Increasing numbers of older patients with cognitive impairment and disturbed behaviour
are likely to present to acute care hospitals in the future. Nurses are not well disposed
towards care due to safety and morale issues caused by knowledge deficits, job stress,
oppressed group behaviours and ageist attitudes. Patient outcomes are often poor with
multiple adverse events, long lengths of stay and levels of mortality. Disturbed
behaviour may be caused by delirium, depression or other mental disorders and
dementia or all.
The research question addressed was “Can the instigation of a person-centred approach
to care of patients with cognitive impairment and disturbed behaviour result in
decreased nursing stress, improved patient care practices, outcomes and relatives’
satisfaction?” A conceptual framework incorporating the constructs of Person-Centred
Care, the Integrated Structural Model of Human Behaviour and Practice Development
informed the action research methods utilised.
The processes of facilitation were used to undertake four action research cycles
incorporating plans, actions, observations and reflections in one 25-bed acute aged care
ward in a large tertiary referral hospital The first cycle involved setting up the study,
recruitment of nurses and patients, gathering of baseline data and application of nonparticipant
observational studies of the quality of nurse-patient interactions which
served to inform the plan for interventions. The following three cycles demonstrated
efforts to undertake those interventions through strategies to increase nursing
empowerment and knowledge in the context of constant staff turnover and diversions
that compromised support and participation.
During the study there were few apparent adverse patient outcomes with significant
improvements in patient analgesic administration, relatives’ satisfaction with care,
nursing care practices involving the completion of a Communication and Care Cues
form and nurses’ interactions with the patients. New care planning tools were
developed that will enable ongoing activities for practice improvement. Conversely,
there was a significant increase in the nurses’ stress levels when caring for hypoactive
delirious patients, a trend towards more emotional exhaustion, high nursing turnover
and increased sick leave rates. Nursing care practices were unchanged and the new care
planning tools were not well utilised.
Reflection on the implications and limitations of action research methods supported by
practice development strategies in the dynamic, often chaotic environment experienced
during the study, suggested that if there is an absence of hierarchical managerial
sponsorship for such activities, then sustainable change is difficult. Therefore, it was
shown that a person-centred approach to care of patients with cognitive impairment and
disturbed behaviour using action research methods in this environment, can result in
some enhanced nurse-patient interactions, patient care practices, outcomes and
relatives’ satisfaction. However, progress is likely to be slow and time consuming.
Further improvements require attention to the well-being status of the nurses through
actions that generate feelings of empowerment through individual recognition,
knowledge enhancement, adequate access to patient information and sufficient time to
undertake their duties as equal members of the multidisciplinary team.