Jan Dewing

Practice development: Realising active learning for sustainable change

Abstract This paper explores the concept of practice development in the context of professional development and strategies for facilitating learning in practice. In this paper we present the background to the methodology of emancipatory and transformational practice development. Key concepts underpinning a contemporary definition of practice development are unravelled and nine principles for effective practice development proposed. An example of a large-scale national practice development programme with older people residential settings in the Republic of Ireland is presented to illustrate the processes in action. The findings of the first year of the programme are offered and these findings demonstrate the ways in which practice development systematically uncovers the deeply embedded characteristics of practice cultures – characteristics that often inhibit effective person-centred practice to be realised.

Process Consent and Research with Older Persons Living with Dementia

There is always a debate around consent in the context of research. Given the expansion of different approaches to qualitative research within dementia care, there is increasing consideration around consent in this context; particularly in research concerning the experiences of living with dementia and the care of persons with dementia. Specifically there is a drive to directly involve persons with dementia as they offer specific expertise concerning living with dementia. Additionally, capacity legislation strengthens the case for ensuring that persons with dementia are actively enabled to make their own decisions for as long as possible. This paper discusses an approach and method that can enable more persons who are living with dementia to participate in some types of research should they want to. Currently, most researchers rely on an extension of the traditional competency-based informed consent method and/or proxy consent or assent. However, related to the development of so-called person-centred and participatory research in dementia, there are now a number of academic publications on approaches and practical methods of ‘inclusionary’ consent. This paper considers the broader contextual influences on inclusionary consent and outlines the key aspects of such approaches based on the development of one specific method for including persons with dementia in consent processes. The method is based on the premise that, for persons with a dementia, informed consent becomes increasingly redundant and consequently exclusionary to them as persons. And even where capacity is said to no longer exist, persons with dementia are often able to make choices and make known their preferences about participating in research where the consent process is made specifically dementia-sensitive. Ethics committees can facilitate researchers both by supporting them when they need to and want to include persons with dementia in gerontological research and by challenging them to ensure that participation is genuine and starts with process consent.

Wandering into the future: reconceptualizing wandering 'A natural and good thing'.

There is still significant scope for improvement in knowledge on wandering in dementia and in the care of persons with dementia who wander. Although progress in research-derived knowledge is evident over the last 15 years, the current state of practice is influenced by an immature research base where the clarification of what wandering is still needs to be achieved. This is fuelled by research which to date, has framed wandering as a problem behaviour and generally starts from the premise that it needs to be prevented or severely controlled. People with dementia may think and feel differently about wandering, as will be suggested in this paper. The voices of those who have experiential expertise of dementia and wandering need to be included in the debate on wandering to influence both nursing research and practice. In regard to the practice context, it is suggested that there is little evidence to suggest that screening for wandering, assessment of wandering, person-centred and evidence-based care planning and interventions or evaluation are yet the norm for older persons with dementia. Thus, these areas must be the priorities for the immediate future. Whilst at a theoretical level, there are three key issues that require attention in the future: the orientation of research on wandering including reconceptualizing wandering to address the lack of theoretical frameworks to explain wandering, addressing the need some care settings might have with application of research and recognition of the experiential expertise of older persons with dementia.

Introducing intentional rounding: a pilot project

AIM To report on the introduction of intentional rounding in an NHS trust. METHOD A two-stage pilot project with participatory methods underpinned by core practice development principles was undertaken to introduce intentional rounding. FINDINGS Patients and staff found intentional rounding to be a positive experience, although nurses and midwives felt they were inadequately prepared to implement the practice. Leaders and managers who engaged in learning opportunities before the pilot study tended to achieve more successful and sustained practice change. CONCLUSION There is disagreement among nurses about the contribution of intentional rounding to patient care, particularly in light of the weak evidence base, time involved and associated documentation. Therefore, further research is needed in this area.

Illustrating the Importance of Including the Views and Experiences of Users and Carers in Evaluating the Effectiveness of Drug Treatments for Dementia

Undertaking a literature review revealed that when evaluating the effectiveness of the drug treatments for dementia few studies purposefully explore the views of users and carers. Their views are mainly derived from secondary analysis of conventional scientific evidence. Where the views of users and carers were explored it was discovered that they evaluate the effectiveness of the drug treatments in terms of quality of life. On its own, the conventional scientific approach of using outcome measures to evaluate the effectiveness of drugs is not sufficiently relevant or meaningful to users and carers. Findings from a study exploring the views of users and carers also demonstrate that professionals are willing to utilize the users’ and carers’ evaluations of the drug treatments for dementia. We suggest that reliable and valid measures are developed which explicitly explore the views of users and carers. This will go towards ensuring clinical trials are relevant and meaningful to the users and carers and not to professionals alone.

Editorial : Tell me, how do you define person-centredness?

The International Community of Practice for Person-centred Practice (PCP-ICoP) coordinated from Queen Margaret University, Edinburgh, recently wrote about the current state of person-centredness across several countries in the world (McCormack et al. 2015). In that publication, we highlighted a number of concerns, the existence of which are working against the advancement of person-centredness as a coherent theoretically informed and practice-embedded framework for nursing. We believe that a focus on person-centredness provides an opportunity for nursing to rise above particular theoretical ‘fan clubs’ and work within a coherent set of principles that are multivariate, context nonspecific and trans-specialist. To begin with, we, as a profession, should have major concerns connected with how person-centredness is defined across the nursing community and it is surprising to us that there is not more concern about this. We repeatedly observe across the arenas of research, education and policy that person-centredness is not defined or incompletely and poorly defined. There are two dominant features that troublingly, currently pervade descriptions of personcentredness. First, we repeatedly see person-centredness being introduced as hard to define. This has been the case since at least 2004 (Dewing 2004; McCormack 2004). Surely, we need to be moving on from this by now? There are now various definitions that can be used, although some caution is needed as not all of these are underpinned by research evidence or theory. Second, person-centredness seems to be more and more defined according to one or two of its more popular or appealing attributes. The favourites we observe recurring in the literature are that person-centredness is working with what matters to the patient; it is about acknowledging the values, choices and preferences of patients, and it is about a certain type of nurse–patient relationship – always a compassionate one! Indeed, person-centredness does include all of these attributes; however, this is not the totality of person-centredness and, to advocate it, promotes an unhelpful simplification of the concept. There is a paradox here, as the oversimplification also misses the point that, for example, facilitating choices and preferences or developing, maintaining and sustaining a compassionate relationship are probably the most challenging aspects of nursing in the complexity of practice contexts. It is easy to ask the question ‘what matters to you’ but it is quite another to meaningfully and authentically respond to another person’s response. Further, should not we question the dominance of compassion as the ‘only thing that matters in our relationships with persons? Is that what is always wanted? And what about my ability as a nurse to be compassionate even in practice settings that show little compassion to me as a nurse or as a person? These are not simple issues and are not ones that can be fixed with short cycles of change or practice artefacts (badges, symbols, aide-memoires). A related concern is what almost amounts to squabbling between champions of different approaches to person-centredness and positioning these to achieve centre stage for their favoured definition. Definitions are being proposed that are not backed up by empirical research and are severely lacking on theoretical underpinnings. For example, we can perhaps see this in how Karl Rogers is repeatedly proposed as the founder of person-centredness when the etymology of the concept predates Rogers, or Tom Kitwood’s definition of personhood unquestioningly accepted as the underpinning framework in research and development work, without considering the implications of using that definition out of context. Sitting on the periphery, we can see a theoretical knot about concepts related to personcentredness and whether or not they fit under the umbrella of person-centredness. Prominent here are the concepts of women-centred care, child-centred care and family-centred care. The simplification of person-centredness for nursing practice in particular is in the longer term unhelpful for a number of reasons. It encourages a na€ıve understanding of person-centredness which immediately limits the potential to have the impact we know it can. Recent doctoral research (WareingJones 2016) indicates that whilst practitioners have an outline appreciation of person-centredness, they tend not to draw on empirically developed theoretical models, have an incomplete personal understanding of what person-centredness is and generally experience working in contexts and cultures that are inherently unsupportive of person-centredness, meaning they cannot embody or practice in person-centred ways. This leads us to raise the most pressing of concerns: that the majority of definitions of person-centredness completely miss that person-centredness is about a specific type of culture, that incorporates but does not isolate care and one that needs to apply to everyone in an organisation. It is not something that can be technically applied, and certainly, person-centredness cannot thrive

The Kuranya/‘Rainbow’ service for indigenous Australians, in New South Wales: Innovative practice

This article describes the development of a service for indigenous Australians with dementia in New South Wales and highlights the need to provide a flexible service responsive to the ethos and values of Indigenous Australians.

Prioritising mealtime care, patient choice, and nutritional assessment were important for older inpatients’ mealtime experiencesCommentary

A Dickinson Dr A Dickinson, University of Hertfordshire, Hatfield, UK; a.m.dickinson@herts.ac.uk What is the experience of mealtimes for older inpatients? Action research study using a qualitative, interpretative, inductive approach to explore the mealtime environment before (phase 1) and after (phase 3) facilitation of changes in staff practice (phase 2). 25-bed ward in the UK. Purposive sample of older patients (6 in phase 1, 4 in phase 3) who had stabilised after an acute admission and needed complex nursing and medical care, and ward staff (19 in phase 1, 15 in phase 3), including healthcare assistants, nutrition assistants, qualified nursing staff, occupational therapists, and physiotherapists. In phases 1 and 3, 6 mealtimes were observed (including breakfast, lunch, and supper), 3 focus groups were conducted with ward staff, and patients participated in semistructured interviews with staff nurses. Focus groups and interviews were audiotaped, transcribed verbatim, and analysed thematically. Data from phase 1 informed the focus of phase 2. 3 themes affected patients’ experiences …

Guest Editorial: the right to walk - an older person's human right

One of the features that stood out for me in the 20th century with regard to citizenship, was the focus on human rights. Despite many abuses, an overall direction of travel focused on expanding human rights for what might be considered the most vulnerable groups in our societies. Older people feature as one of these groups. Human Rights Acts and associated legislation create a framework of fundamental rights and freedoms based on a set of essential principles such as respect, equality and fairness. Any rights, of course, can be open to interpretation. However, despite the implementation of and amendments to Human Rights Acts and related legislation across the world, older people continue to receive treatment and care that runs contrary to their most fundamental human rights as citizens. In addition, Eltis (2006) suggests that there are cultural assumptions that older people do not have the same type or levels of civil liberties. Eltis argues that societies take for granted that older people do (and often should) have limitations on their civil liberties as a natural consequence of ageing. These fundamental rights, for others, are seen as luxuries or ‘abstract’ rights. The treatment of older people in health care and its associated settings is a particular concern in this regard, as in some countries (especially my own, I am disappointed to say), there are legal loopholes which means that older people receiving care in some settings are not protected by Human rights Legislation at all or as fully as they should be. I wonder if older people even know they have such rights? And I also ask, what is it that gerontological nurses can do to offer awareness, advice and access to advocacy for older people and the public in respect of human rights? Much is being done to raise the quality of care for older people through national policy, creation of standards and inspection and numerous quality initiatives worldwide. However, human rights are not always central or overtly placed within such endeavours. This sparks in me the recognition that, as a person-centred practitioner and practice developer, I tacitly work with values about protecting human rights; however, I do not overtly make use of them in my own practice development work with other practitioners. This is something that I, as a gerontological nurse, can address as the 21st century moves forward. Part of our human rights is the freedom of choice ‘to move’. Given my passionate interest for wandering or wander-walking as a means of sense making and creating meaning for persons living with dementia and for their quality of life, I am fascinated by the nature of the ongoing debate or lack of it in some cases, about ‘tagging’ for people with dementia. In the UK, recently, there was a small surge of media interest created to raise awareness of a new policy from the Alzheimer’s Society on electronic tagging and safer walking technology. The media positioned the debate as being a question of choosing between the latest sign of an overzealous Big Brother or the future for empowering persons with dementia. At one extreme, new technology is seen as controlling; almost a new form of elder abuse. At the other extreme, it is seen as freeing or empowering people. This is to simplify the debate too easily. There are multiple concerns and issues around using technology such as GPS monitoring or tagging for wandering/wanderwalking that can impinge on people’s freedom of movement, the person’s right to make choices and to have privacy and dignity respected especially where consent has not been gained from the person with dementia. I want to make it clear I am not against assistive technology per se. I am instead growing more concerned about the lack of depth to the debate. Not to have a serious multiprofessional debate about technology or any new developments touching on the human rights of older persons (and one that includes older persons), undermines the value and dignity of older persons and does little to ensure the public that nursing has seriously questioned the ethics or the multiplicity of interests that lie beyond physical or basic health concerns. It might not be too long before all older people are tagged, monitored or kept under surveillance by one means or another– for their own good of course. Perhaps we need to keep in mind that we cannot, in the face of ever advancing technology, always argue that ensuring physical health and safety are primary and take precedence over other interests. Or as Eltis says, these concerns must not overshadow nor trump all other issues including ‘abstract’ rights such as dignity and privacy. Personhood and the associated human rights must not get swept aside when the waters become muddied. So what is it that gerontological nursing holds up as its primary values? Older persons including those living with dementia are entitled to equal protection of their interests other than physical health. It is in just these sorts of situations that the nature of any allegiance to the values of personhood becomes apparent. Although I do not much like the term ‘victims,’ this quote from Elie Wiesel Nobel Peace Prize Winner (1986), is one that is one that I often use to remind me why, in moments when I feel like avoiding the ethics, I should not look away. In addition, it reminds me why I need to speak out or challenge and support myself and others to work with older people in ways that truly touch on human rights by getting to grips with deeper levels of values, valuing and prioritization:

Practice Development Workbook for Nursing, Health and Social Care Teams: Dewing/Practice Development Workbook for Nursing, Health and Social Care Teams

If you’re looking to develop and improve your nursing, health or social care practice, either individually or as part of a team, the Practice Development Workbook for Nursing, Health and Social Care Teams offers a wide-ranging selection of activities, tools and resources covering vital aspects of practice development. Written as a companion volume to the latest edition of the best-selling Practice Development in Nursing and Healthcare, this new resource grounds practice development in day-to-day nursing and health and social care through accessible, informative learning activities. It also focuses on practical ways in which teams can make their workplace cultures more effective and person-centred, and enables practitioners to empower themselves to make compassionate care a fundamental part of effective health and social care systems.