DEMENTIA IN INSTITUTIONALIZED ELDERLY: A NURSING TEAM’S EXPERIENCES AND PERCEPTIONS

ANCIANOS CON DEMENCIA INSTITUCIONALIZADOS: VIVENCIAS Y PERCEPCIONES DEL EQUIPO DE ENFERMERÍA

ABSTRACT

Objective:

to understand nursing workers' experiences with the nursing care provided to elderly individuals with dementia living in a long-term care facility.

Method:

comprehensive qualitative study conducted in a long-term care facility located in Joinville, Santa Catarina, Brazil, from July to September 2018. Thirteen nursing technicians and one nurse participated. Data were collected using questionnaires, field diaries, individual interviews, and participatory observation. Thematic content analysis was used to interpret content.

Results:

three themes emerged from data analysis: "Knowledge acquired with practice and gap existing in the care provided to institutionalized elderly individuals with dementia"; "Individualized care provided to elderly individuals and bonding"; and "Conflicts the nursing staff faces when reconciling care needs, the time available, and the facility's routines". These themes originated the central theme: Meanings assigned to the nursing care provided to institutionalized elderly individuals with dementia. By sharing information regarding care actions that obtained positive results, the staff perceived the importance of an individualized approach and of establishing bonds as a therapeutic process. Gaps were identified in the professionals' knowledge regarding how to provide hygiene care when individuals become aggressive, agitated, or resist care.

Conclusion:

health workers' experience is a source of evidence for evidence-based practice and is also essential to fill in existing gaps between knowledge and care delivery.

DESCRIPTORS:
Dementia; Nursing; Aged; Homes for the aged; Evidence-based practice

RESUMEN

Objetivo:

comprender las vivencias de los profesionales de enfermería acerca del cuidado de enfermería para ancianos con demencia, residente en institución de larga permanencia.

Método:

investigación cualitativa de abordaje comprensivo, desarrollado en una institución de larga permanencia para ancianos, en el Municipio de Joinville, estado de Santa Catarina, en el período de julio a septiembre de 2018. Participaron de la investigación 13 técnicos de enfermería y una enfermera. Para la recolección de datos fueron aplicados cuestionarios, diarios de asistencia, entrevistas individuales y observación participante. Para el análisis de contenido se utilizó el método de análisis temático.

Resultados:

del análisis de los datos surgieron tres temas principales: “El conocimiento adquirido con la práctica y el vacío existente en el cuidado al anciano con demencia institucionalizado”; “El cuidado al anciano en su individualidad y la construcción del vínculo”; y, “Los conflictos del equipo de enfermería entre el cuidado necesario, el tiempo para el cuidado y las rutinas de la institución”, los cuales dieron origen a la temática principal: significados del cuidado de enfermería para el anciano con demencia institucionalizado. Al compartir informaciones sobre los cuidados con resultados positivos, el equipo percibió la importancia del abordaje individualizado al anciano; de este surgió el establecimiento del vínculo como proceso terapéutico. Se constató un vacío de conocimiento en los profesionales sobre cómo prestar cuidados de higiene y confort, cuando los ancianos se mostraban agresivos, agitados y resistentes.

Conclusión:

la experiencia de los profesionales de la salud es considerada una fuente de evidencias en la práctica basada en evidencias, condición importante, también en el proceso de disminuir el vacío entre el conocimiento y la asistencia prestada.

DESCRIPTORES:
Demencia; Enfermería; Anciano; Hogares para ancianos; Práctica clínica basada en la evidencia

RESUMO

Objetivo:

compreender as vivências dos profissionais de enfermagem acerca do cuidado de enfermagem ao idoso com demência, residente em instituição de longa permanência.

Método:

pesquisa qualitativa, de abordagem compreensiva, desenvolvida em instituição de longa permanência para idosos, no Município de Joinville, Santa Catarina, no período de julho a setembro de 2018. Participaram da pesquisa 13 técnicos de enfermagem e uma enfermeira. Para a coleta de dados foram aplicados questionários, diários de assistência, entrevistas individuais e observação participante. Para a análise de conteúdo utilizou-se o método de análise temática.

Resultados:

da análise de dados emergiram três temas principais: “O conhecimento adquirido com a prática e a lacuna existente no cuidado ao idoso com demência institucionalizado”, “O cuidado ao idoso em sua individualidade e a construção do vínculo” e “Os conflitos da equipe de enfermagem entre o cuidado necessário, tempo para o cuidado e as rotinas da instituição”, os quais deram origem à temática principal: Significados do cuidado de enfermagem ao idoso com demência institucionalizado. Ao compartilhar informações sobre os cuidados com resultados positivos, a equipe percebeu a importância da abordagem individualizada ao idoso e, desta, o estabelecimento do vínculo como processo terapêutico. Constatou-se lacuna de conhecimento dos profissionais sobre como prestar cuidados de higiene e conforto quando os idosos se mostravam agressivos, agitados e resistentes.

Conclusão:

a experiência dos profissionais de saúde é considerada fonte de evidências na prática baseada em evidências, condição importante também no processo de diminuir a lacuna entre o conhecimento e a assistência prestada.

DESCRITORES:
Demência; Enfermagem; Idosos; Instituição de longa permanência para idosos; Prática baseada em evidências

INTRODUCTION

Currently, more than 46 million people live with dementia worldwide. In 2050, this figure is estimated to reach 131.5 million.1 Dementia became a public health problem because it is the leading cause of dependency among the elderly globally, with considerable emotional and financial impact on families. Dementia is the cause of impairment in 11.9% of an individual’s years of life.2^-3

Given difficulties to continually provide care to elderly individuals at home, many families opt to place them in a long-term care facility (LTCF). This new context became relevant for nursing care. Scientific literature reports evidence on how healthcare delivery has become a routine in LTCF. One study emphasizes that 81.5% of the institutionalized elderly have a chronic disease while 83.3% regularly take medications.4 One study addressing Brazilian LTCF identified that 66.1% of the facilities provided medical services, while the percentage of nurses, nursing technicians, and aids is higher than that of caregivers in the facilities located in the northeast and southeast.5 One study conducted in Rio de Janeiro verified that 88.02% of these facilities maintain technical nursing activities.6

These studies reveal that LTCF is a growing field of work for nursing workers. This context indicates a need to produce scientific knowledge to ground nursing care provided to the institutionalized elderly. An approach that may contribute to sound scientific knowledge is evidence-based practice (EBP). EBP refers to the best evidence reported by scientific studies, combined with clinical information and the patients’ values and preferences. These studies contribute to support problem-solving and qualified practice.7

Given the importance of the role of nursing in the care provided to institutionalized elderly individuals and the need to improve the quantity and quality of scientific evidence concerning nursing care provided to institutionalized individuals with dementia, this study proposes the following question: how does the nursing staff experiences the care provided to elderly individuals with dementia living in a long-term facility? Therefore, this study’s objective was to understand nursing professionals’ experience regarding the nursing care provided to elderly individuals with dementia living in long-term care facilities.

METHOD

This comprehensive qualitative study was conducted in a long-term care facility located in Joinville, SC, Brazil. At the time of data collection, this LTCF had one nurse and 14 nursing technicians. All these workers were invited to participate in the study. One nursing technician refused to participate so that the sample comprised 14 participants: 13 nursing technicians and one nurse. Caregivers and informal collaborators were not included.

This LTCF was chosen due to the proximity between the researcher and the facilty’s team and the large nursing staff. Its 48 beds were occupied at the time of data collection. Of these, 15 elderly individuals had a medical diagnosis of dementia. The facility has one nursing ward, where five older women in advanced stages of dementia and entirely dependent for daily living activities were allocated.

Data were collected from July to September 2018, using four different strategies to collect data: a semi-structured questionnaire (in which the participants self-reported personal data and educational and professional backgrounds); individual interviews guided by a semi-structured script; participatory observation; and field diaries. Meetings were initially held with the staff at different times with workers from both the day and night shifts. The researcher explained the study’s objectives, how to complete the diary, and provided clarification regarding the study’s procedures. Experienced in conducting interviews in qualitative studies, the researcher who performed all the data collection procedures has a Master’s degree in nursing and is a professor affiliated with a public university.

The nursing staff kept the diaries for 15 days and recorded all the care actions provided to the seniors with dementia, including doubts that emerged throughout the care provided in that period. Based on the information collected from the diaries, the researcher prepared for participatory observation, during which she monitored and helped the nursing staff provide care to the individuals with dementia. The participatory observation lasted four days, from 6:30 AM to 12 PM, and included two hours in the night shift, as authorized by the facility’s manager. A total of 26 hours of participatory observation was sufficient to collect the necessary data. In this period, the researcher observed and helped provide care to 11 individuals diagnosed with one type of dementia. She accompanied the work of all the nursing workers participating in this study.

The individual interviews were conducted during the professionals’ working hours, scheduled according to their availability. Each participant was interviewed once. All the interviews were audio-recorded and transcribed verbatim and lasted from 12 to 35 minutes. A semi-structured script containing the following guiding questions supported the interviews: how do you feel when providing care to elderly individuals with dementia? What difficulties do you routinely face when providing care to elderly individuals with dementia? How do you deal with these difficulties? What doubts do you have regarding the care provided to elderly individuals with dementia? In your opinion, what would facilitate your work with elderly individuals with dementia? After the initial interview, each worker was identified with the acronym NP and a sequential number to ensure information confidentiality. For instance: NP1, NP2, NP3, and so forth. The study complied with all recommended ethical guidelines, and the participants signed free and informed consent forms.

Data collected from the diaries, participatory observation, and individual interviews were reconciled in a single document using a text editor. All data were analyzed together to achieve the objective initially proposed. The various procedures used to collect data were intended to improve understanding regarding the topic, allowing for different perspectives of the study object. The various techniques used and the nursing workers' expressive participation in this study context led to the conclusion that data saturation was achieved in the space and time in which this study was implemented.

Thematic content analysis was used:8^-10 attentive and in-depth reading of all field diaries, notes derived from the participatory observation, and individual interviews to capture content. Afterward, excerpts, phrases, and fragments of each material collected were highlighted, and the entire material was read once again while relating content to the theoretical framework adopted in this study. At this point, the researcher gathered in a single document all data obtained from the diaries, participatory observation, and individual interviews to identify common meanings.

At first glance, a large number of subsets emerged, as the objective was to expand data. Later, these subsets were grouped and reclassified, synthesizing data. After this stage, specific themes emerged and supported the knowledge obtained from data collected in the different procedures, i.e., interviews, participatory observation, and field diaries.8^-10 The themes that emerged from data analysis were ratified by the nursing staff during meetings in which the themes that constituted knowledge were presented. At the end of each meeting, the nursing staff assessed whether data presented represented their experiences regarding the nursing care provided to elderly individuals with dementia. All participants agreed and confirmed the themes presented.

RESULTS

Characterization of the nursing staff

Thirteen nursing technicians and one nurse participated, totaling 14 professionals working in the LTCF. Among the participants who met the inclusion and exclusion criteria, six were women, and eight were men. Two were aged between 25 and 29; six were aged from 30 to 39 years old; four were aged from 40 to 49 years old, and two between 50 and 59 years old. Regarding time since graduation, six had graduated up to four years ago, five had graduated up to nine years ago, and three workers had graduated up to 14 years ago. Regarding their experience in that specific LTCF and in this type of care, most (n=9) worked in the facility for four years, and most (n=9) had up to four years of experience providing care to elderly individuals.

Three themes emerged from the individual interviews, field diaries, and participatory observation regarding nursing care provided to institutionalized elderly individuals with dementia: 1) knowledge acquired with practice and the gap existing in the care provided to institutionalized elderly individuals with dementia; 2) individualized care provided to elderly individuals and bonding; and 3) conflicts the nursing staff faces when reconciling care needs, the time available, and the facility's routines. These themes led to the central theme: “Meanings assigned to the nursing care provided to institutionalized elderly individuals with dementia”, as shown in Figure 1.

Figure 1 -
Connecting the themes that originated the meanings the workers assigned to the care provided to institutionalized elderly individuals with dementia. Joinville, SC, Brazil. 2019.

Knowledge acquired with practice and the gap existing in the care provided to institutionalized elderly individuals with dementia

This theme concerns how the nursing team perceives the care provided to individuals with dementia, how the workers obtained the knowledge necessary to provide nursing care, and which knowledge gaps they identified regarding dementia and nursing care.

The nursing workers described the care provided to elderly individuals with dementia as a puzzle that needs to be put together (NP 10, NP 13). To understand an elderly individual, various pieces need to be gathered - pieces of knowledge regarding an individual are acquired to provide daily care - and these pieces enable understanding and providing safe and quality care to individuals with dementia.

Analyzing the care that is provided demands workers to reflect upon the process of how care is provided and whether this care benefits an elderly individual or not.You speak one way, but it doesn’t work. […] So, you try something else. You see what didn’t work and try to do things differently(NP 01). Knowledge is obtained slowly, and information needs to be shared with the remaining team to acquire comprehensive knowledge.I’ve learned how to care for elderly individuals by working with my colleagues, observing what works and what doesn’t work in practice(NP 12).I’ve come to understand dementia after these years working here […] I have a notion on how elderly individuals behave(NP 11).

The nursing staff revealed different ways of learning by doing, which include: learning by prating the profession, learning with the elderly individuals, learning with the individuals’ families and acquaintances, and learning with co-workers, watching them, or exchanging experiences.

This empirical knowledge helped the team developing strategies to deal with the problems found in practice. The main problem the workers mentioned was the individuals being aggressive during hygiene care, especially during baths, changing diapers, oral hygiene, and facial shaving.This elderly individual is always very confused and becomes agitated during baths, but I found out that he likes to talk about music and harmonicas, which calms him down(NP 05).

According to the nursing staff, another way to deal with difficulties is by welcoming these individuals, being patient, and trying to distract them: Keep your cool, avoid clashing, discussions (PNP 09). Don’t get tense, always make a joke, kid a little, start a conversation (NP 11). I get into his fantasy, and he calms down (NP 13).

The nursing staff reports that little theoretical-practical information was provided during academic training on how to provide care to elderly individuals with dementia. At school, they taught the theory on how to deal with them. But then we find out it’s different. For me, the practice is really different (NP 07). Only the basics about Alzheimer’s are addressed in the technical nursing program (NP 02).

The nursing workers reported that they missed the theory addressing dementia and that it is essential to know the disease process to provide quality care.We’d have to understand the disease better to approach them appropriately because it changes a lot from one individual to another(NP 08).The team should understand the condition of dementia, the physiopathology of different types of dementia(NP 01).The more you understand, the more you know about the disease, so the better you’ll deal with them(NP 02).

Regarding their doubts about dementia, the nursing workers showed doubts about how to approach elderly individuals, especially aggressive behavior manifested during hygiene care. The person resists changing diapers, and doesn't want to let the technicians change his diapers (NP 06). He is aggressive during showers and facial shaving (NP 07). He gets aggressive during hygiene care (NP 08).

These nursing workers' knowledge is based on their daily practice, the team’s experience, and personal experiences. Academic training provided little knowledge. Even though they developed strategies to provide better quality care by self-assessing practices and exchanging experiences, their knowledge regarding dementia and its clinical repercussions is incipient. The results revealed gaps in how workers should behave when dealing with aggressiveness and resistance on the part of elderly individuals during hygiene care.

Individualized care provided to elderly individuals and bonding

This theme addresses factors the staff perceived triggering aggressive episodes and made individuals resist care, individualized approach, the feelings emerging from interactions and care provided to individuals with dementia, and how bonds were established between workers and the institutionalized individuals.

Aggressiveness and resisting nursing care were identified as the most significant problems during care delivery. The staff mentioned some factors they consider to trigger these behaviors among elderly individuals.There is this blind woman. If you simply start undressing her, she’ll beat you because she’s already suffered violence. It’s her defense. So I get there and hold her hand, and try to calm her down (NP 03). During hygiene care is when most episodes of aggression and resistance occur(NP 06).

An individual’s previous history, the absence of family, and hygiene care are events that trigger resistance and physical or verbal aggression. The staff believes that resistance and aggressiveness are due to the intimate contact these care actions involve, which they consider an invasion of privacy. The greatest difficulty is when an individual resists care. I guess that because they are from older times, they don’t like to be touched (NP 06).

The nursing staff describes the actions and attitudes necessary to provide quality care and avoid conflicts. The primary strategy used is the individualized approach. Knowing each individual and his/her needs was the factor that obtained the most favorable results when resistance, aggressiveness and/or agitation were perceived. When these situations are already underway, the workers try to be patient and protect against physical aggressions. It is crucial to be attentive and plan alternatives to implement nursing techniques.The initial approach is what determines how care will proceed(NF 01).Patience, affection, politeness, and putting yourself in someone else’s place are necessary to provide care. Because each person is different, each person has his/her own pace and rhythm (NP 03).

Feelings toward the care provided emerge in the interaction with the elderly individuals. These feelings range from gratitude and love to fear of hurting the individuals during aggressive episodes. People providing care to elderly individuals with dementia should care with love (NP 10). I’m a little afraid of hurting someone when trying to protect myself from aggression (NP 09). I feel grateful for caring for elderly individuals; I was born for this (NP 11).

The team’s perspective regarding the gap between expected results and results achieved in the care provided, varies from one worker to another. These feelings include frustration for not attaining the expected results and an understanding of the disease’s prognosis, the outcome of which is the finitude of life.Frustration for not seeing any improvement in the individuals’ conditions, not seeing aggression episodes to decrease, even after working with them for so long(NP 12).You witness suffering, and you suffer too. Death is not always the worst. Sometimes, it is even better. It’s a relief for the person who passes away because she won’t suffer anymore. Not that you wish death, but you wish that suffering, without any hope for improvement, to cease(NP 09).

The sum of feelings that emerge from the care provided to elderly individuals with appropriate attitudes and actions results in establishing bonds between elderly individuals and workers. Bonding is seen as a factor protecting against aggressiveness.The bond with elderly individuals is established through the trust they have in a worker(NP 01).At shower time, meal times, when physical contact is greater, we have to exchange feelings, be affectionate, and interact more(NP 09).

This theme shows that bonding is a therapeutic possibility to control aggression episodes and resistance among elderly individuals. It also shows the importance of the team to understand triggers and the feelings experienced when providing care. The results show a need to re-signify the care provided to elderly individuals with dementia so that workers do not feel frustrated when the outcome of their actions is not a cure for or improvement of their clinical condition.

Conflicts the nursing staff faces when reconciling care needs, the time available, and the facility's routines

This theme emerged from the nursing workers’ reports concerning factors that hinder care delivery in the facility, about what they considered to be good nursing care, and how the time they had to provide care and the facility’s routine influence the quality of the care provided to elderly individuals with dementia. Most of the staff members considered that the care provided to an individual with dementia demands more time than the care provided to an individual without this type of impairment.

The difficulties found by the team concern the elderly individuals, their families, and the nursing workers’ emotional conditions during working hours.The families often don’t understand or don’t want to understand the dementia process and insist in medicating the elderly individual(NP 01).You found many problems on the way. You have to leave all your personal problems at home. And get here with a fresh outlook (NP 12).

The staff listed some aspects that characterize good nursing care, such as teamwork, prioritizing care provided to elderly individuals, and assuming responsibility for implementing the therapeutic process.We are an excellent team in this aspect to approach elderly individuals(NP 12).I try to assume the responsibility, the responsibility to approach the individuals appropriately(NP 12).

However, the quality of the care provided is affected by the time the workers have to provide nursing care.We can talk and entertain while implementing a technique; more than that is impossible(NP 10).But there is little time given the number of elderly individuals,… It’d been worse, though. There were four workers; now there are five. It’s improved a lot(NP 12).

Another factor that influences the quality of care is the facility’s routine. The care provided to elderly individuals with dementia takes longer, but we don’t have the time […] They have lunchtime, sleep time, coffee time, and a time they go to mass. We have to work within this schedule(NP 10).Sometimes, you’d give a better bath, not that we provide a poor quality bath, but you know, time runs. It’s our routine; there’s nothing we can do about (NP 12).

This theme portrays the aspects of the nursing care provided in an LTCF and how these influence the care provided to elderly individuals with dementia. The facility’s routine directly influences the time the workers have to provide care and is considered a factor that restricts care quality. The strategies the team uses include: take advantage of the time spent with elderly individuals when performing nursing techniques by talking and interacting with them; teamwork; and taking responsibility for the therapeutic process.

DISCUSSION

The central theme was revealed by three themes representing essential aspects of nursing care: knowledge acquired with practice, knowledge gaps, individualized approach and bonding, and factors that influence care, such as limited time and the facility’s routine. The three themes are connected and self-reinforcing, giving consistency to data, as shown in Figure 1.

In this context of care, the actors are the elderly individuals and the nursing staff. The primary contact and interaction occur during the delivery of nursing care. This interaction involves feelings that emerge during care delivery, and the team needs specific knowledge to provide care. This need is permeated by the knowledge the workers acquired during their practice and by knowledge gaps identified by the staff.

The gaps the staff identified correspond to knowledge concerning the physiopathology of dementia and how to approach an elderly individual with dementia who presents behavioral and psychological symptoms, especially resisting care or manifesting agitation and aggressiveness. These symptoms manifest during hygiene care. The behavioral and psychological symptoms of dementia (BPSD) are not related to cognitive loss. The symptoms include (physical or verbal) aggressive behavior, (physical or verbal) agitation, and resisting care. One study conducted among Australian long-term facilities revealed that all the individuals presented at least one of BPSD while 50% presented two or more symptoms.11

The treatment of BPSD should focus on non-pharmacological interventions because these present improved clinical results without other consequences for these individuals. There are many types of non-pharmacological interventions, classified into sensorial and psychological practices and care protocols. Communication is one of these interventions. Habitual communication with senior individuals with dementia should be more respectful and affective than controlling. This type of approach has shown good results to decrease BPSD.12^-13

One study addressing training needs presented by nursing teams working in long-term care facilities concluded that these teams needed knowledge regarding dementia, how it progresses, and how to communicate with patients and families. These teams also needed to develop skills to provide emotional support to the families. Training should be based on interventions that apply to the “actual world” and be provided to all the nursing team members, regardless of their level of education.14

To solve BPSD-related problems, the staff exchanged experiences, and as a result, they realized that an individualized approach - knowing these individuals’ histories and preferences - presented positive results when dealing with aggressiveness and resistance against hygiene care. As senior individuals with dementia seldom express their feelings or verbalize situations that disturb them, the staff shared the actions that led to a favorable outcome for both elderly and themselves. Another study also highlights that exchanging experiences is a way for the staff to deal with daily difficulties faced in the care provided to individuals with dementia.14

The professionals’ knowledge and expertise derived from practice are characterized as tacit and intuitive. It is an important way to acquire and produce knowledge. A professional’s experience can contribute to the implementation of evidence-based practice because this knowledge supports the process of translating theoretical knowledge and adapting it as needed, without, however, hurting the fundamental principles of evidence. For professional experience to be considered as such, it needs to be explained, analyzed, assessed, and implemented.15

It is worth noting that the factor triggering the problems reported - hygiene care - is also the time the team identified to be crucial to establishing bonds. Bonding emerges as a form of care, a therapeutic process, and occurs through an individualized approach. The direct relationship between care, bonding, and individualized approach explains the good results the staff reported, even when dealing with difficulties. Bonding comprises three dimensions: affective, therapeutic, and continuity.16

Three dimensions were observed in this study. The affective dimension concerns professionals' emotional investment in themselves and the senior individuals, making bonding a powerful work tool. The therapeutic dimension is revealed through attention that is paid to the individual and his/her needs. The continuity dimension involves the responsibility of workers to implement care and lead the interactive process. Responsibility means workers ensure that interaction is calm and harmonious, and obtaining a positive outcome is the responsibility of those conducting interactions.16

Person-Centered Care (PCC) is an approach that migrates from the biomedical model - in which care is centered on the disease and techniques - to care that is centered on the individuals’ needs. It is based on the principle that the team providing care should value one’s history, life experiences, and relationships. The nursing team should establish positive interactions with seniors and recognize them as unique individuals, constantly encouraging them to perform the tasks they are still able to perform and validating positive attitudes, among other attitudes/actions that promote the well-being and self-esteem of elderly individuals with dementia.17

Person-centered care benefits these individuals at many levels because it focuses not on lost skills but on those that remained. The team should identify what an individual can and cannot do, value his/her skills, and encourage them to perform these activities when providing care. There must be an individualized care plan for it to happen. Person-centered care considers that all human beings have value and deserve respect, regardless of impairments. It is believed that an individual with dementia can and should enjoy a full life.17

The team understands the importance of talking and interacting with seniors and perceives them as relevant in care delivery. However, the facility’s routine considerably influences interactions and time spent with the individuals. Concerned in complying with the facility’s schedule, the workers tended to prioritize the technique and its implementation, avoiding entertaining or other approaches that could compromise the time spent with care, so that all the elderly individuals would be ready for their subsequent activities. Corroborating these points, one study also mentions that nursing workers deal with a heavy workload permeated by different responsibilities, and play complex roles in a context in which they often have little support, are isolated, and receive little appreciation for the nursing work provided in LTCF.14

Even though the institutional routine is important for an LTCF’s organization, it may also restrict individualized and humanized care. In practice, seniors and nursing workers are expected to adapt their needs to the facility’s routine, leaving little room for individuals to chose their life pace. Nursing professionals are required to prioritize techniques at the expense of humanized and individualized care. For an LTCF to function well, seniors will seldom be allowed to choose their schedule for meals. However, there is a need to reconsider the facility’s organization to allow some flexibility and so that the individuals have some autonomy to choose their routines.18

This study’s primary limitation is related to a lack of data concerning the elderly individuals, that is, knowledge concerning their preferences and values and those of their families. Care needs and care delivery ground evidence-based practice; however, data concerning the seniors were not collected given the difficulty of contacting their families and obtaining consent. Future studies should foresee this difficulty and seek other forms to obtain consent from elderly individuals and their families.

This study’s contribution to the gerontological nursing practice in the context of LTCF includes understanding the meanings nursing workers assign to the nursing care provided to institutionalized seniors with dementia. Such knowledge can support the management of qualified care, resulting in improved practices adopted in the care provided to elderly individuals and allowing rethinking work processes by considering an individualized perspective and establishing bonds, which need to be valued for the development of knowledge in the field.

CONCLUSION

The professionals’ experiences reveal that knowing the elderly individuals and their preferences was crucial in their practice, so they started interacting with the seniors, considering this information, and using an individualized approach. Health professionals' experience is a source of evidence for evidence-based practice, essential to decrease the gap existing between knowledge and care practice.

The need to establish bonds and meet each individual's specific needs was not taught to the team. They experienced care practice, made mistakes and right choices, and as a team, verified that each individual requires a differentiated and individualized approach for care to be provided without complications. Even though the team is not familiar with Person-Centered Care, their practice and exchange of experience showed them that this is the best strategy to care for elderly individuals with dementia.

With the experience acquired with the care provided to elderly individuals with dementia, the professionals identified the factors that preceded behavioral and psychological behaviors of dementia. By sharing their observations with co-workers, they perceived patterns in each individual and identified ways to deal with these situations, obtaining favorable results.

This study’s findings show that an individualized approach decreases aggression episodes, agitation, and resistance against care, opening an opportunity for both workers and seniors to enjoy a more pleasant interaction, leading to positive feelings. This interaction “system” - positive response-bonding - is self-reinforcing, which in turn, strengthen the bonds between seniors and nursing workers.

REFERENCES

• 1. Prince M, Wimo A, Guerchet M, Ali MG, Wu Y, Prina M. World Alzheimer Report 2015. The global impact of dementia: an analysis of prevalence, incidence, cost and trends. London (UK): ADI; 2015. [cited 2020 June 23] Available from: https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf
  » https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf
• 2. World Health Organization. Global action plan on the public health response to dementia 2017-2025. Geneva (CH): WHO [Internet]. 2017 [cited 2020 June 23]. Available from: https://www.who.int/mental_health/neurology/dementia/action_plan_2017_2025/en/
  » https://www.who.int/mental_health/neurology/dementia/action_plan_2017_2025/en/
• 3. Alzheimer´S Disease International (ADI). World Alzheimer report. Attitudes to dementia. London (UK): ADI; 2019 [cited 2020 June 23]. Available from: https://www.alz.co.uk/research/world-report-2019
  » https://www.alz.co.uk/research/world-report-2019
• 4. Borges C, Silva M, Clares J, Nogueira J, Freitas M. Sociodemographic and clinical characteristics of institutionalized older adults: contributions to nursing care. Rev Enferm UERJ [Internet]. 2015 [cited 2020 Apr 05];23(3):381-87. Available from: https://www.researchgate.net/publication/281819374_sociodemographic_and_clinical_characteristics_of_institutionalized_older_adults_contributions_to_nursing_care
  » https://www.researchgate.net/publication/281819374_sociodemographic_and_clinical_characteristics_of_institutionalized_older_adults_contributions_to_nursing_care
• 5. Camarano AA, Kanso S. As instituições de longa permanência para idosos no Brasil. Rev Bras Estud Popul [Internet]. 2010 [cited 2018 Jan 12];27(1):233-35. Available from: https://doi.org/10.1590/S0102-30982010000100014
  » https://doi.org/10.1590/S0102-30982010000100014
• 6. Rodrigues MA, Santana RF, Paula RCC, Silva MTN, Santo FHE. Professional practice of nursing at long-term care institutions for the elderly: a retrospective study. Texto Contexto Enferm [Internet]. 2018 [cited 2019 Aug 20];27(2):e1700016. Available from: https://doi.org/10.1590/0104-070720180001700016
  » https://doi.org/10.1590/0104-070720180001700016
• 7. Melnik BM, Fineout-Overholt E, Stillwell S, Williamson K. Evidence-Based Practice: Step by Step: The seven steps of evidence based practice. Am J Nurs [Internet]. 2010 [cited 2019 Dec 03];110(1):51-3. Available from: https://doi.org/10.1097/01.NAJ.0000366056.06605.d2
  » https://doi.org/10.1097/01.NAJ.0000366056.06605.d2
• 8. Minayo MCS, Deslandes SF, Romeu G. Pesquisa Social: teoria, método e criatividade: série manuais acadêmicos. Petrópolis, RJ(BR): Vozes; 2016
• 9. Minayo MCS. Qualitative analysis: theory, steps and reliability. Ciênc Saúde Coletiva [Internet]. 2012 [cited 2019 Nov 18];17(3):621-26. Available from: https://www.scielo.br/pdf/csc/v17n3/v17n3a07.pdf
  » https://www.scielo.br/pdf/csc/v17n3/v17n3a07.pdf
• 10. Minayo MCS. Sampling and saturation in qualitative research: consesus and controversies. Rev Pesq Quali [Internet]. 2017 [cited 2019 Nov 18];5(7):1-12. Available from: https://editora.sepq.org.br/index.php/rpq/article/view/82/59
  » https://editora.sepq.org.br/index.php/rpq/article/view/82/59
• 11. Davison TE, McCabe MP, Bird M, et al. Behavioral Symptoms of Dementia that Present Management Difficulties in nursing homes: staff perceptions and their Concordance with Informant Scales. J Gerontol Nurs [Internet]. 2017 [cited 2019 Nov 19];43(1):34-43. Available from: https://pubmed.ncbi.nlm.nih.gov/27711932/
  » https://pubmed.ncbi.nlm.nih.gov/27711932/
• 12. Scales K, Zimmerman S, Miller SJ. Evidence based nonpharmacological practices to address behavioral and psychological symptoms of dementia. The Gerontologist. [Internet]. 2018 [cited 2019 Nov 19];58(Suppl 1):88-102. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881760/
  » https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881760/
• 13. Willians KN, Perkhounkova Y, Herman H, Bossen A. A communication intervention to reduce resistiveness in dementia care: a cluster randomized controlled trial. The Gerontologist [Internet]. 2017 [cited 2019 Nov 19];57(4):707-18. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881770/
  » https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881770/
• 14. Smythe A, Jenkins C, Galant-Miecznikowska M, Bentham P, Oyebode J. A qualitative study investigating training requirements of nurses working with people with dementia in nursing homes. Nurse Educ Today [Internet]. 2017 [cited 2019 Dec 4];50:119-23. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0260691716303173?via%3Dihub
  » https://www.sciencedirect.com/science/article/abs/pii/S0260691716303173?via%3Dihub
• 15. Rycroft-Malone J, Seers K, Titchen A, Harvey G, Kitson A, McCormack B. What counts as evidence in evidence-based practice? J Adv Nurs [Internet]. 2004 [cited 2018 Jan 12];47(1):81-90. Available from: https://pubmed.ncbi.nlm.nih.gov/15186471/
  » https://pubmed.ncbi.nlm.nih.gov/15186471/
• 16. Pinheiro R, Mattos R. Gestão em redes: práticas de avaliação, formação e participação na saúde. [Internet]. 2006 [cited 2019 Dec 03]. Available from: https://lappis.org.br/site/wp-content/uploads/2017/12/Gestão-em-Redes-práticas-de-avaliação-formação-e-participação-na-saúde.pdf
  » https://lappis.org.br/site/wp-content/uploads/2017/12/Gestão-em-Redes-práticas-de-avaliação-formação-e-participação-na-saúde.pdf
• 17. Manso MEG. Cuidado centrado na pessoa para indivíduos com demência. Rev Longeviver [Internet]. 2019 [cited 2020 Apr 05];1(3):75-84. Available from: https://revistalongeviver.com.br/index.php/revistaportal/article/viewfile/797/856
  » https://revistalongeviver.com.br/index.php/revistaportal/article/viewfile/797/856
• 18. Batista AS, Araújo AB. Intimidade e mercado: o cuidado de idosos em instituições de longa permanência. Sociedade e Estado [Internet]. 2011 [cited 2020 Apr 05];26(1):175-95. Available from: https://doi.org/10.1590/S0102-69922011000100009
  » https://doi.org/10.1590/S0102-69922011000100009

NOTES

• ORIGIN OF THE ARTICLE

  Article extracted from the thesis - Translação do conhecimento na construção de diretriz clínica: cuidados de enfermagem a idosos com demência institucionalizados, presented to the Post-graduation Program of the Universidade Federal de Santa Catarina, in 2020.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research with Human Beings of the Universidade Federal de Santa Catarina, opinion. 2.719.522, CAAE: 88965218.8.0000.0121.

Publication Dates

• Publication in this collection
  26 July 2021
• Date of issue
  2021

History

• Received
  11 May 2020
• Accepted
  16 July 2020