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Parallel Session P5 - Nursing home care

Detailed Programme and abstracts

Friday, 1 October – 14.00-15.30 (Red Room)

P5.1. Enhancing nursing students’ understanding of the experience of a person facing dementia by interviewing a close family member of that person.

Margrét Gústafsdóttir, Faculty of Nursing, Eirberg, Eiriksgata 34, 101 Reykjavik, Iceland; University of Iceland;

Gerontological Nursing is taught in the spring semester in the third year of a four-year baccalaureate programme of nursing in Iceland. On entry into the course most of the students have some experience of working with the elderly, especially in nursing homes, and often they have not found it very challenging. The students tend to see most residents of nursing homes as quite similar, and more or less “out of it” and “very demented”.

A large proportion of the ten-unit course is, in spite of that, or rather because of that, devoted to nursing care of persons suffering from dementia, not least during the clinical time. Different means have been explored of finding ways to open the students’ eyes to the individual experience of a person facing dementia, and that of his or her family. The two most successful approaches so far have been, on the one hand, to place the students in special units for people with dementia, mostly daycare units, and on the other hand to organise an interview with a close family member.

This presentation will focus on the latter approach, which has been organised as a clinical assignment with the necessary and very valuable input of the RNs in the respective units. The RNs know the relatives of the clients staying in the unit very well, and they have chosen a few particularly involved family members to contact, and then asked each of them if they would be willing to meet with a nursing student for a confidential interview for an hour or so, either in the relative’s home or in the unit. Before the interview, each student has been in the unit and attended to the person to be discussed with the family member. All the students are then required to follow an interview guideline during their meetings with the family members, in order to focus and frame the interview. Also, when each interview is arranged, it is made quite clear that all information revealed during the interview is strictly between the student and the family member, and will not be brought back to the unit. The interview guideline will be introduced and addressed during the presentation. The students are not allowed to tape the interviews, but they can certainly make notes as the interview proceeds. The students must not, of course, refer to any true names when they write up the interview-based narratives, for evaluation of their work in the course, but they can use pseudonyms. Each narrative throws light on the experience of the person facing dementia, in the words of a close family member, who is one of the person’s nearest and dearest. The students seem to realise very clearly, during the process of writing up the narratives, what it entails to go through the disease process of dementia, as well as the family responses to the changes of behaviour of the person, and different pattern of daily life following in the wake of the disease process.

The emerging new insight evoked by different narratives is, especially, reflected in the way in which the students talk about people with dementia after meeting with the relatives. The students’ manner of talking about people with dementia and the family concerned before and after the interviews will be clarified with a few anecdotes in the presentation.

It will also be emphasised that the RNs in the units have been very positive about this assignment carried out by the students, as they find such meetings between a student and a relative to be beneficial for the family facing dementia.

P5.2. The Imagination method; A new approach for caregivers of people with dementia in nursing homes

Van Dijk, A.M. 1, Dröes. R.M. 2, Van Weert, J.C.M. 3

1 Department of Psychiatry, Alzheimer Center, EMGO, VUmc. Address: Valeriusplein 9, 1075 BG Amsterdam, The Netherlands. E-mail:; 2 Department of Psychiatry/Department of Nursing home medicine, Alzheimer Center, EMGO, VUmc. Address: Valeriusplein 9, 1075 BG Amsterdam, The Netherlands, E-mail:; 3 Amsterdam School of Communication Research UvA. Address: Kloveniersburgwal 48, 1012 CX Amsterdam, The Netherlands. E-mail:

Background: The iImagination method, developed by Theater Veder, is being implemented on a large scale in nursing homes with residents with dementia. Caregivers are trained in the use of theatrical stimuli in combination with elements of proven care methods, such as Reminiscence and Validation Therapy. The purpose is to stimulate the reciprocity in care relations of caregivers and persons with dementia (PwD) and to enhance the personal identity and self-esteem of people with dementia by activating their long term memory. The aim of this study is to describe the Imagination method and its implementation on psychogeriatric nursing home wards as well as to evaluate the effect of its application on people with dementia and their professional caregivers.


Phase 1: Description of the Imagination method based on literature study and participant observation of Imagination method group activities

Phase 2: Process-evaluation of the implementation by means of interviews with key figures (e.g. managers, nurse assistants, activity therapists).

Phase 3: Impact of the Imagination method on people with dementia and caregivers:

- 70 PwD receiving an Imagination method-activity are compared with 70 PwD receiving a usual reminiscence activity. Different aspects of behavior and quality of life are three time points: (t1) pretest; (t2) during the activity and; (t3) posttest.

- Five focusgroups with each 6 to 8 caregivers and volunteers who have been trained in the Imagination method will be conducted in order to discuss job satisfaction and the applicability and usefulness of the Imagination method.

Results: Phase 1 and 2 are finished: (1) Based on systematic participant observation, a detailed description was made of the Imagination method as a group activity regarding the use of theatrical stimuli, quality of communication and PwD reactions. The use of songs, validation and one to one communication had positive effects on PwD reactions. (2) The process-evaluation resulted in an inventory of facilitators and barriers of implementation of the Imagination method as a group activity by using the ‘implementation process evaluation-framework’. Examples of important facilitators of implementation were enthusiasm, support and involvement of every level in the organisation, the presence of a project plan, the presence of stable key figures and contact person, appointing a ‘core-group’ and building in standard evaluation-moments. Examples of important barriers of implementation were insufficient communication about mutual expectations between implementator and the nursing home, lack of management-support, lack of support by the implementator on implementation in daily care, insufficient time for caregivers to prepare and practice the Imagination method.

Conclusion: The Imagination method is a new method which aims to enhance the reciprocity in care relations of caregivers and PwD. The first two phases of the study resulted in a clear description of the Imagination method and insight in facilitators and barriers of implementation. The outcomes of this study can be utilized by care providers who want to implement this method in care homes and nursing homes. Currently, the Imagination method is applied as a group-activity only. Further investigation is needed to explore how to integrate (elements of) this method in 24-h dementia care. The study results of the impact study (phase 3) are expected in December 2010.

P5.3. Criteria to determine appropriateness of hospital admission in nursing home residents with dementia: A systematic review

Anna Renom1, Adriel Ortega2, Eva Mann3, Lisbeth Uhrenfeldt4, Gabriele Meyer5.

1 Institute of Nursing Science. University of Witten/Herdecke. Witten, Germany.

2 Institute of Nursing Science. University of Witten/Herdecke. Witten, Germany.

3 General Practice and Institute of Health Services Research. Rankweil, Austria.

4 Regional Hospital Horsens and Brædstrup. Horsens, University of Aarhus,, Aarhus, Denmark.

5 Institute of Nursing Science. University of Witten/Herdecke. Witten, Germany.

Introduction: Residents of long-term care facilities (LCTF), mainly those with dementia, are at high risk of being transferred to the hospital. Admission to hospitals can encompass residents’ distress, risk of iatrogenic illness, adverse events and deterioration in mobility and cognition. The prevalence of inappropriate transfers to hospital widely varies throughout studies (10-64%), leading to different conclusions. This variability can be partly due to different definitions of appropriateness. The review of the theoretical basis is a first step for the development of interventions aimed to reduce inappropriate referrals. These interventions may increase the quality of care, especially in dementia and end-of-life, and save costs.

Objectives: To review the criteria existing in the literature for determining the appropriateness of hospital admissions in LTCF residents, with special focus on dementia.

Methods: A working team has been established by five researchers from Austria, Denmark and Germany. A research protocol has been developed and finalized. The systematic review comprises: 1) A literature search limited to the last 10 years in MEDLINE and CINAHL, using the following inclusion criteria: prospective and retrospective studies; inclusion of long-term care residents referred to hospital emergency departments or hospital wards; availability of data on diagnostic and/or therapeutic procedures; papers which administer, develop and use or derive criteria to assess appropriateness of the referral. 2) Quality assessment, performed independently by the reviewers; the methodology will be defined according to the design of the studies retrieved, any disagreement will be resolved by discussion. 3) Literature overview.

Results: 183 records have been identified through the systematic search and 27 through other sources. After screening, 36 records have been assessed for eligibility and 18 have finally been included. The systematic search is still to be completed by further search in CINAHL, related articles checking and primary authors’ request. The findings as far include high variation in different aspects: definition of appropriateness (preliminary: more than 7 different definitions); prevalence of inappropriateness; perspective of judgement (appropriateness vs. preventability); organisational aspects; clinical approaches (therapeutic vs. palliative)..

Conclusion: The systematic review is still in progress. It will reveal an overview about internationally available papers on appropriateness criteria for hospital admission in LTCF residents and therefore provide a good basis for complex intervention development.

P5.4. Continuing to care for people with fdementia: Irish family carers’ experience of their relative’s transition to a nursing home

Murna Downs[i], Elaine Arygle2, (authors of report)

Grainne McGettrick (3) (writer of abstract)

1 Bradford University, England

2 Bradford University, England,

3 The Alzheimer Society of Ireland, Ireland

Little is known about the experience and the role of Irish carers when the person (with dementia) they care for has been admitted to a nursing home. There is also a commonly held myth that family caring ceases upon admission. The pre and post transition phase was the focus of a piece of qualitative research carried out by the University of Bradford for the Alzheimer Society of Ireland and St. Luke’s Home. The purpose was to examine carers’ experiences of the transition that would provide evidence-based guidance for the development of initiatives for carers. A range of issues are addressed in the research including the carers’ key influences in making the decision to admit the person, the actual experience of making the transition, the changing role of the carer, the types of roles carers want and how they can be supported in these roles. The researchers used a qualitative approach using both semi-structured interviews, one to one interviews incorporating ‘photo voice’ method and focus groups. The grounded theory approach was used to analyse the data. The findings indicate that the key influences in pursing long term care were an accumulation of a range of contributory factors. The process of transition was characterised by conflicting emotions ranging from relief to guilt, bereavement and loneliness. Carers’ adjustment to the process of transition was facilitated by their perceived quality of the long stay setting, their familiarity with the long stay setting and by the receipt of emotional and spiritual support. The carers’ role following transition was characterised by continuity on the one hand and change on the other. Carers maintained continuity in their caring role by continuing to spend time with their relative and continuing to perform some practical tasks. The key change to their caring role was in taking on the role of quality assurance. All carers wished to be able to continue to participate in the long term care of their relative. Some carers saw the admission of their relative as an opportunity for them to resume their own lives. Carers felt that these aspirations could be filled by establishing good lines of communication with staff, having information and education about dementia and dementia care and having ongoing emotional support. The research has led to the development of a range of recommendations. These recommendations identify the need for significant development of community based services especially respite care services which were acknowledged as a crucial service to support the transition. The ignorance and stigma and both dementia and long-term care need to be challenged through appropriate awareness and education measures. Nursing home managers need to promote person centred care via dementia specific training and education for staff and quality improvement methodologies such as Dementia Care Mapping to promote quality service provision. The development of a pilot intervention-based programme to engage and support carers pre and post transition would further contribute to the learning needed in this area. Education, information and support for family carers are essential as is professional education for a range of health care personnel. As a small-scale qualitative study, this work could be further enhanced by additional research to enhance the knowledge and evidence base for initiatives to support carers.

P5.5. Organisational and personal determinants of the use of physical restraint in Luxembourg nursing homes

Wolfgang Billen

Prof. Dr. Dieter Ferring, University of Luxembourg, Integrative Research Unit; Social an Individual Development (INSIDE)

Introduction: The use of physical and other forms of restraints is still a major issue in the institutional care of people with dementia. Restraints can be used in an area not regulated by law as is sometimes the case in Luxembourg. Furthermore, professional care givers from different countries working in Luxembourg have different training and cultural backgrounds. An interesting question is how many people with dementia in Luxembourg are concerned by physical restraints in this specific situation and what justifications for applying these measures are given by the professionals in nursing homes. In general, one may distinguish here between official reasons such as the risk of falling, and more implicit “unofficial reasons” such as “fear of the relatives” or “anticipation of legal problems in case of a fall”. Guiding research questions of the study were: how important are these “unofficial reasons” to get to the decision of using physical restraints and how stressful is this for the nursing staff members? Which conclusions do we have to draw for the development of training to reduce physical restraints?

Method: In this study, which was carried out in November 2009, 10 nursing homes in Luxembourg were involved. A questionnaire was distributed to 886 nursing workers and to 35 management members of nursing home units. A total of 27.1% of the nursing workers and 51.4% of the management replied to the questionnaire and this comparatively high response rate shows the importance of the subject for professional care givers.

Results: Data analysis showed that a comparatively high rate of nursing home residents in Luxembourg (53.5%) is concerned by physical restraints. Moreover, a total of 61.8% receive psycho-pharmaceutical drugs, and 42.7% of the residents live in “locked” units. Concerning the reasons for applying physical and other restraints 50.9% of the nursing staff members reported that they use physical restraints out of fear of the relatives; altogether 43.3% reported fear of legal problems – thus preferring implicit unofficial reasons in decision making.

The study also showed that many nursing workers evaluated specific kinds of physical restraints not as a limitation of the individual freedom of the elderly person: thus, 37.1 % did not consider bedrails as a physical restraint. Furthermore, 25.4% of the respondents indicated that waist belts are no physical restraints and 47.3% had the same evaluation regarding chair tables.

Conclusion: Results indicate that the issue of physical and other restraints still may be considered as a social and legal taboo involving a high rate of psychological stress for the nursing staff members. Training to reduce physical restraints should not only offer possibilities to reduce e.g. fall risk but also include a discussion about the rights of elderly people with dementia and the fundamental value of individual freedom. The importance of the “unofficial” implicit reasons in decision making should be given special emphasis.



Last Updated: Wednesday 03 November 2010