As the whole World United Kingdom is facing the problem that population is ageing (Office of National Statistics, November 2018). Next decade the number of people over 65 years with care needs is expected to rise by 61 per cent (The King’s Fund). With ageing population healthcare changes (Wittchen et al.2011 cited in Heese K, 2015). Many societies still don’t recognise that ageing is a major risk for dementia (Exalto et al 2014; Llibre 2013; Manavalan et al. 2013; Negash et al. 2013; Sato and Morishita 2013; Tolppanen et al. 2014, cited in Heese, K. 2015),and it’s high effect for healthcare (National Institute on Aging (NIA), National Institute of Health (NIH), U.S. Department of Health and Human Services and World Health Organisation (WHO) 2011). Ageing population requires more trained nursing and healthcare team who have excellent communication and teamwork skills, or it will be the burden to the healthcare system. The King’s Fund (2018) states that deficiency of essential workforce and insufficient funding for training places makes working life of existing staff difficult. Dementia patients have longer hospital attendance for the same treatments than other patients and this causes financial pressure to NHS. (Alzheimer’s Society Report 2009), to avoid it, healthcare professionals must know how to communicate with dementia patients, how to deliver safe care and improve dementia patient’s wellbeing. Without acknowledging dementia barriers have easily become, patients are described as aggressive, confused, hard to manage. This is a big issue due lack of permanent staff and agency or temporary staffing is involved in care. Increased workforce is required to support patients with dementia because many of them have additional care or support needs due to confusion, lack of understanding or progression of the disease. It is important that the whole team is included and involved to get to know how to communicate with those who are victims of dementia. So long the team doesn’t work as one communication bridges are not effective. For example, when nurses are aware of dementia in very high level, but other team members such as students or healthcare assistances don’t know how or doesn’t want to involve in some reason then this will cause disturbance of quality of care team delivers. All examples from placement and previous work experience are written in full confidentiality and patients, staff or places where it happens have not disclosed as NMC (2018) requires.
Teamwork is fundamental for nursing care (St Pierre et al 2011 cited in Gluyas, H. 2014). Without it or low levels of understanding of the importance of teamwork team cannot be successful. A team is as strong as the weakest chain, human errors are easy to raise due to long shifts, low levels of staffing, special patients existing, lack of training, low morale- such as cutting corners, uninterest to develop and change things or way to work. Poor teamwork resulting in errors and unwanted outcomes (Walker 2008, Donohue and Endacott 2010, Lee et al 2012, Lyons and Popejoy 2014, cited in Gluyas, H. 2014). Eduardo Salas’ ‘Big five’ framework of teamwork is based on behaviours and explains the dynamics of teamwork (Kalisch et al 2010 p. 43, cited on Kaiser JA, 2018). The ‘Big Five’ model explains components of highly effective teams, where team always reflex knowledge, skills and attitudes. The successful team has a clear common purpose, everyone knows their responsibilities, staff members compensate for each other, provide feedback between team members, self-correct, take responsibility for their and each other’s actions and needs, regulate and coordinate strategies if need, value the common purpose over individual goals. Teamwork depends on its members’ ability to coordinate their activities effectively and professionally. Teamwork increases the productivity of nursing work, promotes quality of care and patient safety and reduces nurses stress levels (Kalisch & Lee 2009, cited Kaiser JA, 2018).
Good teamwork and effective communicating are essential to approve patient safety and care. (Salas, Cook, and Rosen, 2008, cited in Kaiser JA, 2018). Teamwork involves whole staff members working together to achieve a common purpose (St Pierre et al 2011, cited in Gluyas, H. 2014). I was witnessing on placement how nurses supported each other; one nurse had 2 dementia patients in the bay who needed extra attention and support. When one nurse completed her medication administration round then she offered her help to finish another nurse medication round while she was busy with special tasks. This was very nice to see how 2 confident nurses where the back of each other- this reflect a sign of the strong teamwork and nursing ethics uphold (NMC 2018) to deliver effective care and maintain patient safety in a very busy ward. Nurses worked together and improved each other’s weaknesses efficiently and effectively (Kalisch et al 2010, cited in Kaiser JA, 2018).
Teamwork includes co-operating, co-ordination and communication between staff members to approve the best purpose. It should be clear what is the desired outcome, where the whole team knows their roles and responsibilities. Communications between the members are essential to achieving the common purpose, if additional assistance is required then it should be requested. Situations should be monitored by reviews, adjustments, adaption, and reallocation of the tasks may be required if there is need of it. Information should be shared between team members, communication should be clear, correct terminology in use. Acknowledge communication and ensure by clarification (closed loop communication) (Miller et al 2009, Baker et al 2012, Gluyas and Morrison 2013, cited in Gluyas, H. 2014). Strong teams communicate effectively by sharing ideas and knowledge constantly by written records and verbally by using brief and debriefing (WHO 2011). It is expected from nurses to uphold great communication skills to maintain effective safe care to patients. (NMC 2018).
High standards of communication ensure workplace effectiveness and its competency to deliver great quality and safety. Communication is vital for every aspect of the teamwork, it improves knowledge, creates relationships, is helpful to avoid predictable performance patterns, supports leadership and coordinates teamwork. Usually the sender has an idea that he transfers into a message, delivers it to receivers, who giving feedback of received idea. Two ways communication ensures that sender and receiver are sure and clear of the meaning of the information in the same way. It helps to eliminate and minimise misunderstandings and ensures that sent message is obtained correctly. Challenges of the communications are described as a system, message and reception failures, that happen when individuals have a failure of receive or transfer information or their message is incorrect (CAA 2006, cited in WHO 2009). Communication failures are resulting harm to the patient (WHO 2009). Communication failures can occur in handovers, poor record keeping in patients’ files, not reporting incidents, the hierarchy in wards where those in lower level don’t have a voice, failure to communicate effectively between different organisations.
Even good teamwork may face challenges when poor communication affects the patient’s safety. In placement, most of the team was working as a one in common purpose and there were clear instructions what are everyone responsibilities, then there was an issue with one student nurse. I was told on placement from another more experienced student nurse to help her in a certain task. I knew that it was inappropriate for that patient and I explained it to the student. She wasn’t happy about my response and didn’t believe me- probably because I am a first-year student from another university. I asked her to go and clarify from another staff member. Staff stopped her attempting with an explanation that she nearly put the patient to risk. I reported that near miss to nurse and nursing team was discussing it with a student. I was concerned about that student performance and communications skills because just assume but not clarify what are patients’ abilities isn’t sign of the safe practice. A nurse also told me not to lose my voice, she said that sometimes some people don’t appreciate first-year students as a fresh eye and don’t listen to them. Also, all nursing team told us, that we need to work in our limitations (NMC 2018) and if we aren’t confident, or we are unsure, then we must ask help or guidance.
Communication barriers may occur due to the hierarchical system in healthcare between newly qualified and senior staff in the same profession (Nugus et al 2010, cited in Gluyas, H. 2014). Hierarchy causes communication failures due to professionals at a lower level may not challenge senior staff member, are uncomfortable to raise concerns or seek advice. This may lead to communication failure where new staff may not disclosure concerns about patient safety (Reid and Bromiley 2012, cited in Gluyas, H. 2014). I was a witnessing when a senior nurse told new nurse not to complete a task because it has a very small benefit for the patient. Young nurse was listening but wasn’t satisfied and didn’t feel valued. I have had in my experience in work, where I as new temporary HCA reported to nurse in charge that I have a concern about certain dementia patient and asked guidance to improve care to avoid patient to develop a pressure ulcer. I got ignored and a look down that made me feel very small and a nurse even didn’t come to see that patient. End of that day patient developed a pressure ulcer, I was reported it to nurse, again she didn’t come to see patient, just sent another healthcare assistant with cavilon cream. I discussed that situation with the manager and aren’t volunteer to work there anymore. Now as a student nurse and more experienced nursing assistance I know that there were many options to support this patient, we could change mattress, use inflatable shoes and include one to one support staff who could give patient extra attention and relief patient anxiety and confusion. Also, I learned from that situation that we should not ignore other staff members who are raising concerns- doesn’t matter what level they are working, because we all have the same purpose to look after patient’s wellbeing and safety and deliver the best care.
Studies suggest that poor teamwork can be challenged by educating individuals and whole team throughout competency training (Gaston et al, 2016. Salas et al, 2008, cited in Kaiser JA, 2018). There are many strategies and tools to improve communication processes, including education and training to achieve higher quality communication between team associates’, others who are involved in patient care and of course patients themselves. Strategies should improve understanding of occurring challenges and uplift level of teamwork and communication (Stead et al 2009, Gorman et al 2010, Baker et al 2012, Bunnell et al 2013, cited in Gluyas, H. 2014). Strategies that improve communication include checklists and read-back protocols, the practice of communication tools and briefing and debriefing information when handover in teams (Gorman et al 2010, Knox and Simpson 2013, Brady et al 2013, Goldenhar et al 2013, Lyons and Popejoy 2014, cited in Gluyas, H. 2014). Briefing and debriefing are useful to understand common agreement of responsibilities and purpose to achieve (Wachter 2012, Goldenhar et al 2013, cited in Gluyas, H. 2014). Briefings are helpful to notify reviews and changes in ongoing care and responsibilities or share concerns or highlight new important information (Brady and Goldenhar 2014, cited in Gluyas, H. 2014). Debriefings are effective to the team to discuss occurred errors and success cases (St Pierre et al 2011, cited in Gluyas, H. 2014), they support staff performance, recognise errors and give a chance to speak up. The good team ensures a safe, blame-free environment for feedback, where all members of a team can discuss openly (Wachter 2012, cited in Gluyas, H. 2014).
Structured communication tools, such as SBAR tool are effective to acknowledge problems and improve effective communication (Lee et al 2012, cited in Gluyas, H. 2014).Tools support communication between medics in response to concerns about patient’s condition (Gluyas and Morrison 2013, cited in Gluyas, H. 2014). SBAR tool is useful for considering the patient’s condition by indicating a current situation, medical background, assessment what concerns, response how and how fast to eliminate the concern. SBAR is also a structured communication tool for sharing information between other medics (Porteous et al 2009, cited in Gluyas, H. 2014) and it helps decrease failures of communicating (Lee et al 2012, cited in Gluyas, H. 2014). The CUS tool is ideal for the guidance of communication and useful for resolving communication challenges that are caused by the hierarchy. This framework provides a communication process for escalation, by focussing to safety concern that other members of the team aren’t aware (Mackintosh and Sandall 2010, cited in Gluyas, H. 2014).CUS tool is used only for serious vital issues to ensure patient safety and includes communication induces by expressing concern, uncomfortable and indicate a safety issue.
Dementia care quality is under attention in the UK and focused on improvement (Alzheimer’s Society 2009).The VIPS framework supports people with dementia, it includes valuing dementia patients and their care staff, treating them as individuals, looking world from dementia patient perspective, creating a positive social environment. The UK hospital staff is described as untrained and unskilled and not meeting patient with dementia needs (Thuné-Boyle I.C.V, 2010) in acute medical settings (e.g., Dewing & Dijk, 2016; Francis, 2013, cited in Hung L, 2018). Hospitals fail toprovide basic care needs for dementia patients, such as feeding, drinking, washing, dressing, toileting. Engagements activities poor or not existing. (Spencer K, Foster PER, Whittamore KH, Goldberg SE, Harwood RH, 2013).Also, had been suggested that hospital staff is enable to deliver person-centred care for dementia patients (Francis, 2013; Venturato, Moyle, & Steel, 2011, cited in Hung L ,2018). There is need to achieve and maintain person-centred care (Dewing & McCormack, 2017; Kim & Park, 2017,cited in Hung L ,2018),because it recognises a person by using a holistic approach to reach their care needs (Dewing & McCormack, 2017 cited in Hung L ,2018). Ignorance and overlooking of dementia patients occur due to stigma and stereotyping.(Dewing & McCormack, 2017; Gove et al., 2018, cited in Hung L ,2018).
Dementia is a cognitive disorder that is having an impact on the brain and resulting failing memory and personality changes (Martin 2009, cited in Heese, K. 2015.NHS Coastal West Sussex Clinical Commissioning Group 2013). Dementia affects everyday life. One in four patients in acute hospital settings has dementia. (Alzheimer’s Society Report 2009).
Lack of communication and ineffective teamwork will have a negative impact on patients with dementia; such as weight loss, increased confusion. According to (Alzheimer’s Society Report 2009); 77 percent of patients didn’t get acceptable care. Dissatisfaction included lack of person-centred care, lack of knowledge of dementia, lack of support to intake fluids and diet, lack of dignity and respect and lack of involvement when decisions were made. The high number of nursing staff acknowledge difficulties with working dementia patients, as a result of poor training and knowledge (Alzheimer’s Society Report 2009). Including here work experience from the past, where nurses sent temporary staffing to the tagged bay, where was 3 patients with dementia. One staff member was in the bay, where staff tried to give as best care as possible for patients. New HCA without the experience of challenging behaviour was struggling to manage her own. In handover, she briefly described what to expect and pointed me Behaviour chart. It is still unknown did I was lucky or was it my perception and understanding how to manage with challenges, – I had a very good shift with all these patients. I found an instant connection with them and I concentrated keeping them all involved in communication with me. We had a laugh throughout the day, they let me complete all tasks such as observations and incontinence care without any complication. That day I learned that patients with dementia are difficult to manage only if you make it difficult. If you are giving them change to show who is the person behind dementia, if you show them respect and treat them as all, then more likely you are successful.
Communication is a human basic need. Communication can be verbal or nonverbal or written, but it delivers ideas and information, influences thoughts and following events. Communication remains essential for cognitively impaired patients. Ineffective communication creates challenging behaviour in patients with dementia (Williams KN, Herman R, Gajewski B, Wilson K. 2008),and may cause verbal outbursts, aggression, withdrawal and interrupt care and increase staff stress and is costly.
All adults with or without dementia deserve respect (Alzheimer’s Society 2017).Dementia patients are adults with a cruel disease but deserve respect like everyone else and should receive the same dignified care as adults without dementia. Nurses have a fundamental role to ensure a patient’s dignity and self-respect (NMC The Code 2018). The Alzheimer’s Society (2017) recommends; by taking time to listen to patients and reflecting it in their care in a way that is comfortable for the patient it is possible to build communication bridges between patient and caregiver. Lack of time in healthcare settings and patient’s reduced ability to communicate may lead to challenging performances, to avoid it- dementia should be understood from patients and their family point of view. Dementia patients experience new situations repeatedly throughout the day. Acknowledgment of the patients and their feelings show respect and concern and it may calm patient and reduce medication consuming. When communicating with dementia patients use a calm, pleasant tone, pitch, and speech. Stay respectful, including patient to the conversation, don’t patronise. Be aware of the patient’s level of impairment- adapt simplified sentences only if it is needed. Take time to know patient and their nonverbal cues, restless can be a sign of the pain. Clarify occurring problems. Don’t underestimate nonverbal communication; facial expressions, body language, eye contact helps to build trust between nurse and patient. Demonstrating to the patient before the performance you attempt. Staying calm shows to patient care and interest. Avoid interrupting patient, speaking to a patient with your back turned. Don’t forget,that what works for a patient one day may not work for the patient tomorrow and what works to one patient, may not work for others. Avoid jargon, present one query at a time. If the patient doesn’t understand, then reword your question. Use simple pictures to support patient needs if he or she is unable to speak. (National Institute of Aging 2017).
Excellent communication isn’t always successful. Physical illnesses, medications, nonfamiliar environment and people can trigger the aggressive outburst. Comfort patients both verbally and nonverbally about their safety. If the patient is angry towards you, give time and return when the patient is calmer. Try to understand, was patient in pain, ill, or scared? Strategies for success include improving the ability to communicate with dementia patients by understanding their limitations and exploring reasons that trigger challenging behaviour. Effective communication improves patient care and wellbeing and decreases stress for the staff, family and for the patient (Maureen J. 2017)
Reduced amount of medications with the patient with dementia may improve their quality of life (Lazare J, 2015)Meeting personal needs, such incontinence care, providing snacks, attending in pain, improving staff interaction through activities with the patient is helpful. (Testad I, Corbett A, Aarsland D, et al2014).The Montessori techniques could be adapted to dementia patients, they stimulate their mind and build self-esteem. Activities with cards, shapes, chips, and objects increase the use of motor skills (Van der Ploeg ES, Camp CJ, Eppingstall B, Runci SJ, O’Connor DW2009).Use of families, volunteers and students is a great resource for interacting dementia patients with stimulating activities (Van der Ploeg ES, Camp CJ, Eppingstall B, Runci SJ, O’Connor DW2009, sited in Volland, J. 2014).I noticed on my placement that nurses provide to patients with dementia domino and colouring books, it got their attention and decreased challenging behaviour.
Video-reflexive ethnography (VRE) is successful for educating the staff to see patient point of view by reducing stigma and opens staff eyes to deliver empathic person-centred care (Hung (2017), (Iedema et al., 2013). Iedema et al. (2015) McCormack, Van Dulmen, Eide, Eide, and Skovdahl (2017), cited in Hung L ,2018). On placement induction day we watch and analyse video from patients’ point of view, it was very educating. I learned that emphasising is a basic element of nursing care, and I ensure that it stays as a part of me.
All dementia patients are different and should be treated by following person-centred plans. These person-centred plans are unique, what works for one doesn’t work to all. All patients with dementia have their own unique character that was fully developed before they got affected by the cruel disease. As a student nurse, I was involved in care with many different patients who had dementia and my observation showed that they all were different- they had different needs and wishes, their perception of the life was different. One thing what I found was very helpful if their families or people from close circle were involved in their care. We asked families to fill questionnaire how to support the patient, what they like, and they dislike, what is the most important thing for them, how they like to take their cuppa, what was their daily routine. Most families were helpful and shared information and we found that through those notes support staff had easier to build relationship and bond with the patient and it massively improved patient care. The patients who didn’t have anyone or families didn’t want to share information in unknown reason- we tried to learn to know them. This process was slower, and relationships didn’t develop as fast as patients whose information was known. Here coming in a negative impact of the agency or temporary staffing high levels- they don’t know dementia patients in the level of satisfaction. They may see those patients only once and if they don’t have the time or don’t take time to read patients notes then they are struggling to deliver effective care. However, there is a little information shared on handover, but it may not be enough.
There was a situation when a patient with dementia forgot his family. I was involved in his care and supported him daily bases through my placement and we developed a connection. I was there as supernumerary, and I had moments where I had opportunity and time to deliver him additional support. I learned to know him, and he opened up to me, he spoke about his past memories, sang me army songs, even invited me to drink after work. Every morning he greeted me, he didn’t remember my name, but I got a big smile and hello it’s you again, where had you been. Because this bond I could comfort him if he didn’t want to take medications or was frightened during incontinence care or when observations needed to be taken or when cannulas needed to insert. All this showed me how important is communication with patients, especially with dementia patients. I don’t say that I did anything special, I just treated a patient with respect, I saw a person behind that cruel disease.
When a family member asked me what I do that he is a wide awake and alert with me but pretends to sleep when they are visiting. I told them that I just take my time with him, I am calm, kind, caring and that what he wants. I was using eye-contact when we communicated, spoke clearly, but mostly listened to him and ensured that he knows he is safe and cared. I told to the family not to give up coming to see him, he may forget who they are, but he remembers how they make him feel and these feelings stay with him. Once I tapped a patient shoulder and told him that his loving family is here, and a patient was interacting with them. It was a really rewarding moment, and one of the proudest moments so long in my new career.
In order to improve communication and deliver safe care to patients with and without dementia effective teamwork is required, where the whole team works towards a common purpose. Weaknesses should be considered, education and training stimulated. It is every team member responsibility to improve their communication levels because the team is as effective and strong as the weakest chain. Things can go wrong under pressure and lack of workforce resources, but through effective communication in the blame-free atmosphere should be highlighted what went wrong, why it went wrong, what we could do differently. Owning up mistakes gives the possibility to make changes and helps improve safe care for all including patients with dementia. (Duty of Candour). Good communication with and wise use of resources such as families, carers, students and volunteers should be welcomed because they are helpful to engaging and communicating with patients with dementia(Telford, E.H. 2015, cited in Beardon S, Patel K, Davies B, and Ward, H. 2018) and this support also improves the quality of the care.
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