Effectiveness of Dementia Care Mapping on Patient Centred Care

A report into what is the effectiveness of Dementia Care Mapping (DCM) on patient-centred care for patients living with dementia in care home?

This assignment will explore Evidence Based Practice (EBP), explain what it is and how significant it is in current day nursing which is evidence-based. A clinically researchable question will be formulated and rationale behind the choice of topic will be explained. Details of how the search was conducted will be discussed followed by critically appraising quantitative, qualitative, guidelines and review evidence and finally a conclusion.

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Zimmerman (2017) reports that, EBP is a well-recognised standard of care that is essential for health professionals and is an effective decision -making process which includes the best available evidence. Melnyk and Fineout-Overholt (2015) defines EBP as a practical, accurate and clear use of best available evidence that is current in making nursing decisions about care given to individual patients. Zimmerman (2017), Melnyk and Fineout-Overholt (2015) further explain that when EBP is practised within healthcare and with involvement of nurses of different hierarchical levels, best possible clinical decisions are accomplished leading to positive patient outcomes.

NMC (2015) suggests it is a regulatory requirement for nurses to appreciate the value of evidence-based practice, be able to understand and appraise research, apply nursing theory and research findings to their work, and identify areas for further development. However, Hoe and Hoare (2012) suggest that in providing patient care that is effective, safe and evidence- based, nurses are supposed to decide how relevant the evidence is in making clinical decisions without replacing clinical judgement (Godshall, 2010).

Effectiveness of Dementia Care Mapping on patient-centred care in older people living with dementia in nursing homes is my topic. The reason for this topic is to find the best evidence available used to support the use of DCM in dementia care in comparison from not using it. As healthcare professionals it is important that effective care is provided for people living with dementia which is evidence-based. REF

The topic is important to health professionals because the amount of people living with dementia is rapidly increasing and there are available strategies that are evidence-based that can be implemented in healthcare settings. REF

 Alzheimer’s disease International (2013) reports that provision of care that is suitable to the growing number of older individuals who are living and dying from dementia is a public health concern and it is a global concern.

Mansah et al. (2008) defines Dementia Care Mapping (DCM) as an observational method that is widely used in dementia care to improve person-centred care. This view is supported by Quasdorf et al. (2017) who states that, for the intervention to work effectively, DCM must be implemented successfully in care practice.

SEARCH STRATEGY: 

The Cumulative Index of Nursing and Allied Health Literature (CINAHL) is the most commonly used health database recommended when searching health related literature which consist of Systematic reviews, Random control Trials (De Bruin and Pearce-Smith, 2014). Dementia is a mental health condition, so literature was searched from Psych Info, Medline and Science Direct.

 EBP proposes that clinical problems that emerge from care practice, teaching or research be composed and organised using PICO strategy to find literature. Holland and Rees (2010) define PICO as an acronym for Patient, Intervention, Comparison and Outcome. These four components are the essential elements of the research question in EBP and of the construction of the question for the bibliographic search of evidence. The adequate (well -constructed) research question allows for the correct definition of which information (evidence) is needed to solve the clinical research question, maximises the recovery of evidence in the databases, focuses on the research scope and avoids unnecessary searching state Davies (2011). A literature search was conducted on what is the effectiveness of Dementia Care Mapping on patient-centred care for patients living with dementia? Relevant articles published between 2008 and 2018 were obtained by searching Psych Info and ScienceDirect electronic databases in order to source relevant evidence that is most up to date and still applicable to practice.

 The main outcome measure which is “the effectiveness” was used as a search term and combined with the Boolean operator ‘AND’ with other search terms with respect to the disease (dementia or Alzheimer’s) and cognitive impairment or memory loss. This was followed by place of residence which is care home OR nursing home then finally the focus of the research question (determinant or factor) dementia care mapping and patient-centred care.

When search was conducted, more than 500 hits were returned. This made me realise that dementia is a broad subject with a vast of articles that were in English and non-English. At first, I read abstracts and titles to choose articles relevant to my chosen topic.  Studies were eligible if they evaluated interventions or focused mainly on primarily on focused on DCM and PCC for people living with dementia. Both UK and non-UK materials were used.  According to the World Health Organization (2018), the number of people living with dementia worldwide is currently estimated at 47 million and is projected to increase to 75 million by 2030, it is vital for healthcare professionals to learn about non-pharmacological strategies that have been implemented in other countries and have been effective and improved quality of life for people living with dementia. There are many still going researches that are being conducted in a view to find a cure for dementia.

QUANTITATIVE RESEARCH:

Ingham-Broomfield (2014) defines quantitative research as a study that uses measurable data to answer or explain a phenomenon of interest by collecting and analysing objective numerical data. This is supported by Aveyard and Sharp (2013) who define quantitative research as a study that uses quantifiable variables, presents data in a numerical manner and collecting data using closed questions such as how often, how many and how much. Furthermore, Ingham-Broomfield (2014), Aveyard and Sharp (2013) state that due to strong focus on evidence-based practice in healthcare, it is important for nurses to culture themselves with evidence evaluation.

Watson (2015) reports that randomized controlled trials (RCT) are considered to provide stronger evidence than other quantitative design studies such as cohort studies, case-control studies, or case reports that are quasi or non-experimental for reasons that they are not biased.  Aveyard and Sharp (2013) describes RCTs as studies that experiment the successfulness of a treatment or an intervention between 2 or more groups with a treatment or intervention and a control group.

Hoe and Hoare (2012) emphasised the importance for nurses to learn to critically analysing research technically, Hoe and Hoare (2012 describes critical analysis as a process whereby strengths and weaknesses of a study are evaluated. Nurses must ask questions, such as are the methods appropriate, does the study explain the phenomenon of interest and are the findings useful in checking for credibility (Gordon and Watts, 2011).

Ingham-Broomfield (2014) also agree with Grove et al. (2013) that there is no perfect study, hence  an analysis  and clinical judgement  will help nurses decide on the value of findings and how to apply them into practice, despite identified weaknesses which can also be referred to as limitations of the study and these may include areas such as sampling technique and sample size.

Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomized trial by Chenoweth et al. (2009) is the quantitative research paper found. It is an Australian study that focuses on dementia care mapping which is used in U.K so the information is relevant even though the healthcare systems are different. Researchers aimed to do a large, randomised comparison of person-centred care, dementia-care mapping and usual care.

The aim of the paper was to measure agitation as a primary outcome using the Cohen-Mansfield agitation inventory (CMAI) and secondary outcomes included hallucinations, quality of life and falls (Chenoweth et al., 2009).

Caldwell et al. (2011) suggest that there are numerous frameworks to use when evaluating research studies, the literature suggests areas to consider when critically reviewing reports of quantitative research. This notion is supported by Gray and Grove (2017) who state that title, abstract, introduction; framework, purpose and method are the key areas to critique. This trial addressed clearly focused issue and assignment of patients to interventions was randomised.

Critical Appraisal Skills Program tool (CASP 2018) is the tool used to critique this trial. This tool has been trialled by healthcare professionals and it is in a form of a checklist (Aveyard and Sharp, 2013). The title clearly and accurately illustrates the content of the trial including information of the population and the design giving the opportunity to determine if the paper was relevant to the topic as it answers the research question and is a RCT. The trial has shown that both person-centred care and dementia-care mapping seem to reduce agitation in people living with dementia, however there were more falls with person-centred care.

QUALITATIVE RESEARCH:

Grove, Burns & Gray, (2013) described qualitative research as a collection of descriptive data gathered in people’s own words, written or spoken and recording people’s behaviour. Qualitative researchers are mostly concerned with the meaning people attach to things in their lives (Grove , Burns & Gray, 2013) .Harvey and Land (2017) state that qualitative researchers understand people from their own frames of reference and experiencing reality as they experience it, furthermore, Harvey and Land (2017) adds that qualitative researchers sympathise with people they study in order to comprehend how these people see things and still able to separate or suspend their own perspectives and taken for granted interpretations of the world.

Qualitative methodology is more than a set of data- gathering technique; it is a way of approaching the empirical world.  Glaser and Strauss (1967) state that qualitative research is strengthened by numerous theoretical perspectives such as post-positivist, constructivist-interpretive, critical, feminism and post-structural. According to Borbasi and Jackson (2012), qualitative research consists of five approaches namely phenomenology, ethnography, grounded theory, exploratory and descriptive.

Maz (2013) describes “grounded theory” as an inductive theorizing process involved in qualitative research that has a goal of building theory especially if there is no previous investigation has been conducted on the research topic Maz (2013) further explains that qualitative research is inductive, meaning  researchers develop concepts, insights and understanding from pattern in the data rather than collecting data to assess preconceived models, hypothesis or theories.

 Munhall (2012) state that qualitative evidence is placed lower than the quantitative evidence because it is not replicable and qualitative research does not have statistics on which evidence can be based in the hierarchy of evidence rank. Healthcare professionals can gain understanding into certain problematic questions using an investigative method such as a qualitative research according to Cutcliffe and Ward (2014).

The role of leadership in the implementation of person-centred care using Dementia Care Mapping: a study in three nursing homes by Rokstad et al. (2015) is a qualitative literature found. The study is a non-UK based paper conducted in Norway but still contain relevant information for the chosen topic.

The study shows insight into how important leadership is for the implementation of nursing practice. However, the empirical knowledge of positive leadership processes enhancing person-centred culture of care in nursing homes is limited (Rokstad et al. 2015).

 The study has a clear statement of the aims of the research and research design is appropriate, however trustworthiness is paramount when critiquing this research because it considers credibility, dependability and conformity (Polit & Beck ,2010). The researcher explained how participants were selected and ethical issues were taken into consideration.

GUIDELINES:

Aveyard and Sharp (2013) defines guideline as a set of specifications, standards or criteria which are systematically developed to be followed when delivering evidence-based care. In medical science, guidelines are referred to as a series of suggestions that are published by official associations or institutions where independent experts exist for the management of illnesses (Lee et al.2015).

Woof et al. (2012) refer evidence-based clinical guidelines as clinical pathways or care protocols. Furthermore, Woof et al. (2012) suggest that clinical guidelines have become a paramount feature of patient care which is evidence based. However, health professionals need to refer to published guidelines when delivering evidence-based care in daily practice.

Woof et al. (2012) further explain that the overall aim of clinical guidelines is to improve the efficiency and effectiveness of delivery of care by equipping health professionals and patients with information that aid to make best clinical decisions.

This notion is supported by Graham et al. (2011) who define clinical guidelines as statements of recommendations with the drive of improving patient care. Moreover, guidelines are expected to evaluate the available options in the present circumstances and recommend proper solutions for certain problems.

Furthermore, these guidelines are kept up to date constantly by a methodical evaluation of the current evidence and review of other care alternatives and the possible harm they pose to patients as well as the benefits (Woof et al. 2012).

According to Grove et al. (2013), separate guidelines may be created by different institutions even though they are on the same subjects. The expert panel will provide a guideline with the best available evidence to health professionals for making clinical decisions in practice, however Aveyard and Sharp (2013) state that the challenging part is to overcome obstacles to implementation of EBP to get positive outcomes for patients, healthcare agencies and families.

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Health professionals and patients may not adhere to guideline recommendations immediately or automatically due barriers such as financial or organizational constraints, lack of knowledge about the guidance and resistance to behaviour change, nonetheless active implementation through regulation, financial incentives and education and communication might improve adherence to guidance and minimise suboptimal care for patients reports (Grol ,2010 & Rapu, 2005).

In medical practice, guidelines are mostly established on category level of the evidences, and they present the strong point of recommendations. (Gordon &Watts,2011). Systematic review and good-quality randomized controlled trials (RCTs) deliver the best reliable and valuable sources and create Level 1evidences and Grade A recommendations. (Gordon &Watts,2011).

National Institute for Health Care Excellence (NICE), (2016) state clinical guidelines can be limited in their applicability and purposefulness due to research evidence that is unique and of high-quality to patients when providing care that is patient-centred.

When searching for a clinical guideline, NICE guidelines have been used and Dementia: Supporting people with dementia and their carers in Health and Social Care, is the guideline located (NICE, 2016).

NICE guidelines are developed with an evidence-based approach namely Grading of Recommendations Assessment Development and Evaluation (GRADE) (NICE, 2011). Guidelines lacking the methodological components, especially on topics with enough evidence, whilst conveying the (unstructured) opinions of clinical experts in the field, have a significant risk of providing recommendations that are biased that may be then used to guide patient care (NICE,2009a)

The above guideline is written clearly with statement recommending interventions to support people living with dementia and their carers. There is evidence to show that delivering care that is person-centred help reduce agitation in patients living with dementia in different health care settings.

REVIEWS:

There are two main types of reviews and these are systematic and non-systematic review. Grove, Burns & Gray, (2013) describes systematic review as a comprehensive structured synthesis of literature research to inform the best research evidence available to address a healthcare question.

This view is echoed by Nelson (2014) who explains that a systematic review is a special type of literature that confers added advantages that uses systematic and explicit methods to identify, select and critically appraise relevant research, and to collect and analyse data from the studies that are included in the review.

Craig and Smith (2012) state that, systematic reviews are characterized by being methodical, comprehensive, transparent and replicable and they are used to regulate the existing information for use in practice and for the improvement of national and international standardized guidelines for management of health issues. Furthermore, they include a systematic search process to locate all relevant published and unpublished work that addresses one or more research questions, as well as a systematic presentation and synthesis of the characteristics and findings of the results of that search (Craig & Smith ,2012).

As reported by Higgins and Green (2011), systematic reviews are becoming increasingly popular as they enable consistency to the research. Their nature means that they tend to be of higher quality, more comprehensive, and less biased than any other types of literature review, which makes them more likely to be published and to have an impact and if done well it is an important substantive contribution to knowledge (Higgins and Green ,2011).

Aveyard and Sharp (2013) describes non-systematic review as a critical assessment and appraisal of some but not all research conducted on a specific subject where the researcher does not use any method that is organised when gathering evidence. Non-systematic reviews can also be referred to as descriptive or narrative for they lack detail, research question, search strategy and synthesis of literature or method of appraisal (Aveyard and Sharp ,2013). This view is echoed by Higgins and Green (2011) who state that non-systematic reviews lack trustworthiness, credibility and they are biased.

Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials (Livingston et al. 2014) is the review found from the search conducted. The aim of this review is to review evidence of a randomized controlled trial regarding non-pharmacological interventions systematically. The criteria for inclusion and exclusion in the systematic review are clearly stated and consistently implemented such that the decision to include or exclude particular studies is clear to readers and other researchers. In this study all participants had dementia and they were all analysed separately. The study evaluated non-pharmacological interventions for agitation and agitation was measured quantitatively. Studies were excluded if every individual was given psychotropic drugs or some participants received medication as the sole intervention (Livingston et.al 2014). The results showed that person-centred care and adapted dementia mapping decreased symptomatic and severe agitation immediately, but the review concluded that there are evidence-based strategies for care homes and further research is needed for people living in their own homes (Livingston et.al 2014).

CONCLUSION:

In the healthcare system, nurses lead EBP to facilitate the evidence-based nursing process, nurses must have the knowledge and skills to formulate clinical questions in a searchable manner. EBP is application of research evidence and dissemination into clinical practice directly and health professionals must promote and support use of EBP so that positive patient outcomes can be achieved and also improve clinical practice. Through conducting this research topic about dementia care mapping and patient centred care for people living with dementia, I am now aware that these non-pharmacological interventions are effective, the improve patient quality of life. It is essential for healthcare workers to familiarise themselves on where to find evidence based information and recommendations and to have better knowledge.

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