Week 3 Research Study Analysis Worksheet Part I (40 points) Using the article or

ID: 181600 • Letter: W

Question

Week 3 Research Study Analysis Worksheet Part I (40 points) Using the article or study provided to you by your Instructor, answer the following questions regarding a public health research study: Question Score (to be entered by Instructor) What problem or thesis statement did the authors identify? Is it clearly stated? Provide a rationale for your answer. ____ / 3 points Answer: What is the primary research question? Is it clearly stated? Provide a rationale for your answer. ____ / 3 points Answer: Is the study quantitative, qualitative, or mixed-methods? How did you determine this? Is the approach appropriate given the research questions? Why or why not? ____ / 3 points Answer: Are the literature review and sources provided comprehensive and current? Provide a rationale for your answer. ____ / 2 points Answer: What are the study population and the sample population? Are they clearly identified and defined? Provide a rationale for your answer. ____ / 3 points Answer: How was the sample population selected? ____ / 3 points Answer: Were independent and dependent variables identified? What are they? ____ / 3 points Answer: How were the data collected? ____ / 4 points Answer: How were the data analyzed? ____ / 4 points Answer: What were the major findings? ____ / 3 points Answer: How were the findings interpreted by the researchers? ____ / 3 points Answer: Did the researchers identify any limitations of the study? If they did, what were these limitations? If they did not, did you identify any limitations? ____ / 3 points Answer: What recommendations or suggestions for next steps did the researchers make? ____ / 3 points Answer: Part II (20 points) A. Provide a brief (200 words) critical review of the article or study based on your responses to the preceding questions. (10 points) Answer: B. In your opinion, what are the strengths and limitations of this study? Does this study make a significant contribution to the literature and advance the knowledge base? Why or why not? (10 points) Answer:

Particularly in Japan, until about 2008, measures

of dementia care placed importance on aspects of

nursing support, such as basic maintenance of nurs-

ing care services and construction of the community

care system (Awata, 2010). As a result, 65.2% of

dementia inpatients were in psychiatric wards, and

24.9% were in recuperation facilities (Miura et al.,

2005). Therefore, nurses in Japanese acute care hos-

pitals have had few opportunities to care for patients

with dementia until recently. Thus, they may face

various problems and difficulties in caring for

patients with dementia.

Previous studies have investigated the difficulties

and experiences of nurses involved in the care of

patients with dementia in acute care hospitals.

Eriksson and Saveman (2002) described ethically

difficult situations that can lead to abuse, difficulties

related to disorderly conduct among patients with

dementia, and problems related to the organization

of acute care as an obstacle to good nursing care

for patients with dementia. With regard to experi-

ences in an acute care ward at a university hospital,

a different study revealed several issues that nurses

face in relation to dementia care, including res-

ponsibility for patients, frustrations with regard to

time, frustrations with regard to lack of organization,

divided tasks, and working alone (Sorlie et al., 2005).

Nordam, Torjuul, and Sorlie (2005) revealed the

ethical challenges in male nurse care of older people.

The nurses in this study indicated difficulties co-

operating with nurses in other wards and frustration

at having to use coercion or restraint while caring

for patients with dementia. Nolan (2007) described

the following experiences of nurses who cared for

older people with dementia: structural inadequa-

cies of acute care hospitals as a setting for dementia

care, frustration due to limitations on care im-

posed by structural inadequacies, and complications

from the continually changing needs of people with

dementia. Furthermore, Borbasi, Jones, Lockwood,

and Emden (2006) clarified the following factors

that influence the management of patients with

dementia: time pressure, overwork, lack of re-

sources, and lack of knowledge/understanding of

dementia among medical, nursing, and other health

care professionals.

Issues regarding nursing care for patients with

dementia in acute care hospitals in Japan may differ

from those in other countries because the working

environments of Japanese nurses differ from those

in other countries. For example, nurse staffing levels

are arranged according to supply in Japan but

according to need in the USA and the UK. As a

result, fewer nurses work at night than during the day

in Japan (Yasukawa, 2005). In addition, especially in

acute care hospitals, the number of years of nursing

experience is very short in Japan (70% of nurses had

10 years of experience, and about half had

4 years

of experience; Kanai-Pak, Aiken, Sloane, & Poghosyan,

2008). This length of nursing experience is shorter

than that in Western countries such as the UK and

Canada (Aiken et al., 2011). Therefore, nurses in

Japan have limited opportunities to consult expert

nurses. Moreover, many families of patients with

dementia in Japan have had the experience of being

asked to attend to their family member in hospital

(Hattori, Takeda, & Sasaki, 2010). About 90% of

nurses also report having asked a family member of a

patient with dementia to attend to the patient in

hospital (Kitai & Nakayama, 2012). In Japanese

culture, the cooperation of the family is thought to

be indispensable in the case of a family member with

dementia being hospitalized.

Previous Japanese studies have revealed that nurses

had difficulties accepting patients and their situa-

tions. The tensions associated with routine work

with these patients, conflicts with their families, and

treatments unique to dementia care were all challen-

ging; the nurses feared the increased accident risk

and spent more time administering care only to

patients with dementia (Taniguchi, 2006; Yamamoto,

Yoshinaga, & Ito, 2010). These Japanese studies

targeted the setting, including recuperation and long-

term health care facilities. However, nurses in acute

care hospitals may face difficulties unique to their

setting because patients with dementia receive prior-

ity treatment and various restrictions apply to their

treatment.

Accordingly, the goal of this study was to explore

the difficulties and issues faced by nurses in provid-

ing care to patients with dementia in acute care

hospitals in Japan. Identifying the difficulties and

issues involved in this type of care may provide a

basis for discussion of improvement measures and

future directions of care administration to patients

with dementia.

Definitions

In this study, an acute care hospital is defined as one

that mainly provides general sickbeds (Health and

Welfare Statics Association, 2007). The phrase

‘‘patients with dementia,’’ as used in this study,

includes not only patients diagnosed with dementia

but also those judged by the nurse participants to

have dementia on the basis of their experience. In

Japanese acute care hospitals, 15

20% of the in-

patients have dementia, although most of them do

not have a diagnosis of dementia (Hattori et al.,

2010).

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Methods

Setting

The study was conducted in the western region of

Japan. Hospitals with more than 100 beds and those

with both surgical and internal medicine departments

were approached. Hospitals were selected on the

basis of maximum variation sampling according to

size. Hospital size was classified into three groups

(100

299 beds, 300

499 beds, more than 500 beds),

and three to four hospitals were selected from each

group. As a result of maximum variation sampling,

10 hospitals were selected and asked to participate

in the study. Six hospitals agreed to participate.

The remaining four hospitals declined participation

in the study because of the extremely small number

of patients with dementia in the hospital or lack time

to participate.

Participants

Nurses in multiple surgical and internal medicine

wards participated in this study. Nurses working in

intensive care units, those with

3 years of nurs-

ing experience, those without experience in provision

of care to patients with dementia in their currently

assigned ward, and head nurses were excluded.

Criterion sampling was used. Directors of nursing

departments in the participating facilities were aware

of the exclusion criteria. These directors selected

participants after consulting with the head nurses

of each ward. They were asked to choose nurses

with various levels of experience from multiple wards.

Five to ten nurses were selected from each hospital,

and the total number of nurses was 50. The head

nurses then requested selected nurses in each hospital

to participate in the study.

All participants received both an oral and a printed

explanation of the study from a researcher (RF). All the

nurses who asked to participate in the study agreed to

the request and provided written consent to participate.

Data collection

First, the participants were asked to complete a

questionnaire regarding individual characteristics

and wards. The questionnaire covered items regard-

ing the participants themselves, such as number of

years of experience in nursing, currently assigned

ward, clinical departments for which they had worked

in the past, age, and sex. Other questions regard-

ing wards concerned the total number of admitted

patients and the number of patients with dementia.

After completion of the questionnaire, focus group

interviews (FGIs) were used to collect data in this

study. FGI is a suitable exploratory method to identify

the issues experienced by clinical nurses who care

for patients with dementia at acute care hospitals

(Kitzinger, 1995; Krueger & Casey, 2008; Morgan,

1996, 1997). It is unusual for clinical nurses to

provide care for patients with dementia in acute

care hospitals. The FGI method helped partici-

pants to recall their past experiences with patients

with dementia through interaction with other nurses

(Krueger & Casey, 2008; Morgan, 1996, 1997).

Data were collected from February to December

2008. FGIs were conducted in every hospital, and

FGI sessions lasted 1.0

1.5 hr and were held in

meeting or training rooms at each facility. The FGI

environment in which the interviews were held was

private. Only the participants and researchers were

included in the sessions.

The FGIs were conducted as follows. One re-

searcher (RF)

acting as moderator

provided topics

of discussion and copies of the interview questions,

which are shown in Table I. Discussion was refocused

to the intended topic when the discussion digressed.

The sessions began with the open question. Re-

sponses were recorded using an integrated circuit

recorder and field notes. Field notes were written by

a clerk. Key words associated with each participant

remark or nonverbal response (e.g., facial expression,

posture) and descriptions of the overall atmosphere

were recorded for later use.

Analytical methods

The qualitative synthesis method originally devel-

oped by J. Kawakita (KJ method) was adopted in this

study (Kawakita, 1967, 1970; Yamaura, 2008). This

method has been used in a wide range of fields,

Table I. Interview questions.

What difficulties or issues did you experience when caring for patients with dementia who were receiving surgical or other

internal medical treatments?

What measures did you take in previous difficult situations or incidents? Furthermore, why did the problematic situation

occur?

Have you felt any ethical dilemmas while caring for patients with dementia? If yes, please explain.

Have you had any difficulties obtaining cooperation from a patient’s family or any differences of opinion with them? If so,

please explain. If yes, what measures did you take in these cases?

Does your hospital have any policy regarding admission of patients with dementia? If yes, please explain.

Administering care to patients with dementia

Citation: Int J Qualitative Stud Health Well-being 2015,

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including industry, academia, and local and public

administration, for more than 50 years. It has also

been used recently in nursing to decode hypotheti-

cally random, unexplained phenomena and form

them into a relevant, rational framework (Yamaura,

2008). This method was helpful in extracting issues

in nursing care from participant data regarding their

facilities.

Three processes were involved in the KJ method:

code making, grouping, and chart making (Kawakita,

1967, 1970; Yamaura, 2008). Recordings from the

integrated circuit recorder were transcribed. The data

obtained were then unitized by focusing on issues

experienced during care of patients with dementia

and by breaking down sentences into the smallest

possible units so as not to eliminate the participants’

thoughts. The unitized data were identified as codes.

This process is called code making.

The codes were formed into groups based on

similarities between the main themes under each

code. After the initial grouping, a short summary was

made to describe the essence of all codes belonging

to each group. This short summary was used as the

label to symbolize the group in the next step; this

was the first step in the process of grouping.

The same process was repeated with these labels

(Figure 1). The grouping process was repeated until

approximately six labels were formed, which were

arranged spatially into a chart. The logical relation-

ships between the labels in the final grouping were

identified. The content of the labels in the final

grouping were expressed in a short phrase, which

became the descriptive theme assigned to the short

summaries. This process is called chart making. The

analyses described above were performed for each

hospital. Thereafter, the results of these analyses

were unified.

Ensuring credibility and authenticity

During data collection, a researcher (RF) who was

trained in interview procedures and had previous

FGI experience acted as a moderator. The mod-

erator summarized some of the participants’ remarks

to confirm that the intentions of the remarks were

clear. Prior to the analysis, this researcher took two

training courses in the KJ method. The study was

supervised by a faculty mentor (YS) who had full

Grouping in 2

step

Grouping in 1

step

Code making

Continue to do the same in the next step

until the number of labels is around 6

Label 1

Label 2

Label 34

Label 53

Label 54

Label

Code 1

Code 2

Code 3

Code 6

Code 7

Code 93

Code 81

Chart making

Make a chart based on logical relationships between the labels

A theme based on the label content is assigned to each label

.....

.............

.........

.............

........

.....

Figure 1. Analytical methods.

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knowledge of the method. Nurses with experience

in administering care to patients with dementia in

acute care hospitals verified the logical relationships

between the final labels.

Ethical considerations

This study protocol was approved by the Ethics

Committee, Division of Health Sciences, Faculty

of Medicine, Osaka University (Ref. no. 57). The

directors of the nursing departments and the partici-

pants in the cooperating facilities were informed of

the study’s purpose and methods verbally or in writ-

ing. Written informed consent was obtained from

all participants, who understood that participation

was voluntary, that they could leave the FGI at any

time, that all information would be treated confi-

dentially, and that the data would be stored securely

and destroyed following completion of the report.

Results

Participants

The number of beds in the six studied hospitals

ranged from 188 to 1021 (average: 417). The number

of participant nurses from each facility ranged from

5 to 11 (total participants: 50; 49 female). The char-

acteristics of the participants and their workplaces

are shown in Table II. The average age of participants

was 32.3 years (average years of experience: 9.8).

FGI outline

Eight focus groups of 6

10 participants each were

formed. The characteristics of the focus groups are

provided in Table II. The average time spent in FGI

sessions was 64.1 min.

Relationships between issues faced by nurses caring for

patients with dementia in acute care hospitals

The data acquired from the FGI sessions were

structured using seven themes, and the interrelation-

ships between the themes are shown in Figure 2. On

the basis of these relationships, we can draw conclu-

sions with regard to the issues faced by nurses caring

for patients with dementia in acute care hospitals.

Problematic patient behavior affects many indivi-

duals, including the families and hospital roommates

of patients with dementia. Therefore, families and

hospital roommates may also require nursing care

for fear, anxiety, and frustration related to the

problematic behavior of patients with dementia.

Families are, however, also regarded as assistants

when patients with dementia are hospitalized in

Table II. Demographic data of participants and focus groups.

Hospital

Focus group

Total

Number of participants

Gender

Female

Male

Average age (

)

34.2 (14.4)

33.7 (6.2)

25.8 (2.0)

29.4 (7.2)

34.6 (5.5)

34.6 (3.1)

40.4 (8.7)

29.3 (4.5)

32.3 (7.9)

Age range

Average nursing experience (

)

13.3 (12.4)

10.7 (5.8)

5.0 (1.5)

8.3 (7.0)

12.4 (5.9)

8.8 (2.9)

15.0 (5.5)

7.1 (4.9)

9.8 (6.8)

Range of nursing experience

3.9

Department

Internal medicine department

Surgical department

Mixed ward with internal medicine and surgical patients

Others

Average number of inpatients per ward (

)

55.7 (8.0)

41.8 (1.8)

45.9 (4.3)

36.3 (6.7)

29.0 (5.8)

46.9 (3.8)

42.8 (9.1)

Range of number of inpatients per ward

22.5

Average number of inpatients with dementia per ward (

)

39.0 (17.5)

3.6 (1.6)

22.0 (13.6)

5.1 (3.7)

2.4 (1.2)

2.5 (1.4)

11.2 (14.6)

Range of number of inpatients with dementia per ward

1.5

510

1.5

0.5

Administering care to patients with dementia

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Japan, and they are regarded as essential to prevent

the problematic behavior of the patient and to protect

the patient’s safety. In consequence, problems arise

when the problematic behavior of the patient with

dementia is repeated when the assistance of the family

is impossible to obtain.

These interrelated problems indicate that a burden-

somecycleisatworkinacutecarehospitalsinwhich

nurses are expected to care for patients with dementia.

This cycle is exacerbated by two other problems iden-

tified in this study: lack of nursing experience/training

regarding patients with dementia, and lack of organiza-

tion/cooperation among professionals in various med-

ical fields in acute care hospitals. Nurses reported that

they adapt to the above-mentioned cycle by protect-

ing themselves; thus, protection plans for hospitals

must be implemented to avoid liability issues.

Issues faced by nurses caring for patients with dementia

in acute care hospitals

In this section, we outline the issues faced by nurses

caring for patients with dementia in acute care

hospitals identified in the study. Themes are provided,

along with some codes as examples of the responses

obtained during FGI.

Problematic patient behaviors.

‘‘The effects of the

unfamiliar hospital environment or behavioral

restrictions.’’

Various environmental changes, anxiety when

patients see no familiar faces at the hospital, painful

treatments, and physical restrictions cause proble-

matic behaviors such as falling and wandering. The

codes indicate that patients with dementia feel a

sense of security and calm down when spending time

with their families.

If no family member attended to the patient

during the day, the patient was likely to become

angry and abusive. Thus, a patient’s sense of

security and behavior depends on whether or

not a family member is present. (B hospital)

Patients with dementia had difficulty adhering to the

restrictions of medical treatment and the hospital

environment.

Many patients fall on the day of or within 2

days of admission to the hospital, because they

often wander around an unfamiliar environ-

ment during that period. In addition, nurses

might not be able to adhere to fall prevention

protocols depending on the fall risk of the

Protection plans for hospitals: Creating rules to

protect hospitals and nurses

Protection plan for oneself: Adapting to

conditions despite feeling conflicted

therefore

Problematic patient behaviors:

The effects of the unfamiliar hospital environment or behavioral restrictions

Recurrent problem: Nurses need assistance

from families; however, such assistance is

not forthcoming or is impossible to obtain

Problems that affect many people

equally: Families and hospital

roommates also need care

Lack of nursing: Response to

problematic behavior lags

everywhere despite emphasis

on early detection

Lack of organization in

hospitals: Insufficient

education of nurses about

dementia and inadequate

cooperation with professionals

in other medical fields

combined

The burdensome cycle is accelerated.

interacting

Figure 2. Schematic diagram of the issues faced by nurses caring for patients with dementia in acute care hospitals.

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Citation: Int J Qualitative Stud Health Well-being 2015,

: 25828 - http://dx.doi.org/10.3402/qhw.v10.25828

patient, because they cannot achieve an ade-

quate understanding of the patient’s fall risk.

(E hospital)

Recurrent problem.

‘‘Nurses need assistance from

families; however, such assistance is not forthcoming

or is impossible to obtain.’’

Many problems occur during medical treatment

and hospitalization of patients with dementia, such

as dangerous conduct, unhygienic behavior, and

inability to abstain from food when required. These

problems cannot be solved by nurses’ efforts alone,

and cooperation from families is required.

Patients with dementia often have trouble under-

standing their circumstances, and as a result, they

lash out irrationally. In such cases, nurses take

measures to prevent dangerous behavior; however,

they cannot fully prevent such behavior (i.e., mea-

sures are not always successful). In addition, espe-

cially in staff-shortage situations (e.g., during the

night), nurses find it difficult to provide care even

for patients without dementia. Therefore, patients

with dementia can often receive adequate care in

the acute care setting only with the cooperation of

their families.

Even when I hid the intravenous infusion line

in a bandage or a long-sleeved shirt so that

it was not visible to the patient, the patient

had already extracted the intravenous infusion

line by himself/herself the next time I checked.

(D hospital)

There are times when a nurse will request that

a family member of a patient with dementia

comes in, such as when a patient becomes

angry and abusive at night, leaving the nurse

unable to tend to other patients. (A hospital)

However, the nurses in this study reported difficul-

ties obtaining cooperation from patients’ families.

In addition, many patients with dementia are older

adults; therefore, their family members are often also

older, or they may have no families at all. In such

cases, nurses face problems with obtaining informed

consent regarding care and treatment.

Because patients with dementia cannot take

care of a stoma by themselves, we have to ask

the family to learn how to perform this task.

Even if family members understand how to take

care of a stoma after explanation, it is difficult for

them to maintain a positive attitude, because

taking care of a stoma entails disposal of feces.

(D hospital)

Obtaining informed consent regarding care

and treatment is impossible in the case of

some patients. Many are older, and increasing

numbers of patients have no family. Thus, the

way in which informed consent regarding care

and treatment will be acquired in the future is an

issue. (A hospital)

Problems that affect many people equally.

‘‘Families and

hospital roommates also need care.’’

Families and hospital roommates require care in

many situations.

Hospital roommates often feel uneasy or scared

because of the behavior of patients with dementia.

Thus, the nurses in this study felt that it was necessary

to provide care for these roommates.

Because of problems related to patients with

dementia, such as opening other patients’ cur-

tains during the night, using other patients’

portable toilets, and opening other patients’

drawers without permission, patients sharing

the same room become afraid. I realized that

care for surrounding patients is also necessary.

(F hospital)

Family members may become frustrated with and

abusive toward patients with dementia, which can

cause problematic behavior in the hospital. Their

lack of understanding is a hindrance to the patient’s

medical treatment.

In digestive surgery, one patient used to

remove his own intravenous infusion line every

day. He removed his drain by himself and kept

repeating the same actions. His family mem-

bers must have been irritated, and although

I do not allege abuse

per se

, the patient was hit

when no one was watching. (F hospital)

Although the nurse kept beverages away from

the bed of an older person who was in the

hospital for heart failure, his symptoms did not

improve. Later, we found that the wife had

been giving the patient water at his request. (D

hospital)

Sometimes, family members are also older adults with

dementia. They may also cause trouble with other

patients and often do not understand the concept

of informed consent about care and treatment. As a

result, treatment does not progress.

In one case in which the person attending to

the patient was an older adult, forgetfulness

was common. He would borrow money for the

washing machine from other patients and

forget to repay them or wash other patients’

laundry. This got him into trouble with other

patients. (C hospital)

Administering care to patients with dementia

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Lack of nursing.

‘‘Response to problematic behavior

lags everywhere despite emphasis on early detection.’’

Nurses understand that they must detect any signs

of problematic behavior as early as possible, which

can be achieved by close observation of regular be-

havior, noticing small differences in daily activities,

and comprehensive analysis of examination results.

However, prevention of incidents and detection of

problematic behavior tends to lag behind because

of the difficulties associated with understanding the

symptoms of patients with dementia.

In most cases, nurses reported that they noticed

the signs and causes of incidents only after the fact.

Patients tripped over containers and furniture, fell,

made a scene, or showed sudden change in their

emotional state. All such behaviors can be avoided

through advanced planning and countermeasures.

Each patient with dementia has a unique way of ex-

pressing symptoms. Observation provides the oppor-

tunity to notice minute changes.

One patient did not eat his/her meals at all

and came to dislike even seeing food. I thought

that this was because of the dementia; how-

ever, the actual reason was a cancer metastasis.

(C hospital)

The following codes indicated that nurses inter-

viewed in this study had difficulty preventing in-

cidents because they often did not understand their

causes.

Because we collect patient information during

patientcare,apatientmayfallbeforeitis

judged whether he/she is prone to falling.

Although we sometimes think that we should

have been more careful, it is difficult to antici-

pate and deal with such situations in advance.

(E hospital)

Lack of organization in hospitals.

‘‘Insufficient edu-

cation of nurses about dementia and inadequate

cooperation with professionals in other medical

fields.’’

Nurses have no opportunities to obtain knowledge

and advice regarding dementia. Nurses in this study

did learn from their own experiences and their ob-

servation of how senior nurses handled patients with

dementia. Although difficult cases were discussed

during conferences, issues sometimes could not be

resolved, or the time to discuss the issues during

conferences could not be secured. Thus, nurses were

often left to solve issues related to dementia care

themselves.

Nurses do not have opportunities to acquire

specific knowledge or advice about dementia.

Therefore, they deal with problems as they

occur. (B hospital)

When I was a junior nurse, I did not know how

to care for patients with dementia. At that time,

I learned how to care for patients with demen-

tia by observing senior nurses. (D hospital)

The data indicated that acute care hospitals had

organizational problems related to infrastructure and

insufficient cooperation with professionals in other

fields.

Because the nurse call button is not connected

to a personal walkie-talkie system, it cannot be

heard when nurses are administering care to a

patient in a room far from the nurses’ station.

(C hospital)

Doctors’ understanding of patients with de-

mentia is limited; therefore, even if a nurse asks

for a psychiatric consultation, the doctor might

say that a consultation is not necessary for that

level of dementia and refuse to conduct one.

(F hospital)

Cooperation between psychiatrists, assisting nurses,

and hospital security staff is insufficient. In an acute

care hospital setting, although the number of nurses

available appears to be sufficient, sufficient care

cannot be provided to patients with dementia be-

cause of the multiple other demands on their time.

The organization and structure of hospital systems

are inadequate to meet the needs of patients with

dementia.

Protection plans for hospitals.

‘‘Creating rules to

protect hospitals and nurses.’’

Measures must be taken to respond pre-emptively

to issues that could lead to liability problems for the

hospital. The data gathered in FGIs imply that

nurses meet the demands of hospital administration

through the following measures: they may only admit

patients who have somewhere to go after discharge,

who have agreed to leave 2 weeks after admission,

or whose family members can take care of them

after discharge; these measures may be necessary to

maintain their nursing positions.

Because we were informed of low bed turnover

rates, we have not been admitting patients

unless we know that they will be transferred,

and we ensure with indications on the medical

chart that the patient will be transferred to

another hospital after 2 weeks when consent is

obtained from the patient’s family. (F hospital)

Although nurses take all possible measures to pre-

vent falls and extraction of intravenous infusion

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: 25828 - http://dx.doi.org/10.3402/qhw.v10.25828

lines, accidents still occur. Indicators of their efforts

include placing sensor mats before accidents occur

and taking patients with dementia on rounds; how-

ever, nurses may still be blamed by the patients’

families for these accidents.

When a patient falls and problems ensue, the

family may ask the nurse, ‘‘Why did you not

prevent the fall?’’ or ‘‘Why did the patient fall

down?’’ The use of a sensor mat is an indica-

tion to families that we take many precautions.

(F hospital)

Protection plan for oneself.

‘‘Adapting to conditions

despite feeling conflicted.’’

In terms of care administration to patients with

dementia in acute care hospitals, nurses feel a gap

between the ideal situation and the reality of a

negative atmosphere. Acute care hospitals aim to

treat acute diseases. For various reasons, nurses feel

extra pressure when administering care to patients

with dementia in such hospitals, as indicated by the

following code.

Nurses attempt to ensure that patients with

dementia do not fall, for example, by bringing

them to the nurse’s station or taking them on

rounds. Nevertheless, nurses are blamed by

doctors or other medical workers if the patients

end up falling anyway. However, in an acute

care hospital, nurses may suddenly need to

attend to other patients because of rapid

changes in their condition. Therefore, working

in such a setting is very difficult. (D hospital)

Nurses question practices in which medical treat-

ments and life-supporting measures are prioritized,

even when they lead to patients being restrained

or restricted physically. For example, very old patients

(i.e., those aged

90 years) may be taken to reha-

bilitation or be given treatments against their will;

the same may occur in those with poor prognoses on

the basis of their families’ request.

Reinsertion of central venous catheters is a

physical burden on the patient. Thus, the

patients’ movement must be restricted to pre-

vent them from tampering with or removing

necessary equipment. This is accomplished

using things such as mittens, overalls, and

physical restraints. (C hospital)

In the case of a terminally ill patient in the

internal medicine department, surgery was no

longer possible, and the only option was che-

motherapy. The patient did not understand

his/her situation, but his/her family did and

consented to chemotherapy. Although we

administered chemotherapy to extend the

patient’s life by approximately 1

2 months, this

medical treatment is hard on the patient.

I wonder if this is really necessary. Many people

feel that it may be better for the patient to go

home and spend time eating what he/she likes

and doing what he/she pleases. (F hospital)

Nurses also recognize the dilemma of their lack of

time to communicate with patients, although such

communication would help to maintain the patients’

cognitive function. In other cases, nurses adjust

patient schedules so that they can perform their duties

more smoothly, because acute care hospitals cater for

a large number of patients. Moreover, nurses adapt to

such circumstances.

There is always a gap between the ideal situation

and reality; I know I need to stand up for the

patient’s side, but for work to proceed smoothly,

I sometimes get the patient to adjust to me.

However, I am becoming accustomed to these

situations. (A hospital)

Discussion

Relationships between issues faced by nurses caring for

patients with dementia in acute care hospitals

In this study, we identified a cycle that occurs in the

care of patients with dementia in acute care hospitals.

Nurses are required to deal with patients’ problematic

behavior. They take measures such as hiding intra-

venous infusion lines and placing sensor mats to

prevent problematic behavior. However, these mea-

sures may make the environment less familiar to

patients with dementia, resulting in an increase in

problematic behavior. Studies have found that envir-

onmental stimulation exaggerates the stress response

in patients with dementia (Cunningham & Archibald,

2006; Fetzer, 1999; King & Watt, 1995; Martin

& Haynes, 2000). The present findings support

this idea.

Borbasi et al. (2006) recognized that the family is

important in the acute care setting and reported

that although family members are generally consid-

ered as beneficial assets to patients and staff, they

often require substantial support themselves. The

results of this study were similar to those of previous

studies. In this study, nurses could not resolve

certain issues alone when patients with dementia

were recovering from medical treatment; thus, the

nurses turned to the patients’ families for help. At

the same time, they understood the necessity to care

for the family. Their input during the FGI sessions

indicated a mental struggle between asking for help

from families in resolving difficult problems and

the need to support the same family members.

Administering care to patients with dementia

Citation: Int J Qualitative Stud Health Well-being 2015,

: 25828 - http://dx.doi.org/10.3402/qhw.v10.25828

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A previous study reported that nurses were

frustrated by the lack of time to spend with and

speak with patients (Sorlie et al., 2005). This issue

is an ethical challenge in acute nursing care (Sorlie

et al., 2005). Research on nursing home staff has

found that nurses’ frustration, which is related to a

lack of time, stems from the wide variety of diag-

noses and reasons for hospitalization of the patients

(Jakobsen & Sorlie, 2010). The nursing home study

reported that one nurse said that they ‘‘had sev-

eral patients with dementia for assessment in the

short-stay unit. This takes time, and the disquiet

they create leads to frustration among the staff ’’

(Jakobsen & Sorlie, 2010, p. 295). Participants in

our study might also have been in similar situations,

needing more time to communicate adequately

with patients with dementia. Simultaneously admin-

istering care to patients with and without dementia is

extremely challenging. Our study showed that nurses

feel conflicted because of their lack of available time

to provide nursing care to patients with dementia

and their families.

The cycle identified in the current study was

exacerbated by the lack of nursing training/experi-

ence regarding patients with dementia and organiza-

tion/cooperation among medical professionals in

different disciplines in acute care hospitals. The

data indicated that nurses realized that early detec-

tion was important; however, they had difficulties

understanding symptoms, resulting in delays in the

detection of incidents. They recognized the need

for prevention of incidents in the care of patients

with dementia; however, they felt that they were in

danger of overlooking signs because of their lack of

training and experience. Previous studies have iden-

tified overwork, lack of resources, and lack of

knowledge and understanding of dementia among

staff as difficulties in nursing provision for patients

with dementia in acute care settings (Borbasi et al.,

2006; Eriksson & Saveman, 2002; Nolan, 2007;

Nordam et al., 2005). Lack of communication

between nurses and other health care professionals

made nursing care for patients with dementia at

acute care hospitals more difficult (Sorlie et al.,

2005). In this study, we suggest that these deficien-

cies in hospital systems exacerbated the cycle.

As stated in the previous paragraph, nurses

reported facing various problems and difficulties

caring for patients with dementia; these problems

and difficulties interacted and resulted in a cycle.

Despite this situation, nurses were eager to adapt to

their present conditions. However, they felt pressure

because of a lack of time and an inability to respect

the patients’ wishes, as also reported in previous

studies (Borbasi et al., 2006; Eriksson & Saveman,

2002; Nolan, 2007; Taniguchi, 2006; Yamamoto

et al., 2010). Although nurses accepted their mission

to follow their designated routines in their present

conditions, they questioned the situation.

The results of this study clarified that nurses

attempt to protect themselves and their hospitals

under the organizational limitations characteristic

of acute care hospitals. One previous study reported

that securement of additional community services

for people with dementia was long overdue (Borbasi

et al., 2006). In another study, participants described

‘‘a constant demand from the top of the organization

[to] decreas[e]

...

care time’’ (Eriksson & Saveman,

2002, p. 82). These studies indicate that the problems

identified in our study are characteristic of the

problems of nursing care for patients with dementia

in acute care hospitals. Thus, nurses reported taking

actions to protect themselves because of organiza-

tional pressure.

Unique issues in the nursing of patients with dementia in

acute care hospitals

The results of this study differed from those of

previous studies conducted in long-term care facilities

or nursing homes (Brodaty, Draper, & Low, 2003;

Enes & de Vries, 2004; Jakobsen & Sorlie, 2010;

Kada, Nygaard, Mukesh, & Geitung, 2009; Matsuda,

Nagahata, Ueno, & Gora, 2006). The need to care

for patients’ families and cooperate with them had

not been reported in previous studies of long-term

care facilities or nursing homes for the following

reasons. Long-term care facilities or nursing homes

provide care to people who require full-time help

and cannot receive support from family and friends

(Ministry of Health, Labour and Welfare, 2010;

National Institutes of Health, 2014). In addition,

long-term care facilities or nursing homes in Japan

aim to relieve caregivers’ physical and mental load

(Ministry of Health, Labour and Welfare, 2010).

Therefore, nurses working in long-term care facilities

understand that they cannot gain assistance from

families. These nurses also believe that by caring

for patients with dementia in these facilities that they

are also caring for the patients’ families.

Many patients with dementia are admitted to long-

term care facilities (Awata & Watari, 2007; Lithgow

et al., 2011; Miura et al., 2005; Sandberg et al., 1998;

Yamasaki & Kodama, 1995). For example, Miura

et al. (2005) found that 65.2% of inpatients with

dementia in Japan were in psychiatric wards, and

24.9% were in recuperation facilities. Furthermore,

Sandberg et al. (1998) found that in Sweden, 18.9%

of inpatients with dementia were in emergency

hospitals, and 66.3% were in nursing homes. Thus,

nurses working in these facilities may not feel the

need to ask for assistance from families, unlike nurses

R. Fukuda et al.

(page number not for citation purpose)

Citation: Int J Qualitative Stud Health Well-being 2015,

: 25828 - http://dx.doi.org/10.3402/qhw.v10.25828

working in acute care hospitals, because they are

already familiar with care administration to patients

with dementia. The above indicates that nurses’ need

for cooperation with patients’ families regarding

patient care and the need to care for the families

themselves are characteristic issues in caring for

patients with dementia in acute care hospitals.

Suggestions for nursing practice

The results of this study suggest that the nurses

interviewed lacked both observational methods with

which to understand the symptoms of patients with

dementia who could not communicate, and suitable

measures to deal with problematic behavior. Previous

studies in nursing homes and long-term care facilities

have described the effectiveness of staff training pro-

grams on problematic behavior among people with

dementia (Gould & Reed, 2009; McCabe, Davison,

& George, 2007). By use of these training programs,

acute care hospitals could provide an education

system to train nurses in observation and coping

methods comparable with those practiced in long-

term care facilities.

In this study, nurses described being placed in

situations in which they felt compelled to call on

patients’ families to aid in the care of patients with

dementia. Labor shortages and the misconception

that care administration to patients is a job only for

nurses contributed to this problem. Thus, managers

in acute care hospitals must coordinate the efforts

of different staff members so that nurses do not feel

the need to request aid from patients’ families, and

they must create an environment in which all staff

within the organization understand that dementia

is a disease. This study’s participants stated that if

nurses, other medical staff, and all staff in occu-

pational medicine could work together, patients

with dementia would benefit from better care. Early

detection of problems and prevention of problematic

behavior would be facilitated. Nurses would also be

able to find more time to care for patients’ families

and roommates.

Next, we make a recommendation to nurses in

acute care hospitals in relation to falls prevention.

Many participants in this study have experienced

difficulty preventing patients with dementia from

falling. Participants take all possible measures to

prevent falls, such as observing patients with demen-

tia and using sensor mats. Practice guidelines for

fall prevention recommend that the risk of falls be

assessed upon the occurrence of a fall, upon transfer

to another unit, when a significant situation is likely

to increase fall prediction factors, and on admission

(Gray-Miceli, 2008; Health Care Association of

New Jersey, 2009). In Japan, the manual for fall

prevention created by the National Hospital Organi-

zation provides an assessment sheet for falls, which

provides the same recommendation as the prac-

tice guidelines about the timing of risk assessment

(National Hospital Organization, 2010). Therefore,

we recommend that nurses assess the risk of falls at

appropriate times and execute plans according to

risk assessment results.

Limitations

This study has some limitations. First, hospitals were

selected by maximum variation sampling. However,

most larger hospitals (i.e., those with more than 600

beds) refused to participate in the research. Thus,

this study lacks data from larger hospitals and,

therefore, the research findings may not fully reflect

all opinions. However, the percentage of hospitals

with more than 600 beds in Japan was only 3.0%

in 2010 (Ministry of Health, Labour and Welfare,

2011b). Therefore, the research findings reflect

the situation of care administration to patients with

dementia in most hospitals.

Second, the nurse recruitment process in this

study depended on the directors of nursing depart-

ments and head nurses. Nevertheless, participation

in the study was voluntary, and nurses were allowed

to withdraw from the study at any time. However,

nurses might have been influenced to participate in

the study by their directors and head nurses.

Third, data collected in this study were based on

the recollections of nurses. Therefore, some data may

be affected by recall bias. However, the nurses looked

back on their past nursing experience by group

dynamics and helped each other to remember their

methods of care administration to patients. In addi-

tion, nurses may have been able to recall accurately

the history of care administration to patients with

dementia, as they could get this information from

FGIs (Coughlin, 1990). Therefore, the influence of

recall bias on the data may be minimal. However,

some nurses might have been affected by the opinions

of other nurses.

Fourth, the ratio of male to female nurses in this

study was unbalanced (1 male to 49 female nurses).

The proportion of male nurses in Japan was 5.6% in

2010 (Ministry of Health, Labour and Welfare,

2011a); therefore, the proportion of male nurses in

this study was representative. However, the results

may not adequately represent the opinions of male

nurses.

Finally, generalization of these research find-

ings may be difficult because this is an exploratory

study. Although similar results were obtained from

each hospital targeted in this study, the priority and

importance of the problems discussed here may differ

Administering care to patients with dementia

Citation: Int J Qualitative Stud Health Well-being 2015,

: 25828 - http://dx.doi.org/10.3402/qhw.v10.25828

(page number not for citation purpose)

Explanation / Answer

Author identifies the problems faced by nurses in handling patients with Dementia due to lack of basic nursing care services in acute care hospitals, due to lack of experience, due to longer working hours that are required to work with dementia patients, and due to lack of support from families of patients. They face challenges related to disorderly conduct among patients with dementia and problems related to organization of acute care as an obstacle to good nursing care for dementia patients. Nurses face issues like responsibilities for patients, frustation with regard to time, lack of organization ,divided tasks , working alone, structural inadequacies of acute care hospitals in dementia care and complications from continually changing needs of such patients in Japan. To explore difficulties and issues faced by nurses in providing care to patients with dementia in acute care hospitals in Japan. Identifying the difficulties and issues involved in this type of care may provide a basis for discussion of improvement measures and future directions of care administration to patients with dementia. This study is a mix of qualitative and quantitative analysis beacuse it includes detailed survey of hospitals capacity, number of beds, age and experience of nurses etc by collecting data manually. It also has interviewed many nurses with questions. And has collected data practically. Are the literature review and sources provided comprehensive and current? Yes, the review and sources are comprehensive ,detailed from 2000 to 2011 years duration. What are the study population and the sample population? Study population is Nurses and sample population is the nurses from six different hospitals of western region of japan.

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