How do emergency department staff respond to behaviour that challenges displayed by people living with dementia? A mixed-methods study.

OBJECTIVES: To investigate staff experiences of, and approaches to behaviour that challenges displayed by patients with dementia in the emergency department (ED). Behaviour that challenges is defined as 'actions that detract from the well-being of individuals due to the physical or psychological distress they cause within the settings they are performed', and can take many forms including aggressive physical actions, shouting and verbal aggression and non-aggressive behaviour including repetitive questioning, inappropriate exposure and resistance to care. DESIGN: Mixed-methods study consisting of an online survey and semistructured telephone interviews. Quantitative data were analysed and presented using descriptive statistics. Qualitative data were analysed thematically. SETTING: The EDs of three National Health Service (NHS) Hospital Trusts in Southwest England. PARTICIPANTS: Multidisciplinary NHS staff working in the ED. RESULTS: Fifty-two online survey responses and 13 telephone interviews were analysed. Most (24/36, 67%) survey respondents reported that they had received general training in relation to dementia in the last 2-5 years, however, less than a fifth (4/23, 17%) had received any ED-specific dementia training. All (48/48) felt that behaviour that challenges could potentially be prevented, though resource constraints and practice variation were identified. Four main themes emerged from the qualitative data: (1) the 'perfect storm' of the ED; (2) behaviour that challenges is preventable with the right resources; (3) improvisation and (4) requirement for approaches that are specific to the ED. CONCLUSIONS: The findings of this study suggest that ED staff do not feel that they are prepared to respond effectively to behaviour that challenges displayed by people living with dementia. Future work could adapt or develop an intervention to support ED staff in responding to behaviour that challenges.

Managing behaviour that challenges in people with dementia in the emergency department.

Dementia symptoms can manifest in a variety of ways, such as anxiety, agitation and an inability to communicate unmet needs. In emergency departments (EDs), these symptoms, as well as various environmental factors, can lead to behaviour that challenges in people with dementia. Therefore, ED staff must be skilled in screening, assessing and managing this patient group effectively. This article details a literature review that was conducted to explore the evidence on managing behaviour that challenges in people with dementia in the ED and what de-escalation strategies may be useful. A literature search of eight databases was undertaken, resulting in 11 articles that were included in this literature review. Four main themes were identified: violence and aggression towards staff; manual and chemical restraint in the ED; identifying delirium and dementia; and environment and person-centred care. Strategies identified to de-escalate and reduce the risk of behaviour that challenges include: making environmental modifications to the ED; providing person-centred care; excluding or evaluating pain and unmet needs; using various tools and strategies to improve communication; and using distraction techniques.

A multiple case study of patient journeys in Wales from A&E to a hospital ward or home.

The health service is having to plan for an increasingly older population putting extra demand on services, with a greater emphasis on providing care at home. A health board in Wales brought in an Early Response Service, which assessed whether patients attending accident and emergency needed to be admitted to hospital or could receive care at home. This qualitative study looked at the experiences of both patients and staff members in both settings. A multiple case study was undertaken using semi-structured interviews. The theoretical framework was derived from Kolcaba's comfort theory and the bio-psycho-social model. Staff were identifying the most suitable patients for care at home and all hospital admissions were necessary, as the patients required greater medical/surgical intervention than those cared for at home.