Aggression in people with dementia is a behaviour that can be evident is care environments where dementia care is given. This is a issue that is becoming a growing health concern (Jackson and Mallory, 2009: Alzheimer’s Society, 2014: Cipriani et al. 2011). This is an issue that is likely to keep growing and developing as the population continues to age. (Nguyen, Love and Kunik. 2008). This is an issue that needs to be managed well with good leadership and guidance from management and nursing staff and the input from all relevant members of the multidisciplinary team charged with caring for individuals who show signs of aggressive behaviour and this is critical in making this achievable and protecting patients and residents in long term care environments from potential harm. This piece of work will look at a practice situation from a clinical placement area that highlights how resident safety can be an issue within a care environment. This will explore the nursing leadership skills and management that where utilised to address this particular situation and how all care professionals within the multi-disciplinary team (MDT) were involved and the impact this had on all team members.
The situation developed whilst the student was on a first year placement in a nursing care home which specialised in the care of people with varying types and levels of dementia. The situation involved a male resident who was showing signs of aggression towards other residents, both male and female. The staff where as vigilant they could be, but due to limited staff. Aggressive incidents did occur where staff had to attend and separate the residents and try to diffuse the situation. This particular person was developing unusual behaviours that manifested in the individual was found over a period of time to have been getting into various female residents beds when the residents where in them sleeping. This was initially highlighted by the care staff to the nurse in charge when it was found that this person was found in resident’s rooms and subsequently in female resident’s beds. This was however not acted upon as the nurse thought that this may be a temporary issue and advised care staff to observe this person as much as reasonably possible. This situation however escalated when it was discovered that a female resident was found to be extremely upset and agitated and it was discovered that this was due to this individual in question being in the same bed as her and had woke her up. This resulted in an emergency meeting having to be arranged between the nurse in charge and members of the MDT team who were involved in the care of this individual and then trying to formulate a suitable strategy that would benefit the care environment, i.e. minimise the issues that had happened and to prevent further issues developing. The nurse in charge and the management also were aware this person still had to have a good quality of life within the environment and promote the safety of the other residents within this care environment.
The Nursing and midwifery council (NMC) code of conduct (2008) emphasises that nurses in all care environments have a duty of care to protect individuals in their care from any form of harm, be it from staff, family members or other people within the particular care environment they are being cared in. This can be extremely challenging as nursing care homes may take residents who possibly are not suitable for the care environment, which then adds to the pressure and may increase the violent incidences that potentially may happen (Social Care Institute for Excellence (SCIE), 2011; Care Quality Commission (CQC) 2014)
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Aggression between residents of nursing care homes and other long term care facilities is an issue that is becoming more common as people age and their health issues become more complex (Rosen et al. 2008). Moreover; nursing home resident safety is an issue that has been report widely by media organisations such as daily mail (2014) and governing bodies for example Health and Safety Executive (HSE) (2011) and as Hughes and Lapane (2006) highlight there are some issues with how nurses and care staff perceive resident safety. This shows how important communication of issues, such as highlighted within the practice situation and how there are potential issues with trying to make sure resident safety is uppermost in the way care staff operate. Furthermore; also highlights that training within care environments can play a pivotal role in helping staff recognises when issues as shown in the practice situation are displayed. Agency for Healthcare Research and Quality (AHRQ) (2011) also emphasises an issue which has become so common within care environments, this being ‘staffing levels’ and this can be critical in making sure resident safety is at an optimum level. (Harrington et al. 2011).
Leadership and leadership styles
Nursing leadership as defined by Porter-O’Grady (2003) as, “a multifaceted process of identifying a goal, motivating other people to act, and providing support and motivation to achieve mutually negotiated goals” All nurses will lead and manage individuals throughout their career and for them to be effective leaders. There are specific skills that nurses require to develop, for example; able to delegate, communication, decision making, ability to inspire, conflict management and motivation as emphasized by Middleton (2011) and Contino, (2004). These are only some of the skills that need to be developed by nurses to be effective leaders.
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Moreover; there are a number of leadership theories which have given rise to various styles of leadership, for example; the trait, behavioural and transformational leadership theory (Yoder-Wise, 2014). All the above theories give rise to various leadership styles that are influenced by the following factors; individuals’ flaws, their qualities and the skills they have attained (Bishop, 2009). The trait theory approach relates to traits that create and effective leader and can be seen in an historical context as leaders who were born or advanced into leaders, for examples of such people are royalty, politicians and religious leaders (Valiga and Grossman, 2007; Brown, 2011). Behavioural theory approach is down to the behaviours, characteristics and personal traits and this approach can be seen as; leaders can be made rather than born and that leadership can be learned and transformational leadership can be defined as the use of charisma, inspiration, intellectual stimulation and consideration for individuals (Smith, 2011)
The nurse in charge in the situation demonstrated the following leadership style, this was situational leadership style. Situational leaders can be seen to encompass supportive and directive behaviours and have specific characteristics, these are; telling, selling, participating and delegating. These can be seen with the level of guidance or direction from the leader, level of socio-emotional support from the leader and subordinates maturity (Balista, Furtado and Silva 2011). The leader applies this to whatever situation they come across adapting this as necessary and involves using the appropriate leadership skill to the said situation to motivate and utilize the capabilities of the workforce (Edmonson, 2010). Giltinane (2013) describes situational style leaders as open to change, flexible, evaluating the situation, adapting skills and tasks to the maturity of the individual being led and task orientated.
Even though the nurse in the situation did not initially sort the issue, she evaluated the situation and decided on what leadership skills that best suited the situation and the best approach to use to minimise further issues from developing.
All styles of leadership have benefits and drawbacks
(Sullivan and Garland, 2010)
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