EMPIRICAL STUDIES
doi: 10.1111/scs.12226
Experience of anaesthesia nurses of perioperative communication in hip fracture patients with dementia Ferid Krupic RNA, DMSci, PhD (Researcher)1, Thomas Eisler MD, PhD (Orthopaedic Surgeon)2, € ldenberg MD, PhD (Orthopaedic Surgeon)2 and Nabi Fatahi RN, PhD (Senior Lecturer)3 Olof Sko 1
Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2Unit of Orthopedics, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden and 3Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
Scand J Caring Sci; 2016; 30; 99–107 Experience of anaesthesia nurses of perioperative communication in hip fracture patients with dementia
Background: Perioperative care in hip fracture patients with dementia can be complex. There is currently little scientific evidence on how care should be undertaken. Aims: The aim of the study was to describe the experience of anaesthesia nurses of the difficulties that emerge in care situations and how communication with patients can be maintained in the perioperative setting of hip fracture surgery. Methods: Individual interviews were conducted with ten anaesthesia nurses (5 men and 5 women). The interviews were carried out at a university hospital in Gothenburg (Sweden), and the data were analysed using qualitative content analysis. Findings: Three main response categories were discerned: ‘Communication’, ‘Dementia as a special issue’ and ‘Practical issues’. Dementia was viewed as one of the most difficult and shifting diseases an individual may suffer from.
Introduction There is currently a rapidly increasing incidence of dementia in hip fracture patients (1). Their mortality rate is greater than those without a diagnosis of dementia and the patients who survive may never return to their previous mental and physical functional level. Patients are generally fragile and frail in most settings and require specific health resources to individualise care in relation to their disease level (2). To the best of our knowledge, there is currently little evidence on how these patients in
Correspondence to: Ferid Krupic, Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, G€ oteborgsv€ agen 31, Gothenburg, Sweden. E-mail: [email protected] © 2015 Nordic College of Caring Science
Time must be allocated to communicate clearly and patiently, to meticulously plan and carry out care while providing distinct information to enable patient participation. Establishing a mental bridgehead by confirming the patients’ perceptions/feelings significantly reduced distress in a majority of the patients. A holistic and respectful approach was deemed mandatory at all times. Patients are sometimes dependent on recognition, so that small personal items brought close to the patient during surgery can calm the patient. State-of-the-art analgesia and anxiolytic medications are mandatory. Conclusions: Perioperative problems can be overcome with patience, empathy and profound knowledge of how patients with dementia respond prior to surgery. Our results may serve as a source for future care and provide information about hospital settings for better perioperative care in patients with dementia. Keywords: dementia, nursing, perioperative care, hip fracture, communication. Submitted 5 November 2014, Accepted 14 February 2015
need of imminent hip fracture surgery should be approached. Caregivers in the acute perioperative situation, apart from purely medical data, often lack information about the patient’s social circumstances, personality, coping behaviour or life history. Since a majority of patients should have surgery within 24 hours after admission in order to reduce morbidity and mortality, most of these factors remain unknown when the patient is prepared for surgery (3). In elective surgery, pre-operative appointments have proved to be of importance (4), but in the acute fracture situation, anaesthesia nurses obviously face other problems in demanding situations with the pressure of time (5). Glover et al. (6) argued that when a patient with dementia is affected by acute trauma, severe stress is experienced due to sudden psychological and physical deterioration, and it is not uncommon that patients become aggressive, paranoid 99
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and have tantrums, making the nursing situation very difficult. Anaesthesia nurses are trained that their work should be characterised by responsibility, respect and openness to the patient’s state of health and that the basic contents of the intra-operative encounter are to initiate and reinforce, as well as to complete worthy communication in order to establish the safety of the patient (7). But since communication is based on each patient’s desire and ability to convey this (8), patients with dementia are far more complex to approach (9). One reason might be that previous educational models in nursing have become obsolete, disregarding the current paradigm shift in communication theory and perceptions of human communication (10). In addition, negative attitudes have been noted among nurses towards patients with communication deficits or behavioural disorders, by which nurses avoided creating a relationship beyond interaction in the course of basic nursing (11).
Person-centred care Even though person-centred care (12) has been used in other fields for many years, it is a relatively new concept in patients with dementia (13). The importance of understanding patients’ personal histories and social contexts is currently in focus, where the caregiver attempts to establish a meaningful relationship with the patient. Even primarily dementia has been understood as a biomedical phenomenon, during the last decades, understanding the personal histories and social context is in focus, which has led that attention turned from disease process to the need of better understanding of patients with dementia and provide the better care (14, 15). Creating one can, of course, often be perceived as difficult, due to lack of understanding about how relationships are built (16). Communication difficulties may be related to the absence of practical, everyday guidelines to relieve stress and improve communication outcomes (17, 18). A recent study targeted nursing aide students’ education on their perceptions of dementia and their ability to care for patients with dementia. The results indicated training was effective regarding nursing aides’ understanding of cognitive dysfunction and the need for meaningful contact among patients with advanced dementia. However, the training was not successful in terms of nursing aides’ comfort level or perceived skills in working with this population of patients (19).
Aim The aim of this study was to explore the experience of anaesthesia nurses of both difficulties and opportunities in communication with hip fracture patients with dementia in the perioperative setting.
Materials and methods Setting and participants This exploratory pilot study is based on a qualitative design. The study was conducted at the Department of Orthopedic Surgery, Sahlgrenska/M€ olndal University Hospital. Anaesthesia nurses were contacted by the first author (FK) and asked to voluntarily participate in an open individualised interview. After meeting with study participants, the aim of the study was presented. The nurses with at least 5 years of experience of orthopaedic anaesthesiology were requested to take part in the study, because those who have worked at least five years would have had more opportunity to meet patients with dementia. Fourteen anaesthesia nurses were recruited initially, but four could not participate because of shortage of staff and other personal reasons. An invitation latter with information about the study’s aim has been sent to 14 anaesthesia nurses. Thus, 10 anaesthesia nurses (five men and five women) participated in the interviews. Their ages varied between 35 and 55 (median 40), and they had worked as an anaesthesia nurse between 6 and 28 years (median 15 years). In order to obtain the information, we performed in-depth individualised interviews.
Data collection The interviews were conducted between March and November 2011 by the first authors (FK) through faceto-face interviews using open-ended questions. The interviews began with the question ‘Can you please describe your encounters with hip fracture patients with dementia disease in the perioperative setting?’ All study participants were urged to speak freely using their own words and responds as comprehensively as possible. The interviewer interrupted only to pose further questions or follow up on the information given by the nurses. The interviews, which were conducted at the surgical ward, lasted between 60 and 90 minutes and were audiotaped and transcribed verbatim. More questions are presented in Table 1.
Data analysis A qualitative content analysis method in accordance with Graneheim and Lundman (20) was chosen for analysis and interpretation of the data. This method is capable of condensing a large amount of data into a limited number of themes, categories, subcategories and codes. The analysis of the data was primarily at a manifest level, but as the latent analysis part of this method, so the analysis may contain both the manifest and latent. The
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Table 1 The interview questions Main issues raised at the start of the interviews ‘Can you please describe your encounters with hip fracture patients with dementia disease in the perioperative setting?’
transcriptions were read carefully in order to identify the informants’ experiences and perceptions. Then the analysis proceeded by extracting units consisting of one or several words, sentences or paragraphs containing aspects related to each other and addressing a specific topic in the material. Then units that related to each other by virtue of their content and context were abstracted and grouped together into a condensed unit, with a description close to the original text. The condensed text was further abstracted and labelled with a code. After that, codes that addressed similar issues were grouped together, resulting in subcategories. Subcategories that focused on the same problem were merged in order to create more extensive perceptions, which addressed an obvious issue (20). According to Graneheim and Lundman, the interpretation was done primarily at a manifest level. The results are presented with direct quotes from the interviews. Research rigour. Criteria for qualitative research are differ from quantitative research according to the criteria for research rigour. In this context, criteria for our study, which is a qualitative research, are credibility, transferability, dependability and confirmability. These concepts correspond to internal validity, external validity, reliability and objectivity, which are notions used in quantitative methods (21). The idea behind the development of specific criteria for qualitative methods was that the nature of the study topic, methodology, aims and supposition in these methods did not suit the criteria for quantitative one. Reliability implies getting the same result independently of whoever accomplishes the test. In qualitative research, two researchers who recurrence a similar study may reach approaching experiences; however, it may be impossible to reach the same result, as different persons with different understandings. Based on the research rigour, credibility reflects the ability of the researcher to communicate the validity of the knowledge. Sufficient descriptions of the pre-understanding of the researcher, ways of describing the data collection, sampling, analysis of methods will have an impact on the credibility of data. © 2015 Nordic College of Caring Science
Examples of more targeted issues raised during the course of the interviews. How did you experience your first contact with the patients with dementia? How was the pre-operative communication with patients with dementia? What is the difference between communication with patients with dementia from other patients? What was the most complex issue in communication with dementia patients?
By transferability in a qualitative study means to what extent the results are transferable to other contexts (22). The researcher does not define the transferability; it is determined by the reader and regarded as reasonable or not. The result should be critically evaluated in relation to previous studies in a similar field.
Ethical considerations The head of the participating departments approved the study. The informants’ identities were protected, that is, their names and personal identity numbers were not stated on the recordings. The tapes used for the interviews were stored in a safe. Formal approval for a study of this kind is not required in Sweden. However, the study was performed according to general ethical procedures such as voluntarism, the ability to discontinue participation at any time, and receiving written and oral information.
Results Analysis of the interviews resulted in a theme based on three main categories and seven subcategories, imaging the participant’s descriptions of encountering patients with dementia. The first category contains aspects that influence communication between the caregiver and patient. The second category reflects dementia as a special issue, while the third category contains practical clinical aspects of perioperative care (Table 2).
Communication Pre-operative communication. The nurses stated that the first encounter with patients in the preparation room usually has two stages. The first serves primarily to establish good communication and the other serves to prepare necessary technical measures prior to surgery. The nurses think that the initial communication process should proceed in much the same way as in the treatment of patients without dementia. It was often said to be fundamental not to depersonalise the patients and to establish sound communication since this may open doors to
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Table 2 Overview of categories and subcategories Categories
Subcategories
Modes of communication
Pre-operative communication Intra-operative communication Postoperative communication Complex condition The hospital setting – aspects of the intraoperative session Personalisation Time
Dementia as a special issue
Practical issues
Theme
Multiside and complex communication
reveal not only the patient’s state of mind, but also their needs. One study participant describes his opinions in the following way: ‘I deal with the patient as I would any patient prior to surgery. I introduce myself, make eye contact, control the identity tag, ask about allergies and get a general feel about the patient, i.e. how much (s)he perceives and responds.’p (6) Another study participant states the following: ‘When they come to the preparation room, patients are often anxious, nervous and sometimes aggressive, which is quite difficult.’p (3) Another study participant states the following: ‘Large burdens are often laid upon us anesthesia nurses to keep patients safe and calm. It’s our treatment responsibility of the patient that is at stake. We cannot just sit two or three feet away from the patient and the anesthesia machines; we must always be attentive and present at all times for the patient.’p (7) The study participants believed that the first contact with patients should consist of a fitting introduction adapted to the patient’s cognitive ability while trying to understanding their current environment and needs. For patients to experience safety and security in the perioperative setting, nonverbal communication was generally felt to be of importance. The study participants say that most patients require the permanent presence of at least one medical personnel who is in direct physical contact with the patient by holding his/her hand, etc. Interruption of such a bond, even briefly, should probably be eliminated since this can cause disorientation and anxiety, which may require starting all over again to restoring confidence. Verbal and nonverbal communication should probably be combined at all times, but for patients with dementia, nonverbal is probably the most
important. One of the nurses expresses her experiences with nonverbal communication as follows: ‘To give the patient a warm blanket or put a soft pillow under their head can be a way to communicate.’p (9) Intra-operative communication. During the surgical procedure, new personnel and a new hospital setting are introduced to patients. During this time, patients with dementia are even harder to reach but seem nevertheless able to recognise certain objects. Small personal items such as a pillow, a hat, a photo or a coffee cup recently used may create peace of mind. Nurses encourage bringing any such items to the operating room: ‘Here, at the hospital they do not recognize anything. The hospital setting itself can be negative for the patients, who depend on recognition of familiar patterns. It is through their personal items they can identify with distant, but secure, memories’.p (7) One important problem area identified by the participating nurses was that communication does not usually last very long. For example, it does not help to explain to the patient to lie still once, when the next second (s)he will not remember what was said. This is when patience comes into play, and as a nurse it is always of importance to continue to communicate throughout the intra-operative session. One study participant says: ‘It is sometimes hard to know how much you should tell or inform the patient. It usually depends on the patient and the state (s)he is in. Mostly, I try to give them the same basic information that I provide to the other patients, but the hard part is the patients whom we can’t communicate with at all – those whom we cannot reach.’p (8) Another study participant states the following: ‘It’s difficult to know whether they have pain, whether the spinal anesthesia has worked, whether everything feels good to them. . .difficult, because you cannot have satisfactory communication with them.’p (2) Postoperative communication. Especially in circumstances such as stress, adverse drug reactions or inadequate analgesia, the participating nurses experience loss of communication with patients. Most nurses feel that maintaining communication and regular anaesthesiology work is possible given a properly designed combination of sedatives, anxiolytic drugs and well-functioning spinal anaesthesia. However, despite all such efforts, patients sometimes become physically defiant, resulting in negative experiences for the patient and the health professional team. Nurses also admit that they can become annoyed when a question is repeated 50 times during a 20-minute period, which may give them a guilty conscience later on. Some © 2015 Nordic College of Caring Science
Hip fracture patients with dementia nurses say that intra-operative care of patients with dementia could be improved further and should be the focus of future research. All nurses agree that better knowledge of dementia disorder and its implications for perioperative care is of importance since this might facilitate cooperation between various health personnel groups and shorten hospital stays for patients. One idea that several nurses came up with independently was that people with good knowledge of the patient prior to surgery could provide support during the intra-operative session. A study participant expressed the following: ‘One time I think I gave the patient too much Propofol, then her blood pressure dropped. . ..It was a very trying patient.’p (1) Another study participant states the following: ‘The patients0 families could probably be helpful throughout hospital perioperative care. Relatives could act as messengers or mediators who aid in communication and understanding the various needs of the patient.’p (1) ‘Sometimes I ask, ‘Are you in pain?’ And the patient responds and asks: ‘Where is my mother?’ A truly difficult and miserable situation.’p (5) Dementia as a special issue. All study participants clearly realised the general nature of old, frail and often multi comorbid patients with dementia. However, most of the nurses acknowledged that patients present different clinically depending on the type and extent of their dementia. Most patients, however, cannot remember what they suffer from, or explain their situation, their current needs or their medical history. Some patients cannot remember why they are undergoing surgery from one-second to another. The nurses frequently experienced that they were not given enough time to help patients understand their current health status. Nurses talk about the utmost importance of allocating time to communicating clearly and to meticulously planning and carrying out methodical care measures, such as preparation for spinal anaesthesia. Despite the obvious difficulties, all study participants mention the importance of having patience and providing distinct information to enable active patient participation, such as holding the oxygen mask in place. One study participant described the encounter as follows: ‘I think one should be extra careful at all times in connection with dementia. This might be the pace of your voice, the way you touch or move the patients or even when you put the cap on their head. Clearly, a patient with dementia will require more time to understand, if ever, what is happening to them in this frightening milieu.’p (3) Most of the participants shared the perception that the frightening and alien hospital setting in the operating © 2015 Nordic College of Caring Science
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room created stress and anxiety among the patients, frequently yielding a complex situation despite pre-operative sedation. Trying to assess patients as individuals, more than as ‘just an ordinary patient with dementia,’ was said to be crucial. For example, an aggressive patient may be better off left alone for some time while a nervous patient may need to be assured that there are several people with kind voices and hands ready to assist them before, during and after surgery. Since unforeseen events are not uncommon in hip fracture surgery, the anaesthesia nurse must continuously be on standby to give psychological comfort to the patient. The hospital setting – aspects of the intra-operative session. All study participants stated that fracture pain, drug effects and the alien hospital setting affect patients. It was also reported that perioperative drugs (such as Propofol) increased some patients’ anxiety level. According to nurses, four categories of dementia patients could be discerned: (i) the disoriented, having difficulty distinguishing time, situation and person; (ii) the aggressive, who refuse care and react with punching and profanity; (iii) the depressed, with little or no desire to live, often seeming nervous, anxious and with a decreased ability to concentrate; (iv) the quiet, who seem to accept/ignore surgery but could suddenly pat the nurse on the cheek with a kind look in their eyes. Most participants agreed that intra-operative care was facilitated if adapted to these personality types. A study participant describes her experience as follows: ‘Many patients with dementia arrive at the surgical ward without any knowledge of having sustained a fracture and look upon us as if we were evil green Martians.’p (1) Another nurse adds as follows: ‘. . .pain temporarily accelerates dementia, and they often become even more confused after maneuvers we do that trigger pain.’p (10) Nurses state that one of their main goals is to provide adequate analgesia. Many patients have obviously lacked appropriate analgesia at the previous ward. Staff in orthopaedic wards is sometimes under stress and forget that fracture patients with dementia will probably need more analgesia and anxiolytic medication prior to transport. This would obviously facilitate perioperative patient cooperation; prevent patients from pulling on their urinary catheter, oxygen mask or the peripheral venous catheter, etc. A combination of short-acting and long-acting medications should be used, according to the nurses. On study participant describes his experiences of drug administration: ‘I prepare medication for relaxation and anxiolytics for the patients in the form of midazolam and Propofol. We must help them to be at peace and to sleep during surgery. Maybe they haven’t slept well for a
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long time due to fracture pain, the new ward and all the new personnel they have met over the past few days.’p (2) Another nurse described her experience as follows: ‘I have no patients with dementia who spontaneously understand the need to lie on their side in order to get spinal anesthesia. I have to use sedatives and pain medication to reduce stress and resistance. I try to use medications to facilitate and create a more pleasant experience for the patient when I insert a peripheral venous catheter or administer spinal anesthesia. It makes it so much easier for patients and for us.’p (5) All of the nurses realise that patients with dementia rely on their skill and that they all share the responsibility to provide the best possible care since many physicians seem to pay attention a comparatively short amount of time. Some of the nurses, however, claim that administration of analgesia and anxiolytic drugs is not without problems and some patients respond with more confusion, which is why the initial dosage should be relatively small. The nurses share the belief that agitation and fear in patients may also originate from uncertainty about what is going to happen in the near future. One study participant concluded as follows: ‘We have to be decent and show respect, remembering that these patients have lived a long life and experienced a whole lot. They are still human beings with dreams and wishes. I very rarely meet patients with dementia who want to die. We should all remember this.’p (10) Individualisation. All nurses agree that perioperative care should depend on the patient’s unique needs. In addition, they felt that it is the duty of the anaesthesia nurse to inform the team about the patient’s condition and current needs in order to protect the patient from being harmed. They also state the importance of establishing a ‘safe relationship’ with each patient, described as a bridgehead confirming each patient’s perceptions during surgery. The patient must be assured that the anaesthesia nurse is there to help at all times. A holistic approach was deemed mandatory, which may range from confirming the patient’s feelings to progressively talking about the course of events or informing the patient when pain may occur. One way to get through to patients with dementia was to simply exhibit consistent and clear behaviour. One study participant reports as follows: ‘As well as I possibly can, I try to ‘read’ how the patient thinks and find out what this very person needs. If a patient is aggressive and waves his fists, I think the message is just ‘leave me alone,’ so I leave him alone for a while. When I encounter an anxious person who jumps when I touch her, I make sure to use an extra kind voice and I see to that everyone in
the team does the same thing. I remember that this patient will need to feel that (s)he is in good hands, and I focus on this. Usually it works.’p (4)
Practical issues Time. Most study participants express frustration that they have too little time to provide optimal conditions, especially when patients become agitated during the surgical procedure. Nurses agreed that very few patients are aggressive at baseline and that with comparatively little effort, patients can remain calm throughout the procedure, provided the medical history is analysed and enough time is allocated for the encounter between the anaesthetic nurse and patient. In many such circumstances, a kind hand on the shoulder can be enough to calm an agitated patient during surgery. ‘When they wake up after the surgery, we do not have enough time to take care of them, since they have to be taken to post-op. Sometimes just holding their hand for a while may be of importance. . . there’s a lot of work involved with these patients, but lack of time is the main obstacle and more time is required to be able to provide adequate care.’p (7) ‘One nightmare is if you get such a patient but have no time. . .dementia patients require a lot of time and energy.’p (9)
Discussion In this exploratory, impartial, pilot study, we qualitatively analysed the perioperative subjective experiences of anaesthesia nurses of encountering and communicating with patients with dementia pending or undergoing surgery due to a hip fracture. The main results of the current study regard how nurses handle the difficulties that arise. The nurses seem to agree on a general approach to facilitate perioperative care for the patient and the healthcare team. Generally speaking, the principal goal of health care is to provide high-quality and uniform health care to all inhabitants of a country (23). Health care should be based on respect for autonomy and privacy and promote a sound relationship between patients and healthcare providers (24), simultaneously adjusted to the patient’s situation and capabilities (7). In the care of patients with dementia, this can sometimes be hard to do. Compromised communication abilities are common, and their frailty makes them prone to severe deterioration due to sudden life changes caused by the fracture of the hip. According to Scandol et al. (24), people with dementia account for about 30% of the total population of elderly hip fracture patients in hospitals. The study participants focused on the important initial encounter with the patient and how to maintain a sound © 2015 Nordic College of Caring Science
Hip fracture patients with dementia connection throughout the procedure and the immediate postoperative period. Several studies, which corroborate the present one, point out the significance of meaningful communication and collaboration with such patients (25–27), and this is further validated by the fact that nursing without such communication can create general dissatisfaction among patients, proxies, healthcare personnel. Many ethical problems seem to arise simultaneously (20, 28). One prerequisite is that sufficient time be allocated to acquire detailed knowledge of the patient’s history in terms of personal health and fitness level, life history, personality, coping styles and the environment in which they live. Such information appears crucial to combating negative attitudes among healthcare professionals towards patients with communication deficits; some of them avoid creating a relationship beyond interaction in the course of ‘as needed’ nursing. Obviously, the goal is to accomplish Kitwood’s ‘person-centred care’ (15). The importance of the person-centred care has been indicated by previous study (29). In the study mentioned, the authors compared two groups of patients which undergone the hip replacement. A group that treated according to the person-centred care was more satisfied than the other group. Clearly, modern perioperative care of hip fracture patients with dementia must embody respect for personhood and avoid stigmatisation and objectification of the patient (16, 30). The nurses in the present study repeatedly focused on the importance of doing so by gazing kindly at the patient, maintaining eye contact, using a kind voice and taking the time to convey information clearly and directly. Encountering patients with dementia should probably start by limiting personnel around the patient in order to generate a calm environment for the patient. Verbal and, more importantly, nonverbal/physical communication may be the driving force to establish a bridgehead of personal interaction. To actively demonstrate the respect, these elderly patients deserve was underscored by many nurses and may set an example for the remaining team, including physicians. This may be conveyed by a polite initial handshake and maintained later on by continuous physical contact and active patient participation, conveying the trust most of these patients need in a delicate life situation. However, the above behaviour must take place in association with regional anaesthesia and administration of appropriate sedatives and anxiolytic medication to reduce pain, worry and stress. Most nurses agree with the findings of Lindvall et al. (28) that perioperative care benefits from being well planned. Many patients seemed to be on suboptimal analgesia and anxiolytic medication when they arrive from an orthopaedic ward, which portends communication problems when patients are moved. Frequently, nurses experience frustration with physicians’ © 2015 Nordic College of Caring Science
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pain evaluation and feel resistance to provide nursing in this way (31). Femoral nerve blocks should probably be used on broad indications to provide effective analgesia and to facilitate perioperative care. Pre-operative medication in the form of sedatives or anxiolytic drugs should possibly be scrutinised prior to spinal anaesthesia, since adverse effects that may appear later when nurses are left alone with patients are far from uncommon. Even though the present results were not clearly related to the nurses’ age, gender or working experience in orthopaedic anaesthesiology, nurses with a real interest in patients with dementia should probably undertake the most intimate care. The idea of using proxies or other personnel with knowledge of the patient to follow through care should probably be explored further, since a lot is probably to be gained in terms of a mentally stable patients as well as improved communication and interpretation of the patient’s needs. Since long hospital stays are not uncommon for these patients, who may sustain severe complications of surgery, alternative ways of handling agitation, anxiety, aggressiveness, etc., should be tried. At least in the intra-operative setting, positive effects were consistently seen when personal items were brought to the patients for comfort. Each encounter with a patient requires active listening with the ability to hear details, especially in the presence of dementia (28). It is through language that we understand our community, which is not always easy to apply to daily life. However difficult, a sound dialog with the patient may be effective and save time in the end, since patients can remain calm and at ease if the nurses respond adequately to what patients try to convey. The dialog can be seen as a way for the patient to understand his or her current reality. This, of course, demands experience and patience, especially in aggressive patients, but will probably contribute to improved well-being of the patient (25, 26, 29, 32). According to Rudolfsson et al. (33), it is the sincere talk in the perioperative encounter that will create mutual satisfaction and a sense of safety between the patient and caregiver. In this respect, it has been suggested that patients with dementia be invited to take part in care with the objective of feeling safe and secure and with the promise not to be abandoned (28). In this context, perioperative communication in the present study is in line with the previous study. Good nursing care for individuals in difficult situations can probably overcome some disease and suffering and help the individual to have an acceptable life. However, people with communication deficits may conceptually be uncomfortable for many caregivers in everyday, one-toone situations. Kitwood (15) argues, however, that if caregivers are given the opportunity to process and openly cultivate feelings of discomfort, good care of such patients may ultimately be possible. In order to achieve safe care of hip fracture patients with dementia, more
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evidence-based knowledge is clearly warranted. Future studies should probably be based on multidisciplinary collaboration between all occupational groups in the perioperative encounter, with the aim of identifying risk factors for a poorer outcome. Research should perhaps also focus on the use of personnel and specially designed hospital settings dedicated to dementia care. Meanwhile, it is necessary that communication continues with a focus on providing good and decent health care, tailored as much as possible to individual needs. The findings also suggest a need to improve the way that caregivers are trained in communication techniques. Incorporating this training into the education of anaesthesia nurses has the potential to increase quality of life for people with dementia.
Study limitations and strengths To the best of our knowledge, this is the first study of its kind. The strength of the current data comes from the willingness of participants to tell us their story, based on everyday clinical practice. Our pilot study has some limitations, however, including its qualitative type. The sample is quite small and limited to nurses who work at the department of orthopaedic surgery during office hours only. The interviews in the present study partly were conducted by the first author who has same professional as the study participants. Because of pre-understanding of research subject, this may be considered as a risk factor for impartiality in the planning, execution and analysis of the research (34). On the other hand, the investigators’ background and his pre-understanding might have been advantageous since they were aware of the potential problem that may arise in this area.
Conclusions Patients with dementia who sustain a hip fracture often present with severe pain, anxiety and distress. The present results indicate that such symptoms can be alleviated if healthcare professionals allocate time to analysing the medical and psychosocial history of the
References 1 Ferri CP, Prince M, Brayne C. Global prevalence of dementia: a Delphi consensus study. Lancet 2005; 366: 2112–7. 2 Larsson M, Rundgren A. Geriatrics Diseases. 2003, Studentliteratur, Lund. 3 McLaughlin MA, Orosz GM, Magaziner J, Hannan EL, McGinn T, Morrison RS, Hochman T, Koval K, Gilbert
patients and if pre-operative preparation is performed with an empathetic, warm and supportive approach in addition to a pertinent analgesic regimen. The results also indicate that the nature of communication used in the various perioperative phases is especially important. Some study participants advocate very distinct measures, while others prefer to initiate and maintain warm verbal and nonverbal communication throughout the procedure. There is a need for existing healthcare professionals to develop a thorough understanding of dementia and become skilled at providing person-centred care. One question is whether these patients would benefit from care in specialised geriatric units pre-operatively and postoperatively, perhaps by dedicated anaesthesia nurses intra-operatively. The present results may serve as a source of improved individualised care, providing information about appropriate hospital settings and education in the perioperative care of patients with dementia.
Author contributions Ferid Krupic initiated the study, conducted the interviews and performed the data analysis. All authors drafted the manuscript and did critical revisions.
Ethical Approval The head of the participating departments approved the study. The informants’ identities were protected, that is, their names and personal identity numbers were not stated on the recordings. The tapes used for the interviews were stored in a safe. Formal approval for a study of this kind is not required in Sweden. However, the study was performed according to general ethical procedures such as voluntarism, the ability to discontinue participation at any time, and receiving written and oral information.
Funding None
M, Siu AL. Preoperative status and risk of complications in patients with hip fracture. J Gen Intern Med 2006; 21: 219–25. 4 Larsson Mauleon A, Palo-Bengtsson L, Ekman SL. Anaesthesia care of older patients as experienced by nurse anaesthetists. Nurs Ethics. 2005; 12: 236–72. 5 Morgan DL. Focus Group as Qualitative Research, 2nd edn. 1997,
International Educational and Professional Publisher, London. 6 Glover A, Bradshaw LE, Watson N, Laithwaite E, Goldberg SE, Whittamore KH, Harwood RH. Diagnoses, problems and healthcare interventions amongst older people with an unscheduled hospital admission who have concurrent mental health problems: a prevalence study. BMC Geriatr 2014; 2: 14–43.
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Hip fracture patients with dementia 7 Fatahi N. Cross-Cultural Encounters through Interpreter – Experiences of Patients, Interpreters and Healthcare Professionals [dissertation]. 2010, The University of Gutenberg, Gutenberg. 8 Rudolfsson G. The nurse has time for me: the perioperative dialogue: from the perspective of patients. J Adv Perioperat Care 2003; 3: 77– 84. 9 Mace NL, Coons DH, Weaverdyck SE. Teaching Dementia Care: Skill and Understanding. 2005, The Hopkins University Press, London. 10 Debesay J, N aden D, Slettebo A. How do we close the hermeneutic circle? A Gadamerian approach to justification in interpretation in qualitative studies. Nurs. Inq. 2008; 15: 57–66. 11 Norbergh KG, Helin Y, Dahl A, Hellzen O, Asplund K. Nurses attitudes towards people with dementia: the semantic differential technique. Nurs Ethics 2006; 13: 264–74. 12 Rogers CR. On Becoming a Person. 1961, Houghton Mifflin, Boston. 13 Brooker B. What is person-centred care in dementia? Rev Clin Gerontol 2004; 13: 215–22. 14 Drance E, Donnelly M, Chaudhury H, Beattie L, O’Connor D, Phinney A, Smith A, Small J, Purves B, Perry J. Personhood in dementia care: developing a research agenda for broadening the vision. Dementia 2007; 6: 121. 15 Kitwood T. Dementia Reconsidered: The Person Comes First. 1997, Open University Press, Buckingham. 16 Swedish National Board of Health and Welfare. National Guidelines for Health Care Services for Dementia 2010. Swedish National Board of Health
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doi: 10.1111/scs.12226
Experience of anaesthesia nurses of perioperative communication in hip fracture patients with dementia Ferid Krupic RNA, DMSci, PhD (Researcher)1, Thomas Eisler MD, PhD (Orthopaedic Surgeon)2, € ldenberg MD, PhD (Orthopaedic Surgeon)2 and Nabi Fatahi RN, PhD (Senior Lecturer)3 Olof Sko 1
Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2Unit of Orthopedics, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden and 3Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
Scand J Caring Sci; 2016; 30; 99–107 Experience of anaesthesia nurses of perioperative communication in hip fracture patients with dementia
Background: Perioperative care in hip fracture patients with dementia can be complex. There is currently little scientific evidence on how care should be undertaken. Aims: The aim of the study was to describe the experience of anaesthesia nurses of the difficulties that emerge in care situations and how communication with patients can be maintained in the perioperative setting of hip fracture surgery. Methods: Individual interviews were conducted with ten anaesthesia nurses (5 men and 5 women). The interviews were carried out at a university hospital in Gothenburg (Sweden), and the data were analysed using qualitative content analysis. Findings: Three main response categories were discerned: ‘Communication’, ‘Dementia as a special issue’ and ‘Practical issues’. Dementia was viewed as one of the most difficult and shifting diseases an individual may suffer from.
Introduction There is currently a rapidly increasing incidence of dementia in hip fracture patients (1). Their mortality rate is greater than those without a diagnosis of dementia and the patients who survive may never return to their previous mental and physical functional level. Patients are generally fragile and frail in most settings and require specific health resources to individualise care in relation to their disease level (2). To the best of our knowledge, there is currently little evidence on how these patients in
Correspondence to: Ferid Krupic, Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, G€ oteborgsv€ agen 31, Gothenburg, Sweden. E-mail: [email protected] © 2015 Nordic College of Caring Science
Time must be allocated to communicate clearly and patiently, to meticulously plan and carry out care while providing distinct information to enable patient participation. Establishing a mental bridgehead by confirming the patients’ perceptions/feelings significantly reduced distress in a majority of the patients. A holistic and respectful approach was deemed mandatory at all times. Patients are sometimes dependent on recognition, so that small personal items brought close to the patient during surgery can calm the patient. State-of-the-art analgesia and anxiolytic medications are mandatory. Conclusions: Perioperative problems can be overcome with patience, empathy and profound knowledge of how patients with dementia respond prior to surgery. Our results may serve as a source for future care and provide information about hospital settings for better perioperative care in patients with dementia. Keywords: dementia, nursing, perioperative care, hip fracture, communication. Submitted 5 November 2014, Accepted 14 February 2015
need of imminent hip fracture surgery should be approached. Caregivers in the acute perioperative situation, apart from purely medical data, often lack information about the patient’s social circumstances, personality, coping behaviour or life history. Since a majority of patients should have surgery within 24 hours after admission in order to reduce morbidity and mortality, most of these factors remain unknown when the patient is prepared for surgery (3). In elective surgery, pre-operative appointments have proved to be of importance (4), but in the acute fracture situation, anaesthesia nurses obviously face other problems in demanding situations with the pressure of time (5). Glover et al. (6) argued that when a patient with dementia is affected by acute trauma, severe stress is experienced due to sudden psychological and physical deterioration, and it is not uncommon that patients become aggressive, paranoid 99
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and have tantrums, making the nursing situation very difficult. Anaesthesia nurses are trained that their work should be characterised by responsibility, respect and openness to the patient’s state of health and that the basic contents of the intra-operative encounter are to initiate and reinforce, as well as to complete worthy communication in order to establish the safety of the patient (7). But since communication is based on each patient’s desire and ability to convey this (8), patients with dementia are far more complex to approach (9). One reason might be that previous educational models in nursing have become obsolete, disregarding the current paradigm shift in communication theory and perceptions of human communication (10). In addition, negative attitudes have been noted among nurses towards patients with communication deficits or behavioural disorders, by which nurses avoided creating a relationship beyond interaction in the course of basic nursing (11).
Person-centred care Even though person-centred care (12) has been used in other fields for many years, it is a relatively new concept in patients with dementia (13). The importance of understanding patients’ personal histories and social contexts is currently in focus, where the caregiver attempts to establish a meaningful relationship with the patient. Even primarily dementia has been understood as a biomedical phenomenon, during the last decades, understanding the personal histories and social context is in focus, which has led that attention turned from disease process to the need of better understanding of patients with dementia and provide the better care (14, 15). Creating one can, of course, often be perceived as difficult, due to lack of understanding about how relationships are built (16). Communication difficulties may be related to the absence of practical, everyday guidelines to relieve stress and improve communication outcomes (17, 18). A recent study targeted nursing aide students’ education on their perceptions of dementia and their ability to care for patients with dementia. The results indicated training was effective regarding nursing aides’ understanding of cognitive dysfunction and the need for meaningful contact among patients with advanced dementia. However, the training was not successful in terms of nursing aides’ comfort level or perceived skills in working with this population of patients (19).
Aim The aim of this study was to explore the experience of anaesthesia nurses of both difficulties and opportunities in communication with hip fracture patients with dementia in the perioperative setting.
Materials and methods Setting and participants This exploratory pilot study is based on a qualitative design. The study was conducted at the Department of Orthopedic Surgery, Sahlgrenska/M€ olndal University Hospital. Anaesthesia nurses were contacted by the first author (FK) and asked to voluntarily participate in an open individualised interview. After meeting with study participants, the aim of the study was presented. The nurses with at least 5 years of experience of orthopaedic anaesthesiology were requested to take part in the study, because those who have worked at least five years would have had more opportunity to meet patients with dementia. Fourteen anaesthesia nurses were recruited initially, but four could not participate because of shortage of staff and other personal reasons. An invitation latter with information about the study’s aim has been sent to 14 anaesthesia nurses. Thus, 10 anaesthesia nurses (five men and five women) participated in the interviews. Their ages varied between 35 and 55 (median 40), and they had worked as an anaesthesia nurse between 6 and 28 years (median 15 years). In order to obtain the information, we performed in-depth individualised interviews.
Data collection The interviews were conducted between March and November 2011 by the first authors (FK) through faceto-face interviews using open-ended questions. The interviews began with the question ‘Can you please describe your encounters with hip fracture patients with dementia disease in the perioperative setting?’ All study participants were urged to speak freely using their own words and responds as comprehensively as possible. The interviewer interrupted only to pose further questions or follow up on the information given by the nurses. The interviews, which were conducted at the surgical ward, lasted between 60 and 90 minutes and were audiotaped and transcribed verbatim. More questions are presented in Table 1.
Data analysis A qualitative content analysis method in accordance with Graneheim and Lundman (20) was chosen for analysis and interpretation of the data. This method is capable of condensing a large amount of data into a limited number of themes, categories, subcategories and codes. The analysis of the data was primarily at a manifest level, but as the latent analysis part of this method, so the analysis may contain both the manifest and latent. The
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Table 1 The interview questions Main issues raised at the start of the interviews ‘Can you please describe your encounters with hip fracture patients with dementia disease in the perioperative setting?’
transcriptions were read carefully in order to identify the informants’ experiences and perceptions. Then the analysis proceeded by extracting units consisting of one or several words, sentences or paragraphs containing aspects related to each other and addressing a specific topic in the material. Then units that related to each other by virtue of their content and context were abstracted and grouped together into a condensed unit, with a description close to the original text. The condensed text was further abstracted and labelled with a code. After that, codes that addressed similar issues were grouped together, resulting in subcategories. Subcategories that focused on the same problem were merged in order to create more extensive perceptions, which addressed an obvious issue (20). According to Graneheim and Lundman, the interpretation was done primarily at a manifest level. The results are presented with direct quotes from the interviews. Research rigour. Criteria for qualitative research are differ from quantitative research according to the criteria for research rigour. In this context, criteria for our study, which is a qualitative research, are credibility, transferability, dependability and confirmability. These concepts correspond to internal validity, external validity, reliability and objectivity, which are notions used in quantitative methods (21). The idea behind the development of specific criteria for qualitative methods was that the nature of the study topic, methodology, aims and supposition in these methods did not suit the criteria for quantitative one. Reliability implies getting the same result independently of whoever accomplishes the test. In qualitative research, two researchers who recurrence a similar study may reach approaching experiences; however, it may be impossible to reach the same result, as different persons with different understandings. Based on the research rigour, credibility reflects the ability of the researcher to communicate the validity of the knowledge. Sufficient descriptions of the pre-understanding of the researcher, ways of describing the data collection, sampling, analysis of methods will have an impact on the credibility of data. © 2015 Nordic College of Caring Science
Examples of more targeted issues raised during the course of the interviews. How did you experience your first contact with the patients with dementia? How was the pre-operative communication with patients with dementia? What is the difference between communication with patients with dementia from other patients? What was the most complex issue in communication with dementia patients?
By transferability in a qualitative study means to what extent the results are transferable to other contexts (22). The researcher does not define the transferability; it is determined by the reader and regarded as reasonable or not. The result should be critically evaluated in relation to previous studies in a similar field.
Ethical considerations The head of the participating departments approved the study. The informants’ identities were protected, that is, their names and personal identity numbers were not stated on the recordings. The tapes used for the interviews were stored in a safe. Formal approval for a study of this kind is not required in Sweden. However, the study was performed according to general ethical procedures such as voluntarism, the ability to discontinue participation at any time, and receiving written and oral information.
Results Analysis of the interviews resulted in a theme based on three main categories and seven subcategories, imaging the participant’s descriptions of encountering patients with dementia. The first category contains aspects that influence communication between the caregiver and patient. The second category reflects dementia as a special issue, while the third category contains practical clinical aspects of perioperative care (Table 2).
Communication Pre-operative communication. The nurses stated that the first encounter with patients in the preparation room usually has two stages. The first serves primarily to establish good communication and the other serves to prepare necessary technical measures prior to surgery. The nurses think that the initial communication process should proceed in much the same way as in the treatment of patients without dementia. It was often said to be fundamental not to depersonalise the patients and to establish sound communication since this may open doors to
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Table 2 Overview of categories and subcategories Categories
Subcategories
Modes of communication
Pre-operative communication Intra-operative communication Postoperative communication Complex condition The hospital setting – aspects of the intraoperative session Personalisation Time
Dementia as a special issue
Practical issues
Theme
Multiside and complex communication
reveal not only the patient’s state of mind, but also their needs. One study participant describes his opinions in the following way: ‘I deal with the patient as I would any patient prior to surgery. I introduce myself, make eye contact, control the identity tag, ask about allergies and get a general feel about the patient, i.e. how much (s)he perceives and responds.’p (6) Another study participant states the following: ‘When they come to the preparation room, patients are often anxious, nervous and sometimes aggressive, which is quite difficult.’p (3) Another study participant states the following: ‘Large burdens are often laid upon us anesthesia nurses to keep patients safe and calm. It’s our treatment responsibility of the patient that is at stake. We cannot just sit two or three feet away from the patient and the anesthesia machines; we must always be attentive and present at all times for the patient.’p (7) The study participants believed that the first contact with patients should consist of a fitting introduction adapted to the patient’s cognitive ability while trying to understanding their current environment and needs. For patients to experience safety and security in the perioperative setting, nonverbal communication was generally felt to be of importance. The study participants say that most patients require the permanent presence of at least one medical personnel who is in direct physical contact with the patient by holding his/her hand, etc. Interruption of such a bond, even briefly, should probably be eliminated since this can cause disorientation and anxiety, which may require starting all over again to restoring confidence. Verbal and nonverbal communication should probably be combined at all times, but for patients with dementia, nonverbal is probably the most
important. One of the nurses expresses her experiences with nonverbal communication as follows: ‘To give the patient a warm blanket or put a soft pillow under their head can be a way to communicate.’p (9) Intra-operative communication. During the surgical procedure, new personnel and a new hospital setting are introduced to patients. During this time, patients with dementia are even harder to reach but seem nevertheless able to recognise certain objects. Small personal items such as a pillow, a hat, a photo or a coffee cup recently used may create peace of mind. Nurses encourage bringing any such items to the operating room: ‘Here, at the hospital they do not recognize anything. The hospital setting itself can be negative for the patients, who depend on recognition of familiar patterns. It is through their personal items they can identify with distant, but secure, memories’.p (7) One important problem area identified by the participating nurses was that communication does not usually last very long. For example, it does not help to explain to the patient to lie still once, when the next second (s)he will not remember what was said. This is when patience comes into play, and as a nurse it is always of importance to continue to communicate throughout the intra-operative session. One study participant says: ‘It is sometimes hard to know how much you should tell or inform the patient. It usually depends on the patient and the state (s)he is in. Mostly, I try to give them the same basic information that I provide to the other patients, but the hard part is the patients whom we can’t communicate with at all – those whom we cannot reach.’p (8) Another study participant states the following: ‘It’s difficult to know whether they have pain, whether the spinal anesthesia has worked, whether everything feels good to them. . .difficult, because you cannot have satisfactory communication with them.’p (2) Postoperative communication. Especially in circumstances such as stress, adverse drug reactions or inadequate analgesia, the participating nurses experience loss of communication with patients. Most nurses feel that maintaining communication and regular anaesthesiology work is possible given a properly designed combination of sedatives, anxiolytic drugs and well-functioning spinal anaesthesia. However, despite all such efforts, patients sometimes become physically defiant, resulting in negative experiences for the patient and the health professional team. Nurses also admit that they can become annoyed when a question is repeated 50 times during a 20-minute period, which may give them a guilty conscience later on. Some © 2015 Nordic College of Caring Science
Hip fracture patients with dementia nurses say that intra-operative care of patients with dementia could be improved further and should be the focus of future research. All nurses agree that better knowledge of dementia disorder and its implications for perioperative care is of importance since this might facilitate cooperation between various health personnel groups and shorten hospital stays for patients. One idea that several nurses came up with independently was that people with good knowledge of the patient prior to surgery could provide support during the intra-operative session. A study participant expressed the following: ‘One time I think I gave the patient too much Propofol, then her blood pressure dropped. . ..It was a very trying patient.’p (1) Another study participant states the following: ‘The patients0 families could probably be helpful throughout hospital perioperative care. Relatives could act as messengers or mediators who aid in communication and understanding the various needs of the patient.’p (1) ‘Sometimes I ask, ‘Are you in pain?’ And the patient responds and asks: ‘Where is my mother?’ A truly difficult and miserable situation.’p (5) Dementia as a special issue. All study participants clearly realised the general nature of old, frail and often multi comorbid patients with dementia. However, most of the nurses acknowledged that patients present different clinically depending on the type and extent of their dementia. Most patients, however, cannot remember what they suffer from, or explain their situation, their current needs or their medical history. Some patients cannot remember why they are undergoing surgery from one-second to another. The nurses frequently experienced that they were not given enough time to help patients understand their current health status. Nurses talk about the utmost importance of allocating time to communicating clearly and to meticulously planning and carrying out methodical care measures, such as preparation for spinal anaesthesia. Despite the obvious difficulties, all study participants mention the importance of having patience and providing distinct information to enable active patient participation, such as holding the oxygen mask in place. One study participant described the encounter as follows: ‘I think one should be extra careful at all times in connection with dementia. This might be the pace of your voice, the way you touch or move the patients or even when you put the cap on their head. Clearly, a patient with dementia will require more time to understand, if ever, what is happening to them in this frightening milieu.’p (3) Most of the participants shared the perception that the frightening and alien hospital setting in the operating © 2015 Nordic College of Caring Science
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room created stress and anxiety among the patients, frequently yielding a complex situation despite pre-operative sedation. Trying to assess patients as individuals, more than as ‘just an ordinary patient with dementia,’ was said to be crucial. For example, an aggressive patient may be better off left alone for some time while a nervous patient may need to be assured that there are several people with kind voices and hands ready to assist them before, during and after surgery. Since unforeseen events are not uncommon in hip fracture surgery, the anaesthesia nurse must continuously be on standby to give psychological comfort to the patient. The hospital setting – aspects of the intra-operative session. All study participants stated that fracture pain, drug effects and the alien hospital setting affect patients. It was also reported that perioperative drugs (such as Propofol) increased some patients’ anxiety level. According to nurses, four categories of dementia patients could be discerned: (i) the disoriented, having difficulty distinguishing time, situation and person; (ii) the aggressive, who refuse care and react with punching and profanity; (iii) the depressed, with little or no desire to live, often seeming nervous, anxious and with a decreased ability to concentrate; (iv) the quiet, who seem to accept/ignore surgery but could suddenly pat the nurse on the cheek with a kind look in their eyes. Most participants agreed that intra-operative care was facilitated if adapted to these personality types. A study participant describes her experience as follows: ‘Many patients with dementia arrive at the surgical ward without any knowledge of having sustained a fracture and look upon us as if we were evil green Martians.’p (1) Another nurse adds as follows: ‘. . .pain temporarily accelerates dementia, and they often become even more confused after maneuvers we do that trigger pain.’p (10) Nurses state that one of their main goals is to provide adequate analgesia. Many patients have obviously lacked appropriate analgesia at the previous ward. Staff in orthopaedic wards is sometimes under stress and forget that fracture patients with dementia will probably need more analgesia and anxiolytic medication prior to transport. This would obviously facilitate perioperative patient cooperation; prevent patients from pulling on their urinary catheter, oxygen mask or the peripheral venous catheter, etc. A combination of short-acting and long-acting medications should be used, according to the nurses. On study participant describes his experiences of drug administration: ‘I prepare medication for relaxation and anxiolytics for the patients in the form of midazolam and Propofol. We must help them to be at peace and to sleep during surgery. Maybe they haven’t slept well for a
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long time due to fracture pain, the new ward and all the new personnel they have met over the past few days.’p (2) Another nurse described her experience as follows: ‘I have no patients with dementia who spontaneously understand the need to lie on their side in order to get spinal anesthesia. I have to use sedatives and pain medication to reduce stress and resistance. I try to use medications to facilitate and create a more pleasant experience for the patient when I insert a peripheral venous catheter or administer spinal anesthesia. It makes it so much easier for patients and for us.’p (5) All of the nurses realise that patients with dementia rely on their skill and that they all share the responsibility to provide the best possible care since many physicians seem to pay attention a comparatively short amount of time. Some of the nurses, however, claim that administration of analgesia and anxiolytic drugs is not without problems and some patients respond with more confusion, which is why the initial dosage should be relatively small. The nurses share the belief that agitation and fear in patients may also originate from uncertainty about what is going to happen in the near future. One study participant concluded as follows: ‘We have to be decent and show respect, remembering that these patients have lived a long life and experienced a whole lot. They are still human beings with dreams and wishes. I very rarely meet patients with dementia who want to die. We should all remember this.’p (10) Individualisation. All nurses agree that perioperative care should depend on the patient’s unique needs. In addition, they felt that it is the duty of the anaesthesia nurse to inform the team about the patient’s condition and current needs in order to protect the patient from being harmed. They also state the importance of establishing a ‘safe relationship’ with each patient, described as a bridgehead confirming each patient’s perceptions during surgery. The patient must be assured that the anaesthesia nurse is there to help at all times. A holistic approach was deemed mandatory, which may range from confirming the patient’s feelings to progressively talking about the course of events or informing the patient when pain may occur. One way to get through to patients with dementia was to simply exhibit consistent and clear behaviour. One study participant reports as follows: ‘As well as I possibly can, I try to ‘read’ how the patient thinks and find out what this very person needs. If a patient is aggressive and waves his fists, I think the message is just ‘leave me alone,’ so I leave him alone for a while. When I encounter an anxious person who jumps when I touch her, I make sure to use an extra kind voice and I see to that everyone in
the team does the same thing. I remember that this patient will need to feel that (s)he is in good hands, and I focus on this. Usually it works.’p (4)
Practical issues Time. Most study participants express frustration that they have too little time to provide optimal conditions, especially when patients become agitated during the surgical procedure. Nurses agreed that very few patients are aggressive at baseline and that with comparatively little effort, patients can remain calm throughout the procedure, provided the medical history is analysed and enough time is allocated for the encounter between the anaesthetic nurse and patient. In many such circumstances, a kind hand on the shoulder can be enough to calm an agitated patient during surgery. ‘When they wake up after the surgery, we do not have enough time to take care of them, since they have to be taken to post-op. Sometimes just holding their hand for a while may be of importance. . . there’s a lot of work involved with these patients, but lack of time is the main obstacle and more time is required to be able to provide adequate care.’p (7) ‘One nightmare is if you get such a patient but have no time. . .dementia patients require a lot of time and energy.’p (9)
Discussion In this exploratory, impartial, pilot study, we qualitatively analysed the perioperative subjective experiences of anaesthesia nurses of encountering and communicating with patients with dementia pending or undergoing surgery due to a hip fracture. The main results of the current study regard how nurses handle the difficulties that arise. The nurses seem to agree on a general approach to facilitate perioperative care for the patient and the healthcare team. Generally speaking, the principal goal of health care is to provide high-quality and uniform health care to all inhabitants of a country (23). Health care should be based on respect for autonomy and privacy and promote a sound relationship between patients and healthcare providers (24), simultaneously adjusted to the patient’s situation and capabilities (7). In the care of patients with dementia, this can sometimes be hard to do. Compromised communication abilities are common, and their frailty makes them prone to severe deterioration due to sudden life changes caused by the fracture of the hip. According to Scandol et al. (24), people with dementia account for about 30% of the total population of elderly hip fracture patients in hospitals. The study participants focused on the important initial encounter with the patient and how to maintain a sound © 2015 Nordic College of Caring Science
Hip fracture patients with dementia connection throughout the procedure and the immediate postoperative period. Several studies, which corroborate the present one, point out the significance of meaningful communication and collaboration with such patients (25–27), and this is further validated by the fact that nursing without such communication can create general dissatisfaction among patients, proxies, healthcare personnel. Many ethical problems seem to arise simultaneously (20, 28). One prerequisite is that sufficient time be allocated to acquire detailed knowledge of the patient’s history in terms of personal health and fitness level, life history, personality, coping styles and the environment in which they live. Such information appears crucial to combating negative attitudes among healthcare professionals towards patients with communication deficits; some of them avoid creating a relationship beyond interaction in the course of ‘as needed’ nursing. Obviously, the goal is to accomplish Kitwood’s ‘person-centred care’ (15). The importance of the person-centred care has been indicated by previous study (29). In the study mentioned, the authors compared two groups of patients which undergone the hip replacement. A group that treated according to the person-centred care was more satisfied than the other group. Clearly, modern perioperative care of hip fracture patients with dementia must embody respect for personhood and avoid stigmatisation and objectification of the patient (16, 30). The nurses in the present study repeatedly focused on the importance of doing so by gazing kindly at the patient, maintaining eye contact, using a kind voice and taking the time to convey information clearly and directly. Encountering patients with dementia should probably start by limiting personnel around the patient in order to generate a calm environment for the patient. Verbal and, more importantly, nonverbal/physical communication may be the driving force to establish a bridgehead of personal interaction. To actively demonstrate the respect, these elderly patients deserve was underscored by many nurses and may set an example for the remaining team, including physicians. This may be conveyed by a polite initial handshake and maintained later on by continuous physical contact and active patient participation, conveying the trust most of these patients need in a delicate life situation. However, the above behaviour must take place in association with regional anaesthesia and administration of appropriate sedatives and anxiolytic medication to reduce pain, worry and stress. Most nurses agree with the findings of Lindvall et al. (28) that perioperative care benefits from being well planned. Many patients seemed to be on suboptimal analgesia and anxiolytic medication when they arrive from an orthopaedic ward, which portends communication problems when patients are moved. Frequently, nurses experience frustration with physicians’ © 2015 Nordic College of Caring Science
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pain evaluation and feel resistance to provide nursing in this way (31). Femoral nerve blocks should probably be used on broad indications to provide effective analgesia and to facilitate perioperative care. Pre-operative medication in the form of sedatives or anxiolytic drugs should possibly be scrutinised prior to spinal anaesthesia, since adverse effects that may appear later when nurses are left alone with patients are far from uncommon. Even though the present results were not clearly related to the nurses’ age, gender or working experience in orthopaedic anaesthesiology, nurses with a real interest in patients with dementia should probably undertake the most intimate care. The idea of using proxies or other personnel with knowledge of the patient to follow through care should probably be explored further, since a lot is probably to be gained in terms of a mentally stable patients as well as improved communication and interpretation of the patient’s needs. Since long hospital stays are not uncommon for these patients, who may sustain severe complications of surgery, alternative ways of handling agitation, anxiety, aggressiveness, etc., should be tried. At least in the intra-operative setting, positive effects were consistently seen when personal items were brought to the patients for comfort. Each encounter with a patient requires active listening with the ability to hear details, especially in the presence of dementia (28). It is through language that we understand our community, which is not always easy to apply to daily life. However difficult, a sound dialog with the patient may be effective and save time in the end, since patients can remain calm and at ease if the nurses respond adequately to what patients try to convey. The dialog can be seen as a way for the patient to understand his or her current reality. This, of course, demands experience and patience, especially in aggressive patients, but will probably contribute to improved well-being of the patient (25, 26, 29, 32). According to Rudolfsson et al. (33), it is the sincere talk in the perioperative encounter that will create mutual satisfaction and a sense of safety between the patient and caregiver. In this respect, it has been suggested that patients with dementia be invited to take part in care with the objective of feeling safe and secure and with the promise not to be abandoned (28). In this context, perioperative communication in the present study is in line with the previous study. Good nursing care for individuals in difficult situations can probably overcome some disease and suffering and help the individual to have an acceptable life. However, people with communication deficits may conceptually be uncomfortable for many caregivers in everyday, one-toone situations. Kitwood (15) argues, however, that if caregivers are given the opportunity to process and openly cultivate feelings of discomfort, good care of such patients may ultimately be possible. In order to achieve safe care of hip fracture patients with dementia, more
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evidence-based knowledge is clearly warranted. Future studies should probably be based on multidisciplinary collaboration between all occupational groups in the perioperative encounter, with the aim of identifying risk factors for a poorer outcome. Research should perhaps also focus on the use of personnel and specially designed hospital settings dedicated to dementia care. Meanwhile, it is necessary that communication continues with a focus on providing good and decent health care, tailored as much as possible to individual needs. The findings also suggest a need to improve the way that caregivers are trained in communication techniques. Incorporating this training into the education of anaesthesia nurses has the potential to increase quality of life for people with dementia.
Study limitations and strengths To the best of our knowledge, this is the first study of its kind. The strength of the current data comes from the willingness of participants to tell us their story, based on everyday clinical practice. Our pilot study has some limitations, however, including its qualitative type. The sample is quite small and limited to nurses who work at the department of orthopaedic surgery during office hours only. The interviews in the present study partly were conducted by the first author who has same professional as the study participants. Because of pre-understanding of research subject, this may be considered as a risk factor for impartiality in the planning, execution and analysis of the research (34). On the other hand, the investigators’ background and his pre-understanding might have been advantageous since they were aware of the potential problem that may arise in this area.
Conclusions Patients with dementia who sustain a hip fracture often present with severe pain, anxiety and distress. The present results indicate that such symptoms can be alleviated if healthcare professionals allocate time to analysing the medical and psychosocial history of the
References 1 Ferri CP, Prince M, Brayne C. Global prevalence of dementia: a Delphi consensus study. Lancet 2005; 366: 2112–7. 2 Larsson M, Rundgren A. Geriatrics Diseases. 2003, Studentliteratur, Lund. 3 McLaughlin MA, Orosz GM, Magaziner J, Hannan EL, McGinn T, Morrison RS, Hochman T, Koval K, Gilbert
patients and if pre-operative preparation is performed with an empathetic, warm and supportive approach in addition to a pertinent analgesic regimen. The results also indicate that the nature of communication used in the various perioperative phases is especially important. Some study participants advocate very distinct measures, while others prefer to initiate and maintain warm verbal and nonverbal communication throughout the procedure. There is a need for existing healthcare professionals to develop a thorough understanding of dementia and become skilled at providing person-centred care. One question is whether these patients would benefit from care in specialised geriatric units pre-operatively and postoperatively, perhaps by dedicated anaesthesia nurses intra-operatively. The present results may serve as a source of improved individualised care, providing information about appropriate hospital settings and education in the perioperative care of patients with dementia.
Author contributions Ferid Krupic initiated the study, conducted the interviews and performed the data analysis. All authors drafted the manuscript and did critical revisions.
Ethical Approval The head of the participating departments approved the study. The informants’ identities were protected, that is, their names and personal identity numbers were not stated on the recordings. The tapes used for the interviews were stored in a safe. Formal approval for a study of this kind is not required in Sweden. However, the study was performed according to general ethical procedures such as voluntarism, the ability to discontinue participation at any time, and receiving written and oral information.
Funding None
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