caring conversations' promotes compassionate, relationship-centred care but that these conversations involve practitioners taking risks. Such 'relational practices' must therefore be valued and accorded status. Staff require appropriate support, facilitation and strong leadership if these practices are to flourish.