Medication and care in Alzheimer’s patients in the acute care setting: A qualitative analysis

Abstract

The acute hospital admission of patients with dementia is associated with poor outcome and higher costs. Much of our knowledge on how hospital stays are experienced by patients and staff is generated from short and fragmented data collections, in which the significance of knowledge about day-to-day care might be overlooked, and might partly explain why the poor outcome for this group of patients is not fully understood. This study used participant observation to follow patients with Alzheimer’s disease admitted to orthopaedic wards after fall incidents. To gather longitudinal data, patients were followed during day and evening shifts, from admission to discharge. The data were interpreted from a phenomenological-hermeneutic perspective, inspired by Ricoeur's interpretation theory. The data showed that, despite having little specific knowledge about dementia care, staff were able to gather information about the patient’s needs and wishes relevant to administrating medicine in a person-centred way. However, much of this valuable information was lost between shifts or became hidden among the overwhelming amount of information in electronic patient records. As a consequence, much of the knowledge about individual patients’ needs and wishes had to be collected all over again at every shift. The study concludes that careful handover of information on person-centred dementia care can play an important role in making hospital stays more dementia-friendly.

Keywords

Alzheimer’s dementia hospital nursing orthopaedic ward

Introduction

Hospital admission for hip fracture patients with dementia represents an essentially acute care scenario. None of the involved parties – the person with dementia, relatives, supporting staff from residential care/nursing home or hospital ward staff – have time to plan for the admission. Hip fractures are associated with severe pre- and post-operative pain (Foss, Kristensen, & Palm, 2009) and, if untreated, increase the risk for: longer hospital stays, reduced mobilization and delirium (Morrison & Siu, 2000). This increases care demands on those hospital staff who are responsible for day-to-day care. In the case of patients with dementia, this is a challenging task that is all too well known among hospital staff, and one for which most find themselves less than well-prepared for (Alzheimer’s Society, UK, 2009). People with dementia are three times more likely than other citizens to be hospitalised for hip fracture (Baker, Cook, Arrighi, & Bullock, 2010). Of all patients treated for hip fracture in the course of a year at regional hospitals in Copenhagen, 19,2% showed to have dementia (Jensen-Dahm, Palm, Gasse, Dahl, & Waldemar, 2016). It is safe to assume that the true proportion of patients with dementia is substantially higher, because the study only accounted for patients diagnosed with dementia, or how had filled a prescriptions for an anti-dementia drug, prior to admission. Studies from England have shown that the figure can be as high as 42% in an acute general hospital (Sampson, Leurent, Blanchard, Jones, & King, 2012).

This paper investigates the care of patients with Alzheimer’s disease in an acute setting, as a comorbidity to a hip fracture, and focuses on challenges and opportunities in medicating such patients during admission. The study is part of a larger prospective study on hospitalization of people with dementia in acute care settings.

Background

It is recognised that hospital stays for people with dementia constitute a considerable risk factor. The outcome is generally poorer, and costs higher, compared to patients without dementia (Organisation for Economic Co-operation and Development (OECD), 2015). With the expected increase in the number of people with dementia in the years to come (World Health Organization (WHO), 2012), the topic of hospital care for patients with dementia is on the agenda among both national agencies and some hospital trustees, with a view to narrowing the gap between patients with and without dementia (Dewing & Dijk, 2016). Dewing and Dijk (2016) reviewed literature related to acute care, and discussed themes such as: the care environment, cultures of care, attitudes, challenges for people with dementia, carers, staff and volunteers, and researched service models. The authors concluded that there is much to be desired in care for people with dementia in the hospital setting.

It has been found that hospital staff’s awareness of dementia can be raised and their practice changed to a more person-centred, dementia-friendly care (Scerri, Innes, & Scerri, 2019). Positive results of a multidisciplinary post-operative intervention programme after hip fracture surgery, in terms of rehabilitation and functional outcomes, have also been documented (Stenvall, Berggren, Lundström, Gustafson, & Olofsson, 2012). However, when results were viewed in relation to the overall benefits, it was concluded that the results simply were not worth the effort, in terms of costs, so changes have largely not been implemented. The additional cost related to acute stays of patients with dementia is already significant, and with the future expected increase in dementia patients, this will represent an additional burden on an already economically stressed healthcare service, unless action is taken (Connolly & O’Shea, 2013). Therefore, it is of paramount importance to investigate the care and treatment of patients with dementia during acute hospital stays. In understanding why hospital admission is so difficult, we have a chance to design cost-effective solutions for the future.

Previous studies about patients with dementia in hospital wards have contributed significantly to the body of knowledge in this field (Cowdell, 2008, 2010; Moyle, Borbasi, Wallis, Olorenshaw, & Gracia, 2010; Norman, 2006), but there is still a lack of knowledge about the administration of medicine to patients with dementia in acute hospital settings. Looking at studies from nursing homes, it is clear that the concealment of medication in food and beverage by staff is common in caring for residents with dementia (Haw & Stubbs, 2010; Treloar, Beats, & Philpot, 2000). The literature also shows that the procedure tends not to be documented. Although a Norwegian study showed an increase in documentation rates from 2000 to 2007, little had changed over the period in the frequency of covert medication (Kirkevold & Engedal, 2009).

Studies in which some form of field work or participant observation were used all showed similar characteristics. Because a large number of patients were studied at once, or because observations were fragmented (of a few hours’ duration at a time) over the course of several admissions, observations of the patient’s experience across the whole admission were lost (Cowdell, 2008, 2010; Norman, 2006). The risk inherent in fragmented data is that important insights into hospital dementia care practice could be overlooked. Detailed observations of smaller numbers of patients and longitudinal data from admission to discharge would be more useful in increasing our understanding of why patients with dementia have a poorer outcome from hospital stays than other groups of patients.

It is necessary to study in depth how dementia care is being planned and executed, and ascertain both the immediate outcome and the outcome in the following hours and days. This present study focuses on the acute care situation of patients with Alzheimer’s disease during hospital stay. In light of the risks, poor outcome and increased costs related to patients with dementia in acute care, this area still needs investigation. This study will redress some of the limitations of previous studies by generating an overview from admission to discharge of the care of a small number of patients by way of a longitudinal, observational data-gathering process.

Aim

The aim of the study was to investigate how oral medicine was administered to hip fracture patients with Alzheimer’s disease during acute hospital admission on an orthopaedic ward.

Method

A qualitative design with a phenomenological-hermeneutic approach inspired by the French philosopher Ricoeur was chosen for the study (Pedersen, 1999; Ricoeur, 1976). The study was designed to follow one patient at a time, for as many hours as possible during the day, to get longitudinal data on dementia care during hospital admission. The setting for the study was a hip fracture unit on an orthopaedic surgery ward in a general hospital in Denmark.

Participants in the study

Inclusion criteria were patients with an Alzheimer’s diagnosis (F00.1), admitted to the hip fracture unit. No distinctions were made as to type of hip fracture, dementia level, age, gender or whether they were living at home or in residential care/a nursing home. Exclusion criteria were non-Danish-speaking patients, patients suffering from other known psychiatric disorders and patients who were blind and/or deaf. Only patients with an Alzheimer’s diagnosis from a memory clinic were eligible for inclusion.

The hip fracture unit contacted the first author whenever a patient who fit the inclusion criteria was scheduled to arrive at the ward. The staff and first author together screened the patient for the inclusion and exclusion criteria, and an overall initial assessment was made as to whether or not to include the patient. The staff’s judgement on whether the presence of an observer during the patient’s stay would have a negative impact was also taken into consideration. The introduction between the patient and the observer was mediated by the staff. If positive, the patient was invited to participate in the study by the first author, who briefly described how, as an observer, he wished to be present during the hospital stay, and that the patient could ask him to leave at any time. On acceptance of participation, informed consent was obtained using the standard formula of the Danish National Ethical Committee (National Committee on Health Research Ethics, 2017).

The ward staff were also informed, both orally and in writing, that data collection would be taking place on the ward. The observer, at the beginning of every shift, asked the primary caregiver for each patient for consent to follow and observe their praxis.

Data collection

An ethnographic approach was taken, based on Spradley’s method of participant observation (1980) and ethnographical interview (1979). Observation was performed as a passive observer. Observational data were obtained from admission to discharge, in day and evening shifts, typically from 6.30 a.m. to between 9.00 p.m. and 11.00 p.m. If the observer was not present at the end of a shift, the unit was contacted by telephone to get a verbal report about activities that had taken place, but which were not recorded by direct observations. In this way, substantial efforts were made to gather longitudinal observational data from patients’ entire hospital stay.

The observation was two-pronged; both the patient and the staff were observed while interacting together, and were also observed separately. Observation of the patient was conducted only at the bedside while a staff member was present. Otherwise, observation took place from the hallway outside the room, or at the nursing station. Observations were written as field notes, and transcribed into a coherent text in the days and weeks after the data collection ended. The first author, who performed the observations on the ward, was not a member of the medical/caring team at the hospital.

Data analysis

The data analysis was inspired by Ricoeur and carried out on three levels: naïve reading, structural analysis and critical interpretation and discussion (Ricoeur, 1976).

The naive reading is regarded as a first conjecture in revealing topics for further investigation. The data material was read and re-read as objectively as possible to get an understanding of what the text was talking about (Dreyer & Pedersen, 2009). Data were systematized by using NVivo 11, and by identifying objective activities related to caring, such as giving medicine, hygiene, eating, mobilization, situation around pain, etc. (NVivo 11, 2017). In cases where only a small part of a transcribed paragraph describing a caring situation involved pertinent activities, such as the administration of medication, the whole paragraph was nevertheless included in order to preserve the context.

In the structural analysis, we moved from what the text said, to what it talked about, by first describing units of meaning (what is said) and then by identifying and formulating units of significance (what is talked about) and, lastly, by formulating themes/sub-themes for the text. The text was viewed as objectively as possible by deconstructing the units of meaning from the text as a whole (Dreyer & Pedersen, 2009). Table 1 illustrates the process of how field notes were transformed from units for meaning into units of significance, and then into themes and sub-themes.

Table 1.

Example of the structural analysis process, and themes and sub-themes that emerged from the structural analysis.

Units of meaning	Units of significance	Themes/sub-themes
The patient finds a pill in her mouth – she thinks that it is a stone. The staff member says that it is not at stone, but a pill that the patient needs to take. The patient takes the pill.	An attempt is made to administer medication to the patient without informing him/her beforehand.	Concealed medication– try first, inform if revealed– disregard for patient’s autonomy
The staff member enters the room and starts a dialogue with the patient about some medication she must have. The instruction is short and precise and the patient takes all the medication with some assistance in drinking to swallow the pills.	The involvement of the patient through engaging dialogue makes administering medication successful.	Dialogue and engagement on medicine intake– involving the patient– respect for patient’s autonomy

The process of generating themes through the structural analysis was not a linear process, but rather cyclical, where themes were checked against the initial interpretation and the original text until the choice of words constructing the themes made the best possible representation of the content. Thereby, there was a backwards and forwards movement between text and themes/sub-themes – between understanding and explanation. This was particularly important, given that data collection was created in a longitudinal form, so the themes and sub-themes needed to comply with care-giving situations over multiple shifts and days for multiple patients. From the text, key themes and sub-themes were created for further investigation.

In the critical interpretation and discussion, the themes and sub-themes will draw on relevant theories and other studies, to unfold the results. As a concept, person-centred care has begun to be included in clinical guidelines for dementia care and national dementia strategies (Dewing & Dijk, 2016). The discussion will draw on Tom Kitwood’s (1997) thoughts on person-centred care as a way of making a cultural change, in terms of valuing personhood, seeing the person as an individual and supporting their lived experience (Brooker & Latham, 2016) – which represents, all in all, a more holistic approach to caring and putting the person first.

The discussion will also make use of Merry Elisabeth Scheel's interactional nursing practice theory in relation to the nursing aspects of the observations (Scheel, Pedersen, & Rosenkrands, 2008). Inspired by Jürgen Habermas’ forms of knowledge: cognitive-instrumental, aesthetic-expressive and moral-practical knowledge, interactional nursing practice theory sets out a framework for understanding nursing in general, but can also take isolated incidents and give plausible explanations as to what drives staff’s actions and reactions. Cognitive-instrumental actions are proactive, interventional and problem-solving. Aesthetic-expressive actions deal with self-reflection, self-understanding and self-interpretation and an understanding of the environment, while the moral-practical modes of action deal with nurses’ sensitivity towards ethical challenges and knowledge of ethical norms (Scheel et al., 2008).

Ethics

Research involving patients with dementia requires special considerations – especially when recruiting participants in an acute setting, shortly after admission to hospital. Because of the nature of Alzheimer´s disease, the patients’ relatives were involved in the recruitment process. They were asked if they considered that the patient was willing to participate in the study. They were given the same information in writing, and a more in-depth oral presentation of the study, especially concerning participants’ rights to withdraw from the study at any time during and after the observation period. If the relatives had reservations about the patient’s participation in the study, the patient was excluded. This decision was not taken because the relatives’ decisions overruled the patients’ acceptance; it was based on further collaboration between the relatives and the ward during the patient’s stay in hospital. The project thereby tried to balance respect for the autonomy of individuals with dementia by involving them in decision-making processes, and by involving the patient’s relatives to help the patient understand their rights as a research subject – in accordance with Alzheimer Europe’s guidelines for involving people with dementia in research (Europe, 2011).

Anonymity was assured for the participants, and all field notes and transcriptions were kept confidential, anonymous and in accordance with the regulations of the Danish Data Protection Agency (2017). The study obtained approval from all relevant authorities in relation to Danish law on ethics and data protection.

Results

Data were based on three admissions and a total of 257 hours of observation performed in November and December 2014 and in January 2015. In all, 22 days (in three periods of four days, four days and 14 days, respectively) were spent observing patients (P1, P2 and P3) and staff on the ward. In total, 37 shifts were covered. The patients were between 87 and 95 years of age, and all lived in nursing homes prior to admission. The cause of admission in each case was a fall, resulting in a fracture of the femur and, in some cases, additional injury to shoulder and/or arm. Observation began within a few hours of the patient arriving at the ward.

The patients observed in this study ranged from relatively easy to care for (P1), a more challenging patient who at times expressed a lot of unrest (P2), and a patient with severe difficulty and unrest, where a member of staff was assigned to the bedside at all times during the entire 14 days of admission (P3).

The staff observed in this study consisted of nurses and social and healthcare assistants working on the ward. Some staff were also hired from external agencies to help cover some shifts.

Naïve reading

The initial reading of the text showed that the ward in many ways prioritised caring for this group of patients’; for example, by allocating them to a single room close to the nursing station. To the extent that it was possible, a relatively small number of staff was involved in caring for the patient with dementia, but over the course of the admission, the patient still came in contact with a lot of different members of staff. Even basic caring tasks proved difficult for the staff. Across patients and shifts, there was a common pattern; planning and executing the administration of prescribed oral medication – both medicine relevant to the hip injury and subsequent operation, and other prescribed medication which the patient had been taking before admission – proved problematic. The longitudinal data showed big differences in how medication was administered. The issue of giving Alzheimer’s patients oral medication is therefore taken as an example of daily caring tasks, and explored using the structural analysis.

Structural analysis

The results of the structural analysis revealed the following themes for further exploration: ‘Concealed medication’ and ‘Dialogue on medicine intake’. Four sub-themes were identified, all of which reflected the process of giving the patient oral medication. The following sections further elaborate on the findings from the study.

Concealed medication

The process of giving patients medicine was frequently an issue of concern for the staff. Concealment of medicine – in the sense of giving it to the patient while assisting them with eating, was prevalent. However, concealment also implies that the patient was not informed about the pills being administered to them.

The study showed two outcomes of combining medication and food. Either the patient never realised the pills were there, and was not informed, and thereby took all the medication, or at some point during the process of eating, the patient realised that there was something other than food in the meal and reacted, sometimes by saying ‘… there is a stone in the food!’ (P2). Once the concealment was discovered, one of two outcomes emerged: either the medication was taken, or it was refused by the patient and the staff eventually stopped trying to give the medication.

In cases where the medication was taken after the patient had become aware of the pills, two scenarios emerged: either the staff engaged in a conversation with the patient about the pills, saying that they were something the patient must take, sometimes with further information about what the pills were for, e.g. pain after the operation, and sometimes drawing on arguments such as ‘it is so good for you’ or ‘the doctor has said you must have these pills’ (P3). When staff engaged in a conversation with the patient about why they should have the medication, the patient took the pills. On other occasions, medication was administered without any communication from the staff, until all the medication was taken. This happened either because the staff member was not paying attention to the patient while giving the medication, or was ignoring the patient’s signals. ‘The staff member keeps feeding the patient food and pills, even though the patient has rejected the food by trying to close his mouth and looking the other way’ (P3).

In cases where the staff member stopped trying to give the patient their medication, two types of scenario played out. In the first, the patient said that she did not want the medication, but the staff tried to convince the patient otherwise, by saying, for example, ‘… it is for your broken hip’ (P2) or ‘… it is so you don’t have pain after the operation’, to which one patient replied ‘Have I had an operation?’ (P1). On that occasion, the patient’s decision to decline the medication was respected – for the time being. The second scenario was that the staff member continued to try to administer the medication, even though the patient had verbally and physically communicated a clear refusal. Eventually, the staff gave in and stopped.

The staff member is feeding the patient a dessert with a pill hidden in the food. The patient takes the pill out of his mouth, but the staff member continues to feed both new and previously rejected pills along with more dessert. The patient is being offered some water in such a manner that there is little alternative but to take a sip. The patient starts coughing and both the water and the pills come out, and apologizes. The staff member looks at the observer and says, “He can’t – but I tried”. The patient says, “I can’t anymore”, starts to whine, and looks away from the staff member (P3).

Underlying the previously mentioned situations in which there was an unsuccessful outcome was the fact that the staff demonstrated a lack of knowledge about how colleagues had previously successfully given the patients their medication, by engaging in dialogue with the patient, or by following advice given by the nursing home.

Although the caring situation was experienced as difficult by the staff, they did not consult colleagues on the matter. Instead, they either pressed on with the same failing method, or gave in after very little effort and excused themselves to the observer and/or colleagues that the patient could not take the medication.

The staff member tries to press the patient to take the pills, and is not successful because the patient refuses. She looks at the observer and admits that she has been a little too eager, but that one has to try the best one can. (P3)

No second attempt was made to give medication to the patient in the above quotation using a different method, but it was noted in the electronic patient record that the patient could not take the medication.

Dialogue and engagement on medicine intake

In contrast to the above findings, some caring situations around giving the patient oral medication involved a dialogue on the topic right from the beginning. Sometimes, the administration of medication was linked with mealtimes, and sometimes it was a standalone task.

In situations in which staff involved the patient in the process by showing the pills, letting the patient put the pills in their mouth and assisting them to drink, if needed, the medicine was taken. This type of situation demonstrated a good relationship and cooperation between staff and patient, with the result that the patient received all the prescribed medication.

The staff member enters the room with pills for the patient and explains to the patient that she has come with pills and that they will help the patient get rid of her pain. The patient takes the pills and continues to eat more food afterwards. (P1)

In another type of situation, a staff member and a patient were engaged in a casual conversation about something other than medication.

The patient eats the dinner herself and is in a casual conversion with the staff member. The staff member places the previously mentioned pills in the food while talking to her. They both know about the pills, but do not make an issue of it. As the patient is given the final pill, the staff member says “this is the last pill” and the patient says, “That’s good”. The staff member and patient keep on talking and the patient finishes her dinner. (P2)

On some occasions, if the patient at first declined to take their medication, an engaging dialogue could make them change their mind and take at least some of the medication. Staff referred to what the pills were for, in terms of, e.g. painkillers due to the operation. Mention of the operation, however, could result in the patient becoming confused about what operation the staff member was talking about, and could even lead to an expression of confusion about being in hospital. Thus, while there was a possible solution in giving clear and factual information about the nature of the treatment, there was a risk that the patient might become confused.

If the patient declined to take his/her medication, staff were respectful but kept the task in mind and only postponed it.

The staff member again brings up the need to take medication, and makes an agreement with the patient that he needs to takes his pills and to drink a little afterwards. The staff member is very clear in her communication with the patient. “If you say so, I will take them”, the patient replies and the process of taking the pills with a little water went smoothly. (P3)

Despite the higher success rate when dialogue and engagement were involved, medication administration was performed very differently among staff members.

In the case of the 14-day admission (P3), in particular, where clear instructions and advice had been provided by the nursing home on how best to give the patient pills, the advice was often not followed – even though it was clearly documented in the electronic patient records. Furthermore, the staff ended up contacting the nursing home several times, and received the same advice each time about administering medication.

There also occurred a type of situation in which – despite the staff’s great efforts of engagement and communication – medication was not successfully administered. This occurred when staff tried to interact with the patient about medication while the patient had a very different agenda. This resulted in a situation where both were engaged in a conversation – but they were not talking about the same topic. The study showed that caring tasks superseded the patients’ needs, e.g. the need for communication and contact. This could lead to a waste of valuable one-on-one time, because it was used to try to get the patients to conform to the daily tasks and routines of the ward.

Discussion

Dementia care in acute settings is regarded as professionally challenging, which findings from this study also confirmed. However, the data analysis revealed that caring for patients with Alzheimer’s can be done professionally and successfully, in terms of performing a task like giving oral medication. The results showed two major themes: ‘Concealed medication’, which involved an approach that disregarded the patient’s autonomy by not involving the patient in medicine administration, and ‘Dialogue and engagement on medicine intake’, which involved the patient and showed a respect for their autonomy. The longitudinal nature of the data showed that there was a gap in the transfer of knowledge from the successful (and unsuccessful) caring situations from one shift to subsequent shifts. Planning for dementia care therefore almost started from scratch at every shift. There was no set guideline for giving medication to patients with dementia and, furthermore, staff did not draw on information available in the electronic patient records, or from colleagues, who, through hard work and good praxis, had already gathered valuable knowledge while caring for the patient.

The everyday caring situations showed that staff were observant and eager to learn about the patients’ wishes and habits through dialogue and contact with them. Contact with the nursing home and relatives was made if the staff had problems communicating with and understanding the patient. In general, the staff were able to gather substantial information relevant to planning and performing person-centred care in relation to the VIPS framework (Brooker & Latham, 2016).

However, information gathered in the person-centred practice was lost in the handover from one shift to another. This meant that hard-earned information and knowledge gathered through dialogue with the patient, and through contact with the nursing home and relatives, was lost, either because it was not documented or, where it was documented, because it got lost among the vast amount of information in the electronic patient records.

The consequence was that the same information was collected over and over again, and at the start of each new shift, the nurses had little information or knowledge to plan and execute person-centred care for individual Alzheimer’s patients. Communication among staff members on the same shift helped, but it was a case of chance as to whether or not any of those on duty during a shift had experience of caring for the patient. Information that was already documented in the electronic patient record was verbally communicated among staff, yet staff continued to complain that they lacked information which they felt was relevant to perform day-to-day care for the patient, even though this information was, in fact, documented in the electronic patient records.

In line with the findings of the present study, Clissett Porock, Harwood, and Gladman demonstrated that ‘… health care professionals in acute settings were not grasping all opportunities to sustain personhood for people with dementia’ (2013, p. 1495). Our study’s focus on longitudinal observations demonstrates that one aspect of the unfulfilled potential to perform person-centred care was a gap in the information transfer. Staff were therefore focused on collecting the same information repeatedly, in addition to getting to know the patient. From the patient’s point of view, the same questions were asked over and over again, and care was performed in many different ways, depending on the individual staff members´ relative levels of skills and knowledge about person-centred care.

The results of having a VIPS-inspired caring style, as demonstrated by the staff in this study, but without a functional system to transfer the acquired knowledge, can help explain Clissett et al.’s findings, as mentioned previously. ‘Grasping all opportunities to sustain personhood’ is an ambitious task, but because, in our study, staff needed to focus primarily on collecting basic information, it is easy to see how such opportunities could be overlooked in a task-orientated setting that is not conducive to following the principle of ‘sustain[ing] personhood for people with dementia’.

Drawing on Scheel’s theory (Scheel et al., 2008), hospital dementia care is challenged on all three modes of action. The care system is focused on performing certain tasks at certain times during the day, which is in conflict with person-centred caring principles and which brings staff into conflict with the cognitive-instrumental aspect of nursing. The aesthetic-expressive mode of action has a certain ‘waste of time’ element built into it. In order to make sense of the caring situation, the staff collect as much information as possible, to be able to perform person-centred care. This is time-consuming and describes a praxis that is based on guessing, experience and to some extent trial and error, but also good communication with the relatives and the nursing home. The ‘waste of time’ element happens on the shifts, where little information on person-centred care is passed on, either through oral dissemination or in the electronic patient records. This leaves their colleagues in much the same situation and the process of knowledge gathering in the aesthetic-expressive mode of nursing starts all over again at every shift. In order to balance the poor outcome of the cognitive-instrumental aspect of nursing and the excessive time spent on the aesthetic-expressive modes of action, the staff sometimes cut corners and perform actions that conflict with legal and ethical guidelines; thereby, they activate the moral-practical mode of nursing.

An example of this is demonstrated in the present study by staff resorting to concealment of oral medication. This is highly problematic from an ethical and legal perspective, but from an outcome perspective, it is a successful intervention that helps solve the tasks in the cognitive-instrumental mode of nursing. A review by Haw and Stubbs (2010) demonstrated that this process is not uncommon, and although the data were gathered in nursing home settings, it is relevant to our findings. They point to education and training of staff to safeguard vulnerable patients from covert medication and, with such patients, the person-centred VIPS framework (Brooker & Latham, 2016) proves to be a viable model of care. However, as mentioned previously, having a person-centred focus does not help when work routines do not support the person-centred approach. The existence of covert medication, as found in the present study, not only illuminates a dilemma that impacts patient and staff interaction, but it should also be of concern to the doctors and ward management responsible for the staff. Covert medication ‘… should never be undertaken without thoughtful consideration of the circumstances, the possible consequences, and the practice of good care. It is rarely ethically justifiable’, as Lisa Honkanen (2001) puts it in her comment, in response to the article ‘A pill in the sandwich: covert medication in food and drink’ (Treloar et al., 2000). It is nothing short of an expression of paternalism and is not to be taken lightly, she says. By observing and focusing on the administration of medication in acute dementia care in the present study, it becomes clear that the moral-practical mode of nursing is often challenged. This could help explain the staff’s description of finding themselves ill-prepared to care for patients with dementia in the acute setting, as found in the Alzheimer’s Society, UK report (2009).

The present study therefore demonstrates that an increased focus on the transferral of knowledge between staff working on different shifts that is relevant to person-centred caring has the potential to improve dementia care in acute settings. Even basic tasks, such as giving the patient oral medication, proved difficult for staff in the present study, without a person-centred focus. Furthermore, the failure or only partial implementation of treatment might help explain why patients with dementia have such a poor outcome for hospital admission. It was beyond the scope of this study to ascertain the extent to which electronic patient records represent an appropriate vehicle for the transferral of knowledge about patients’ needs and wishes in the acute setting.

Methodological considerations and limitations

The study was purposely designed to give in-depth knowledge about a small number of admissions of patients with Alzheimer’s as a comorbidity, rather than cover and or compare dementia care across a number of wards. The critical interpretation and discussion method was thus applied, to allow the findings in this study to be aligned with other studies or theories, to ensure perspectives of the results. It is therefore not claimed that the conclusions are generalizable for all orthopaedic wards in Denmark. Rather, an interpretation of actions observed is offered, to broaden our understanding of acute dementia care. The setting was also chosen because the staff on this ward had no prior training in dementia care. Therefore, the results are limited to a description of care in acute settings, and are not an assessment of the quality of dementia care performed by the staff. On the other hand, the fact that the knowledge was generated from staff untrained in dementia care makes the results more easily transferable when training programmes are being designed in the future for staff in acute hospital settings. To limit the effect of factors such as social desirability bias in our results, the observer was on the lookout for discrepancies between how staff described their praxis and the way they performed – especially in challenging caring situations. Acknowledging that relevant findings could emerge from this discrepancy between praxis and verbalisation of their praxis, it was important to thoroughly document any instances of such a discrepancy. The observer endeavoured to account for the potential of the Hawthorne effect to influence staff’s behaviour during observation, by looking for changes in behaviour over the course of both individual shifts and the three-month observation period. Apart from a brief period in the beginning, when staff were getting used to having the observer around, little was observed that would lead to the conclusion that the observations documented deviated much from everyday praxis.

Conclusion and implications for nursing

This study demonstrates, by illustration of the complexities involved in giving patients with Alzheimer’s disease oral medication in the acute setting, that there is room for improvement in terms of making sure that knowledge relevant to performing person-centred care is not lost between shifts.

Staff actions might vary, depending on how the ward operates, but a combination of oral dissemination and written documentation is advisable, in situations where care proves to be difficult. The argument against setting aside time for staff to communicate on person-centred care at the handover of a patient, is that it is costly. While this is true, without it staff can spend a lot of time on repeated information gathering in an effort to be person-centred, and dementia care does not improve in quality to the benefit of the patient.

While the documented concealment of medication illustrates the challenges and ethical dilemmas in acute dementia care, the study also sheds light on the many opportunities that exist to perform quality person-centred dementia care in the acute setting.

Staff are expected to ensure that patients are informed and aware of what is about to take place. In the context of dementia care, it is particularly important that staff focus only on one thing at a time, and not let themselves or the patient become distracted by other activities. When the complexity of the situation is reduced as much as possible, staff must draw on the required knowledge about the patient, so that they can engage in a dialogue that the patient can understand. This might involve using knowledge about the patient’s life history, or other information from relatives or the nursing home. Successful and professionally executed administration of oral medication to a patient with dementia revolves around a positive relationship with the patient. Therefore, if concealment of medication is to be avoided, it is advisable to spend time building up good communication and a relationship with the patient. Many of the unsuccessful attempts to give patients medication observed in the present study were connected to the fact that medication was administered to a work schedule, rather than choosing the time that was considered to be right to try to give the medication. The ethical dilemmas involved in concealment of medication can have far-reaching consequences for relations and cooperation between staff and patient for the rest of the shift – if not for the rest of the hospital stay. Therefore, it cannot be emphasized enough that person-centred care that sustains personhood for patients with dementia is the way forward – both for patients and staff.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research is funded by the University of Southern Denmark, Odense, Denmark and VIA University College, Denmark as part of a ph.d. grant.

Anders Møller Jensen, PhD student, MSc, OPEN, Department of Clinical Research, University of Southern Denmark. Since the formation of VIA University College in 2008, Anders has been employed at VIA Aging and Dementia – Centre for Research, with focus on dementia care. Since 2010, AMJ has served as an external consultant in reminiscence at the National Research Centre for Dementia, Copenhagen. In 2014 the National Board of Social Services appointed AMJ to an expert group on physical activity and dementia. AMJ has been a board member of the Danish Gerontological Society, member of the editorial board at the Danish journal Gerontology and is currently chairperson of the Danish reminiscence research network.

Birthe D Pedersen, PhD in nursing, BA Philosophy, associate professor emerita, Department of Clinical Research, University of Southern Denmark. Her competences deal with Nursing Practice, Qualitative research methods, Field work as a research approach in the field of nursing science, the daily life of patients with chronic illness and their relatives in relation to treatment, everyday life and rehabilitation.

Rolf Bang Olsen has worked as a consultant psychiatrist in the field of gerontopsychiatry until retirement. Main clinical experience has been building up an interdisciplinary geropsychiatric team working outside Institution. His research field deals with experimental studies dealing with neuroanatomical connectivity studies. Clinical research has focused on psychotropic medication in the elderly and social networks and longevity.

Lise Hounsgaard, PhD in nursing, professor, OPEN, Department of Clinical Research, University of Southern Denmark. Her competences deal with Qualitative research methods, Field work as a research approach in the field of nursing science concerned with improving knowledge about E-health, patient security, nursing and the daily life of patients with mental and/or chronic illness and their relatives in relation to treatment, everyday life and rehabilitation in a global perspective.

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