A labour of love: Reward and satisfaction for nurses: Findings from a grounded theory study in dementia care

Abstract

Aim

To understand nurses’ perceptions of quality nursing care in the dementia-specific care unit. As the world’s population ages, the incidence of dementia is projected to rise in tandem. The requirement for skilled, dementia-trained registered nurses who can provide quality nursing care will need to increase accordingly to meet the needs of these individuals. Extensive research has been completed on dementia nursing care in a variety of settings; however, little research has been undertaken into nurses’ perceptions of quality nursing care in the dementia-specific care unit. Understanding how registered nurses perceive quality nursing care in the dementia-specific care unit is important and provides valuable information about nursing practice in this environment for nurses and decision-makers. Gaining a better understanding of quality nursing care in this care unit may result in better nurse education and an improved patient experience. It may also assist nursing organisations, residential aged-care facilities, government bodies and nongovernment agencies that support, manage, and oversee dementia-specific care units.

Method

A grounded theory study was conducted to understand nurses’ perceptions of quality nursing care in dementia-specific care units. The study involved interviewing nine registered nurses working in two dementia-specific care units on the Gold Coast, Queensland. Data were collected during semi-structured interviews and analysed using both constant comparison and thematic analysis.

Findings

Three themes emerged from this study—Caring at the Coalface, Labour of love and the Business of Dementia Healthcare. The largest theme, Labour of love, represents the personal reward and feeling of satisfaction six nurses said they experienced when interacting with individuals living in the dementia-specific care unit. They identified and repeatedly discussed the joy and fulfilment they experienced when caring for them, and considered this to be an essential element of quality nursing care. It was evident from the data that the nurses cared very deeply about these individuals, and despite increased risks to personal safety at work, they did not want to work anywhere else. This article reports on the largest and key theme identified in the study Labour of Love.

Keywords

nurse patient therapeutic relationship dementia quality nursing care dementia specific care unit

Introduction

Quality nursing care

Quality has been defined as “a personal attribute, a trait, a feature of a person’s character” (Oxford Online Dictionary, 2018), The World Health Organization considers that quality care is based in the provision of healthcare services which are safe, effective, and result in improved health outcomes (WHO, 2017). Much remains unclear regarding what constitutes quality nursing care, but what is known is that it is poorly defined. Also, while there is a significant amount of literature regarding dementia care and nursing care in general, no theories have been located that are specific to nurses’ perceptions of quality nursing care in the dementia-specific care unit. Registered nurses, nurse managers, educators, researchers, healthcare organisations and policy-makers appear to have differing views of just what constitutes quality nursing care, and they are unable to agree on a definition that satisfies the needs of all (Aiken et al., 2018; Backhaus et al., 2014; Department of Health, 2017).

What is apparent from a review of the current research literature is that quality nursing care is complex, multidimensional and subject to the perceptions of patients, healthcare practitioners, organisations and researchers (Cho et al., 2016; Falk & Wallin, 2016; Koy et al., 2015). A clear definition of quality nursing care therefore remains elusive, reinforcing the value of research into what nurses perceive is quality nursing care in dementia-specific care units. The findings from this grounded theory study are important to inform the theoretical frameworks of future research into dementia nursing care.

In recent decades, there has been an increasing interest in the development of a more sociological approach to dementia care, where the person is the focus and nursing care interventions are based in patient preferences and needs, not in a prescribed regime of treatment (Brooker, 2003; Brooker & Latham, 2015; Epp, 2003). Central to this approach is the nurse–patient therapeutic relationship based on mutual trust and respect, compassion and empathy, with a focus on meeting all the needs of the individual (Brooker, 2003). Kitwood and Bredin (1992) laid the foundations for the conceptualization of personhood in dementia care, advocating for a change in focus from the medical condition of dementia to focus instead on the person living with dementia. The concept of person-centred dementia care was supported by Kitwood (1997), who considered that dementia care was based on the recognition and respect shown to the patient by nurses, and that each person had value and deserved to be treated with respect at all times. Kitwood (1997) also advocated for the provision of a social and psychological environment that supports the person with dementia.

Individuals who experience significant cognitive decline as their dementia progresses and require nursing care may be admitted to a dementia-specific care unit to both support preservation of their cognition for as long as possible and to promote well-being (Evripidou et al., 2019). As the number of individuals admitted to dementia-specific care units is forecast to rise in coming decades, understanding how nurses perceive quality nursing care in this environment is critical. This information may assist registered nurses and decision-makers to understand what quality nursing care is and how they can influence and deliver quality nursing care in practice. Although this study focused on nurses working in dementia-specific care units, findings from this study have wider significance through the provision of information and theoretical understanding of quality nursing care for nurses working in other clinical settings.

Dementia-specific care units emerged as separate areas within Australian residential aged-care facilities in the late 1980s due to increased numbers of people with progressive dementia, and the associated need to manage their behavioural changes (Morgan & Stewart, 1999). The term ‘residential aged-care facilities’ is Australian specific. Prior to the development of and common acceptance of dementia-specific care units in Australia, people with advanced dementia lived in close proximity to others in the residential care facility (Frisoni et al., 1998; Grant et al., 1996). This meant that they shared common areas such as dining and lounge rooms with others, and this freedom of movement often led to intrusive and confronting disturbances (Leon & Ory, 1999; Ohta & Ohta, 1988). Many care staff working in residential care homes did not understand dementia and its progression, and struggled to support people living with advanced dementia. As a result, many were subject to increased use of physical and pharmacological restraint to manage their behaviour, often with catastrophic outcomes (Gold et al., 1991; Sloane et al., 1991).

A dementia-specific care unit is a small, locked unit within a residential aged-care facility that aims to minimize cognitive and physical decline and maximize the quality of life of people with advanced dementia (Adlbrecht et al., 2018; Ballard et al., 2017). Dementia-specific care units also offer people with advanced dementia a safe, homelike environment supported by dementia-trained staff and dementia intervention programs to provide optimum quality of life and well-being (Crespo et al., 2013; Gilbert et al., 2019). The dementia-specific care unit is a separate space for people who are experiencing increasing agitation, aggression and adverse behaviours as a result of their dementia progression (Adlbrecht et al., 2018; Ballard et al., 2017).

Researchers explored the efficacy of dementia-specific care units as a legitimate alternative to the frequent physical and chemical restraint of people with advanced dementia (Frisoni et al., 1998; Leon & Ory, 1999). Findings from this research confirm that admission to dementia-specific care units resulted in a reduction in the use of both physical restraints and psychotropic medication use (Appelhof et al., 2019; Leon & Ory, 1999). It was also noted that behavioural disturbances including delusions, hallucinations, anxiety and sleep disturbances had significantly improved following admission to a dementia-specific care unit (Frisoni et al., 1998). These findings confirm that the specific dementia care provided to people admitted to dementia-specific care units can significantly control behavioural symptoms without the use of additional restraint and medication.

Nurses have reported that dementia nursing care is exhausting, repetitive and hard work, often characterized by frequent verbal and physical aggression (Honda et al., 2016). Dealing repeatedly with aggression in dementia-specific care units is often considered to be part of working in dementia care, but can result in physical and emotional harm, exhaustion and high nurse attrition rates (Schmidt & Diestal, 2013). Research confirms that despite these challenges, nurses decide to work in dementia-specific care units for many reasons, including altruism and the opportunity to interact and build nurse–patient therapeutic relationships based on compassion and affection (Stanyon et al., 2017; Wang et al., 2018). Nurses have also reported that the provision of comfort and familiarity with staff enables nurturing nurse–patient therapeutic relationships to be established, resulting in an improved quality of life for people with advanced dementia (Beerens et al., 2014; Lee et al., 2016). These nurse–patient therapeutic relationships frequently occur in the face of daily aggression and violence and are characterized by frequent social contact, engagement with and attachment to staff members, and the provision of pleasurable patient activities (Mjørud et al., 2017; Røsvik et al., 2013).

Method

A grounded theory study with the research question What are nurses perceptions of quality nursing care in Dementia Specific Care Unit? was conducted as part of the requirements for completion of a PhD. The study aim was to describe and explore registered nurses’ perceptions of quality nursing care in dementia-specific care units. Ethics approval was obtained from the Latrobe University Ethics Committee.

Grounded theory methodology is a qualitative research method that is “grounded” in data. The data are logically and systematically gathered, continually compared and analysed, and culminate in the generation of a substantive theory that is used to describe and explain the phenomenon (Bryant & Charmaz, 2019; Charmaz, 2006; Flick, 2018). This is important for nursing research as not only can data regarding the patient experience of healthcare be identified but this information may also serve to modify clinical nursing practice. In contrast, thematic analysis is a data analysis technique that is used to make sense of the data collected (Flick, 2018).

The study involved interviewing nine registered nurses of diverse ages, clinical experience and cultural backgrounds, working in two separate dementia-specific care units on the Gold Coast in Queensland. Participant clinical experience varied from 1 year to over 40 years’ experience as a nurse in a variety of clinical settings. There was no preexisting relationship between the researcher and participants in this study. Participants were informed of the researchers’ experience and clinical background and the reasons for completing the research prior to recruitment via the Plain Language Information Statement. The key ethical issue was to ensure the anonymity of participants and those living within the dementia-specific care units. This was addressed by the researchers’ use of pseudonyms for all parties in all published materials. Another ethical issue related to the possibility that participants in this study may identify abusive or criminal behaviour during interviews. The researcher addressed this issue by including information in the Plain Language Statement stating that if abusive or criminal behaviour was identified during the study, then this would be reported to the relevant organisations. This information was reiterated by the researcher verbally prior to the commencement of each participant interview.

Full grounded theory methodology was utilized in this study, characterized by concurrent data collection and constant comparative data analysis. Data were collected using semi-structured interviews utilizing the following questions:

How would you describe quality nursing care? and

What kinds of nursing care activities have you seen in the unit that you consider to be quality nursing care?

The interviews were of between 60 and 90 minutes duration and were audio-recorded, with the researcher making notes following each interview. Interviews were conducted in a variety of settings including participant homes, the beachfront and a private room in a local library.

Each interview in turn was transcribed verbatim and analysed by the researcher using constant comparison and thematic analysis before conducting the next interview. Interviews and analysis continued until saturation was achieved. Significant words or series of words were identified, and participant words and phrases in the transcripts that kept recurring were allocated codes. These codes were evaluated for commonality; grouped, separated, or renamed as necessary; and then combined to form subcategories. The subcategories were, in turn, evaluated for commonality, relevance and their relationship to other data, and combined to form categories. Following evaluation of the relevance to, and links between these data, categories evolved to form the subthemes. The subthemes were evaluated and they in turn evolved to form the three themes—Caring at the coalface, Labour of Love and the Business of Dementia Healthcare.

Results

This article reports on the largest theme identified in the study—Labour of Love and the subsequent subthemes: What if that was me, Moments of happiness and the normal everyday things. Labour of Love identified that quality nursing care was linked to the nurse–patient therapeutic relationship in the dementia-specific care unit. This relationship was considered a significant part of the nurses’ experience and the stories that emerged in this theme. Six nurses discussed their awareness of the humanity of the individuals living in the dementia-specific care unit and provided anecdotes demonstrating that they were mindful of providing care that acknowledged this. The remaining three nurses identified the importance of the nurse–patient relationship, but felt they were unable to provide more than basic nursing care in the dementia-specific care unit due to high workloads and clinical inexperience. These comments reflected their view of the poor leadership, managerial priority given to cost containment above patient care delivery and the lack of support and dementia-specific staff training prevalent within the residential care facilities. One nurse, Phyllis, discussed her view that meeting basic patient needs was all that was required and said:

I do the basics…feed them, wash them, give a drink when I can…I have to work fast as there is so much to do.

This view was echoed by another nurse, Lee, who was a newly graduated nurse and felt unable to provide any more than basic care due to his clinical inexperience. Lee said:

I am very junior…I don’t know much about dementia and I can’t cope with everything I have to do so I just do the bare basics—feed them, wash them, no time to talk to them.

The six nurses repeatedly talked about the pleasure and satisfaction they received when they could reach the person ‘within the disease’ and make a difference to their quality of life. They used words such as ‘love’, ‘joy’ and ‘care’ when discussing how they provided individualized care for individuals living in the dementia-specific care unit. The following discussion of each of the subthemes highlights the importance these nurses placed on the nurse–patient therapeutic relationship. Three vignettes have been included, which are representative of the loving relationships between three of the nurses and people living in the dementia-specific care unit. Pseudonyms have been provided for both participants and individuals living in the dementia-specific care unit to maintain anonymity.

What if that was me?

One nurse, Sally, discussed the close relationship she had formed with Bill and his wife, and how she spent time each day with them. She said she loved talking to Bill and felt her interactions made a difference to his day as he always greeted her with a big smile and held out his hands to her. She said:

What was their job, things they used to do when they were younger…I love it that when he sees me, he breaks into a big smile, holds out his hands so I sit down with him and just talk…

Sally said that she had noticed Bill repeatedly walking up and down the corridor in the dementia-specific care unit during the evening and late into the night. In her conversations with his wife, she said she learnt that Bill had been a supervisor in a biscuit factory, working night shifts for 40 years. Sally believed, because of his incessant walking, Bill thought he was still in that role. His wife said that Bill had always proudly worn a long white coat at work, which represented his authority and status in the factory. Sally spoke about how Bill had touched her, and she wondered how she could connect his past and present. She decided to give Bill her old laboratory coat from the university to wear to replicate the white coat he had worn as a supervisor. Sally said:

I thought about what he must be experiencing back at that time, so I found my old lab coat from uni and brought it in for him. He wore it proudly and every shift I made sure we sat together to discuss how the shift at the factory had been, and I told him he was doing a great job.

This is important to him, so it is important to me… what if that was me? …I just make the time each day, doesn’t matter how busy I am, talking to him, asking about how his shift at the factory was ….this is important as it connects his past with his present. I love it, it’s the highlight of my day too and such an important part of our relationship.

Sally went on to discuss how she had noticed Bill’s endless walking had reduced along with his anxious behaviours as a result of their time together. She said:

He was more relaxed and calm every time we talked about his shift at the factory

She also spoke about the feelings of ‘joy’, ‘love and affection’ she experienced working with Bill and that this was, to her, part of the nurse–patient therapeutic relationship that kept her working in the dementia-specific care unit. She said she often reflected on how such a simple action as giving Bill an old white coat had such a profound impact on his physical and psychological well-being. Sally said:

It is nothing, really…an old coat, but to him he is back there, in charge.…

Moments of happiness

Connecting with and providing a moment of happiness for those living in the dementia-specific care unit was a priority for many nurses in this study. One nurse, Wendy, identified that her nurse–patient therapeutic relationships often involved giving of herself and doing things for them that they had not requested or expected. Wendy spoke about the joy she felt caring for Lenny, who had exhibited aggressive and abusive behaviours to some staff members and said:

He smiles when he sees me, holds out his hand and seems happy to see me…it makes me feel happy that he trusts me. I love it…I want to do what I can to help him...

She said the basis for the nurse–patient therapeutic relationship she had with Lenny and others, lay in knowing each patient well, including their life story and experiences. Wendy said:

They have done so much in their lives…everything is important to them...their kids, pets, work.... I just want to know about what was important to them and try and connect…the connection is important…they feel happy and so do I.

Wendy spoke about the importance of taking time each day to greet each person, look into their eyes and connect with them as an individual. Due to knowing each person so well, she said she was able to interpret if they were happy, anxious, in pain or fearful by their facial expressions and body movements. She said:

Yes, the thing is we get to know them…I greet them by name, look into their eyes and connect with them. We talk to the family, talk to other staff members to know more about the particular dementia patient—if they are aggressive at 5 or 6 o’clock; if the patient doesn’t want to get up because they were used to working the night shift, you leave them—so that the more you know, the more you can look after them...

Looking at the person…know them, really know them…if they are happy, anxious, fearful or in pain, I can tell just by looking at them because I know them so well.

Wendy said that this ability to connect with people living in the dementia-specific care unit at such a deep and personal level was the basis of her close nurse–patient therapeutic relationship. She said it gave her great joy and a feeling of fulfilment. Wendy said:

I love it…makes me feel warm and happy all over and this intense feeling of joy…just spending time with them is everything.…I can pick up the cues and clues if there is anything wrong just by touching them and spending time with them because I know them so well…things that others might miss, I can pick up because I touch their hand, give them a hug, then I can do something about it.

The ability of nurses to connect with hospital inpatients on a multitude of levels in order to gain satisfaction, joy and engagement was explored by Kelly and Adams (2018). Findings from their study confirm that nurses choose to engage in activities with patients that bring them satisfaction and meaning. The importance of nurses looking beyond the dementia diagnosis to ‘the individual living with dementia’ has been explored by researchers (Brannelly et al., 2019; Conn et al., 2017; Digby et al., 2017). What is evident from these studies is that dementia nursing care is challenging and complex, and nurses who are able to see the person as an individual amid the chaos of the progression of their dementia report feelings of deep connection and warmth towards the person they are caring for.

The normal everyday things

Engaging with people living in the dementia-specific care unit through talking about and doing everyday things also emerged as an important element in the nurse–patient therapeutic relationship. Laura, another nurse, spoke about the close nurse–patient therapeutic relationships she had in the dementia-specific care unit. She said that these relationships allowed her to engage with individuals and make every effort to meet their needs. Laura highlighted how important a nurse–patient therapeutic relationship was to her when discussing a situation involving Alice, a dying woman in the dementia-specific care unit, and Alice’s daughter Penny. Laura said she had known and cared for Alice for many years and had formed a close nurse–patient therapeutic relationship with her and her family. Laura talked at length about the joy and delight she felt when spending time with Alice, often just talking or holding her hand and connecting on a very personal level with her and said:

Doesn’t matter how busy I am, I make sure I spend time with her every day I am on shift…nothing dramatic, just the normal everyday things we do, sometimes I just tell her about my day, what was happening with my family, other times I just sit next to her for a while and hold her hand…she love is it and so do I….the highlight of my day really

Laura went on to discuss the situation when Alice’s condition deteriorated suddenly, and she was approached by Penny who requested a glass of gin for her mother. There was no gin available in the dementia-specific care unit or residential aged-care facility, so Laura asked another staff member to go to the local bottle shop and buy a bottle of gin, paying for it with her own money. Laura ensured that Alice and Penny were provided with a glass of gin each and were comfortable. Later that evening, Alice died with Penny sitting beside her bed, both having enjoyed a last glass of gin together. Laura talked about how much it meant to her to be able to grant Alice’s dying wish by such a simple act, which meant so much to Alice and Penny, and said:

We knew her mother was dying. Her daughter said, “My mum wants a glass of gin”. I said, “Well, I don’t have any, but there might be some in H Wing”, and sent a carer over to see. They came back…no gin… so I got $20 from my purse and sent the carer to the bottle shop down the road to buy some.…She comes back and Mum dies with a glass of gin in her hand and the daughter has one, too.…I felt so good that she had her last wish granted.…It’s nothing special, just what I do…what she would do at home if she could, normal, everyday things like having a drink with your daughter.

Laura was self-deprecating regarding her actions and repeatedly said it was ‘just what I do’. She discussed at length the love she felt for Alice and how proud she was to be able to provide her with love and comfort at this time. She said:

I don’t need a box of roses…if I can make a difference to one patient then I have done a good job…makes me feel happy and warm inside, part of loving her and caring for her to the best of my ability…just what I do

The nine nurses who participated in the study identified what they perceived quality nursing care to be in a number of ways. Six nurses talked of the joy and delight they experienced interacting with people in the dementia-specific care unit when they did ‘the little things’ that meant so much to them. This ability to connect with people living with dementia is clearly based on the natural trust that exists between the nurse and the individual. The nurses stated they experienced a sense of reward and fulfilment when they provided what was to them, quality nursing care in the dementia-specific care unit. They considered that the relationship with those living in the dementia-specific care unit should be based on love and compassion and confirmed that this was an essential part of quality nursing care.

Discussion

The objective of this study was to explore nurses’ perceptions of quality nursing care in the dementia-specific care unit. The challenges of dementia nursing care have been well documented in the literature, but what are largely absent are the descriptions of nurses’ perceptions of quality nursing care in dementia-specific care units. The nine nurses who participated in this study willingly provided a depth and richness of information and context regarding the complexities involved in delivering quality nursing care in this clinical setting. Six nurses perceived quality nursing care in the dementia-specific care unit to be person centred and based on the nurse acknowledging the personhood of the individual in every aspect of the care they provided, and they achieved this through nurse–patient therapeutic relationships. The nurses demonstrated that they focused on attending to all the individual’s needs and ‘being with’ them, physically and emotionally. These findings align with what is currently known about loving and caring nurse relationships in dementia care literature (Chambers & Ryder, 2018; Ersser, 2019; Evripidou et al., 2019). Additionally, findings from this grounded theory study revealed that love, compassion, reward and fulfilment are considered by these nurses to be essential components of quality nursing care. They identified that knowing each person as an individual, feeling wanted and needed, and making a difference to the person every day formed the basis of quality nursing care in the dementia-specific care unit. This information adds depth to the current information regarding what constitutes quality nursing care from the perspective of nurses.

Nurses who develop effective nurse–patient therapeutic relationships have been shown to be more connected and responsive to the needs of the person they are caring for (Tremayne, 2014). Nurse–patient therapeutic relationships are based on the interpersonal skills of the nurse who seeks to form a close and personal relationship and the genuine concern nurses show for those in their care (Burgio et al., 2018; Tremayne, 2014; Weaver, 2015). Kelly and Adams (2018) explored the presence of engagement, satisfaction and joy in nurses, and their relationships with those they care for. They consider that nurses work on a continuum that ranges from burnout to engagement, choosing to generate satisfaction and meaning from interactions with people within the nurse–patient therapeutic relationship. The nurse–patient therapeutic relationship in the dementia-specific care unit experience is evident in the current literature (Edvardsson et al., 2014; Lee et al., 2016; Person & Hanssen, 2015). Findings from these studies confirm that nurses working in this clinical area who connect closely with individuals and remind them of their past life experiences can increase feelings of well-being and improve their quality of life.

Six nurses in this grounded theory study identified and discussed the importance they placed on the nurse–patient therapeutic relationship in the dementia-specific care unit, which they said was based on love and compassion for their patients. The words ‘joy’, ‘loving’, ‘caring’, ‘persistence’, ‘compassion’ and ‘trust’ were used often and in different contexts, conveying the importance of these relationships to these nurses who said their role was a labour of love. Human love, where nurses exhibit cultural respect and an affirming presence, has been shown to be fundamental for effective communication and establishing trust in the caring nurse–patient relationship, and validates the comments of the nurses who participated in this study (Ersser, 2019; Nilsson et al., 2019).

They said they felt they provided love, comfort and emotional support through touch or just sharing time with people living in the dementia-specific care unit, providing what they considered to be quality nursing care. This ability to connect with people living with advanced dementia is clearly based on the natural trust that exists between the nurse and the individual, and has been recognized by research as an essential component of the nurse–patient therapeutic relationship (Dunn et al., 2013; Ersser, 2019; O’Brien, 2018). The three nurses said they took pride in providing dignity, comfort, hope and love for those who live in, for them, a confusing and foreign world. Current research supports the importance of caring and loving nurse–patient therapeutic relationships through the provision of empathy, love and compassion (Chambers & Ryder, 2018; Ersser, 2019; Monroe et al., 2015).

The six nurses also identified that developing nurse–patient therapeutic relationships in the dementia-specific care unit required openness with the person, the ability to preference the persons’ needs and connect with them as an individual at every opportunity. The importance and reward nurses experience from knowing each person’s life history, habits and preferences has been supported by research (Dunn et al., 2013; Ersser, 2019; Monroe et al., 2015). Literature also supports the value of the nurse knowing the persons social context, which then sustains a nurse–patient therapeutic relationship that values the person as an individual and is nurturing to both the nurse and the person (Kitwood, 1997; McCormack & McCance, 2016).

Six nurses in this study said they felt satisfaction and enjoyment through altruism and that they just liked the job and the experience of working with people in dementia-specific care units. They said they felt empathy for these individuals and could look beyond the disease to see the person within and the value that person still had to offer. Literature supports the importance to the nurse–patient therapeutic relationship of nurses continuing to view people in the dementia-specific care unit as valued individuals (Bird, 2014; Harmer et al., 2017; Marshall, 1993). Despite the increased risk to personal safety at work, these nurses said they would not work anywhere else because they loved and cared for the people living in the dementia-specific care unit. Although providing quality nursing care in the dementia-specific care unit is stressful and challenging, the literature confirms that nurses continue to work there because they have deep feelings for and feel needed by the people there (Chenoweth et al., 2014; Cleary & Doody, 2017; Cronfalk et al., 2018).

The results of this study have contributed to the understanding of what is quality nursing care in the dementia-specific care unit, but there were some limitations. As in many qualitative studies, the sample size was small due to the limited number of registered nurses working in dementia-specific care units in these two organisations. However, the participant number was sufficient to reach data saturation according to the grounded theory criteria. The nine nurses who participated in this study represented a small, homogenous sample that reflected the current aged-care workforce within residential aged-care facilities in Australia.

Conclusion

In the absence of a cure for dementia, there is an increased need to recognize the value of the caring and rewarding nurse–patient therapeutic relationship in the dementia-specific care unit. This relationship, characterized by moments of engagement and recognition, has been shown to assist in reducing feelings of social isolation and depression, and can significantly improve the quality of life for people in the dementia-specific care unit (Evripidou et al., 2019).

The results of this study are valuable and have implications for nursing practice. Findings from this study have highlighted the physical and emotional load nurses work under within the dementia-specific care unit every day. Despite these pressures, six nurses identify the strategies they use in order to satisfy their intrinsic need to provide quality nursing care. Understanding what quality nursing care is in dementia-specific care units can also provide a coherent picture of the relationships between nurses and individuals with advanced dementia. The significance of this study lies in its potential to improve the understanding of what constitutes quality nursing care in the dementia-specific care unit from the perspectives of nurses. Findings from this study indicate that nurses provide person-centred care and truly care for people living in the dementia-specific care unit. The provision of person-centred care includes meeting the physical, spiritual and emotional needs of each person, providing comfort for the patient, reaching the person within the disease and making a difference to each person every day. The importance of a caring environment, characterised by respect and dignity, was highlighted by six of the nurses who participated in this study as an essential part of quality nursing care. Although this study focused on nurses working in dementia-specific care units, findings from this study have wider significance through the provision of information and theoretical understanding of quality nursing care for nurses working in other clinical settings.

Footnotes

Declaration of Conflicting Interests

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

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

We confirm that Ethical Committee approval was sought where necessary and is acknowledged within the text of the submitted manuscript.

ORCID iD

Julia Gilbert

Julia Gilbert is a lecturer at the School of Nursing and Healthcare Professions at Federation University Mt Helen campus. She has over 35 years clinical experience in various areas including critical care, midwifery, and dementia care. Julia has recently completed a PhD on nurses’ perceptions of quality nursing care in dementia-specific care units.

Louise Ward is the associate professor of clinical nursing at the School of Nursing and Midwifery LaTrobe University, Melbourne, Victoria. Her research interests include mental health nursing, nurse education, arts and health and workplace culture.

Ruby Walter is a lecturer at the School of Nursing and Midwifery, LaTrobe University, Melbourne, Australia.

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