Abstract
As a staff nurse working in inpatient dementia care, I am continually frustrated regarding the lack of consistent information regarding those that I care for when I try to plan their care and treatment, particularly when a patient has recently been transferred from another hospital or from institutional care (nursing or care home). In my other role as a researcher, investigating the experiences of people living with dementia related to acute hospital care (specifically orthopaedic trauma), I see this same frustration in my participants with dementia, whose care is sometimes based on a short snapshot of how they appear (subjectively) at the time of assessment without much wider knowledge or context. Hence, that care is not always person-centred or appropriate and can contribute to new institutionalisation. I was therefore very interested to read this paper about the interRAI Long-Term Care Facilities Assessment System (interRAI LTCF) in New Zealand. This is an international computer-based application that has been designed to assist in the comprehensive assessment of care needs, strengths and preferences for older adults who are living in institutional care. LTCF is one of approximately 23 interRAI instruments that can be used to assess the needs of vulnerable people across multiple healthcare sectors and settings (interRAI, 2009). In theory, if this system was adopted by the UK National Health Service (NHS), it would not only lessen my noted frustrations but also improve the care and treatment of my patients and potentially improve the service that I help provide, and others like it (and shape its underpinning strategy, policy and research activity). But if my experiences as a nurse to date have taught me anything, it’s that the best idea is only going to be as good as its implementation. The cynical nurse in me raised his eyebrows and tutted when this paper informed me that less than a third of registered nurses working in long-term care facilities were trained using the system when the New Zealand government made its use mandatory in 2015 . This paper, then, with its focus on registered nurses’ experiences of, and attitudes towards, the system, should be a vital contribution to the successful implementation of it and ensuring that it is used to its maximum potential with regards to improving the lives of residents and those that care for them (including a skilled and satisfied workforce).
The small group of interviewed participants held views about the inter-RAI that, in the main paper, had been highlighted elsewhere (see the paper’s cited sources and Bandaranayake and Campin, 2017) and, despite the reported negativity that came with mandatory implementation (and my cynicism), their views were mostly positive. Responses are encouraging not only in terms of increased quality of care for those living in the long-term care facilities but also the career satisfaction (and future possibilities) of those working in these areas. I immediately thought that the inter-RAI system had, in some ways, brought about the beginnings of a ‘senses framework’ approach to care (Nolan et al., 2006). This is a framework for providing care based upon achieving specific needs of all in the caring relationship. Nolan et al. (2006) explain that if each participant in the caring relationship achieves a sense of security, continuity, belonging, purpose, achievement and significance, then an enhanced environment of care will result. With the interRAI-LTCF being used to its full potential, one could assume that individual care is being planned from a person-centred perspective and is thus significant for the LTCF resident. As noted in this paper, the system has promoted communication with, and involvement of, family members also likely leading to a sense of significance for them in contributing to the care of their significant other. For the nurse, their contribution to the system means that their expertise adds not only to an improved experience for their residents but also to their career development and thus fosters a sense of significance. This framework was developed specifically for use in dementia care, where care environments are often found to be impoverished.
I was surprised, then, to find that one of the negative views of the interRAI-LTCF reported in this paper (and not elsewhere) was that staff did not think that it was particularly relevant for residents living with dementia. Nurses interviewed for this study said that their ‘job satisfaction was greater when they were able to look after patients’ physical and emotional needs by spending time with them, not on a computer’. In some ways I agree – spending time with patients is the best part of my job – but I cannot do that and achieve therapeutic benefit for them (in terms of our relationship) without knowing the details of who they are and what makes them them . And yes, I can get some of that from spending time with them, but I also need to know about their history (medical and personal), which means some time spent at the computer and with their significant others.
Time is important in this study, and as a group of professionals, we nurses often cite lack of time as interfering with our ability to provide the best possible care, but I think sometimes we mean something else, particularly when it comes to the care of people living with dementia. This is reflected in a fascinating study by Flaskerud et al. (1979), who see nurses complain about the lack of adequate staffing and time to provide humanistic care in environments where staffing is actually at an optimal level. Their observed behaviours suggest that time is available for those practices, something that I still experience in the clinical environment today. Time spent with people can be challenging, emotionally demanding and stressful, particularly if they are experiencing distress. Dementia can challenge our views of what it means to be a person, particularly if we have not had the appropriate training, education and experiences to try and understand it. So I think that, consciously or not, we use lack of time to justify our avoidance of, for example, a strengths-based approach to care planning for our patients with dementia. It moves down our list of priorities as we don’t see the benefit of it, or because on some level we know it will be difficult to implement and will require something much more complicated than a change in paperwork, a change to the way that we think about people living with dementia. There is, therefore, comfort in doing things the way that we have always done them, particularly task-focussed activities, even if it is not necessarily the best way for our individual patients or residents.
To me, this small study highlights the strengths of nursing, a group of professionals working together to successfully implement a system that they believe will ultimately improve the lives of those that they care for. The costs to them in terms of pressure to complete reports, yearly assessments of competence, lack of trained staff, unfamiliarity with computerised systems and so on are outweighed by the perceived benefits to their residents, which is what they value the most. But given that a significant number of residents in these facilities (possibly a majority) will have dementia, it also highlights a related stigma that is common and perpetuates, even in the presence of staff that value the quality of the lives of their residents above all else. This is something that needs to be researched more thoroughly and could be facilitated by the use of an innovative system such as the interRAI-LTCF. This paper highlights the potential of the interRAI-LTCF to produce results that will be beneficial to all participants in the caring relationship and give rise to enriched environments of care and, at the same time, highlight the entrenched cultural aspects of nursing that will make this potentially difficult to achieve in reality without further research and change.