Healthcare professionals may not be maintaining person-centred care for people with dementia hospitalised on acute wards
- Correspondence to: Dr Joseph E Gaugler, School of Nursing, 6-153 Weaver-Densford Hall, 308 Harvard Street SE, Minneapolis, MN 55455, USA;
Implications for practice and research
Healthcare professionals in acute care require additional education to implement person-centred care of persons with dementia.
Person-centred care in hospital settings can be enhanced through the promotion of attachment, inclusion, identity, occupation and comfort.
Organisational factors, such as productivity goals, may influence the implementation of person-centred care in acute care settings.
Many organisations have identified person-centred care as key to promoting quality of life for persons with dementia. The majority of efforts to enhance person-centred care have largely occurred in residential long-term settings as part of a multipronged effort to enact culture change and make these environments less ‘institutional’. However, less research has focused on acute care settings as sites to promote person-centred care in persons with dementia, due in part to the short-term stays that often define such settings. Utilising the five domains of Kitwood's1 model of personhood in dementia (identity, inclusion, attachment, comfort and occupation) as an a priori theoretical framework, Clissett and colleagues examined the person-centred care process for cognitively impaired older adults in acute care.
A multimethod qualitative data collection strategy was used to apply Kitwood's personhood framework to identify whether core elements of person-centred care were apparent for hospitalised persons with dementia. Thirty-four patients over the age of 70 and their relatives were initially recruited from two acute care wards from the East Midlands region of the UK. A screening process identified 29 patients with cognitive impairment, who became the focus of the analysis. Seventy-two hours of observational data on the acute care wards were collected and 30 formal interviews with family caregivers and persons with dementia were conducted following patients' discharge. Field notes and interviews were transcribed, and two researchers coded the data to ascertain whether the core elements of Kitwood's person-centred care framework were apparent or whether ‘opportunities were missed’ to provide such care.
Person-centred care for persons with dementia occurred in pockets; while some acute care professionals appeared to promote certain elements of personhood (attachment and inclusion) there were fewer instances of person-centred care in the other domains (identity, occupation and comfort). For example, continuity of staff care and appropriate communication appeared to promote attachment in persons with dementia. Alternatively, lack of personalisation of the person's environment or absence of meaningful activity appeared detrimental to the identity and occupational elements of personhood, respectively.
The care complications that dementia pose to persons while hospitalised and their families demand greater attention. Over the past 20 years, residential long-term care environments have engaged in ‘culture change’ efforts to enhance person-centred care and empower staff to deliver such care.2 Given the organisational barriers that often stymie culture-change initiatives in residential long-term care, encouraging person-centred care in hospital settings, which are fully ensconced in the philosophies and financing mechanisms of acute care, may prove even more challenging.
Much to their credit, Clissett and colleagues note that there are a wide range of interpretations of person-centred care across healthcare disciplines. Similarly, some point out that the term ‘person-centred’ is becoming so pervasive that any approach to dementia care now has to use it to remain politically correct.3 Using the Kitwood model as a framework alongside observational and semistructured interviews yielded rich qualitative data to describe the strengths and gaps in the process of care of those with dementia in hospitals. We are hopeful that the insights offered will lead to stronger operationalisation of the construct of person-centred care and thus more appropriate measurement protocols.4 ,5 Ideally, the accumulation of these efforts will result in more effective clinical and system-level initiatives to assist persons with dementia and will determine whether person-centred care is actually occurring, or in the words of Clissett and olleagues, identify ‘opportunities that are missed.’