Improving Dementia Care Training for Registered General Nurses and Adult Student Nurses: examining the need, efficacy, content and barriers.
This Independent Project aims to explore the efficacy of current provision for Dementia care training for Adult branch Student Nurses and Registered General Nurses (RGN’s). A range of audits and research literature on this area of special interest will be examined to obtain a better picture of the situation with an aim to discover a recommendation for whether more training in this area is needed. The content and provision needs of training will also be explored with barriers to effective care and training critically analysed.
Introduction
Dementia is an umbrella term used to describe a wide range of symptoms caused by certain diseases or conditions associated with decline in a person’s cognitive abilities such as memory, personality changes, impaired reasoning and use of verbal language, which are severe enough to reduce a person’s ability to perform every-day activities (Chater and Hughes 2012). The most common of these diseases is Alzheimer’s reference. Dementia is progressive and incurable, therefore it is vital these people are supported and cared for by nurses who have been trained with the skills and knowledge needed to deliver high quality evidence based care. ADD IN STRONG REFERENCE THAT TRAINING IMPROVES QUALITY EVIDENCE-BASED CARE.

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There are currently 800,000 people with dementia living in the UK, with these figures expected to rise by 40% over the next 12 years and by 156% over the next 38 years due to an ageing population. Evidence from the Department of Health (2012) shows that 95% of these people are over the age of 65 and are therefore more likely to have complex medical needs. As a result; they spend increased time in acute hospital wards under the care of RGN’s, making training in this area for this group of health professionals a contemporary issue which needs exploration (Department of Health 2012) .

The rising number of patients with dementia presents a challenge for all acute hospital trusts and many different health professionals. Such patients experience higher mortality rates and are more likely to have longer lengths of stay than others, they are also more at risk of falls and other incidents whilst in hospital (Cornwell et al 2012). Aside from the cost implications to the NHS when trusts do not get to grips with this challenge, the patients are not getting appropriate care – they are not ‘living well with dementia’ (Department of Health 2009). The National Dementia Strategy set a clear vision that people with dementia and their carers should be helped to live well with dementia, no matter what the stage of their condition or where they are in the health and care system. Through examination of Dementia training efficacy, it is hoped a recommendation will be made to improve the lives of those living with Dementia through changes in Dementia Care training for RGN’s.

Following initial exploration of evidence available surrounding Dementia care training, the following issues will be addressed and critically analysed:

Why is Dementia Training for RGN’s needed?
How can the efficacy of training on Dementia care for RGN’s be improved?
What content should be used in Dementia care training?
What are the barriers to implementation of Dementia care training?

Why is Dementia Training for RGN’s needed?

Patients admitted to acute hospital wards with dementia have comparatively poorer outcomes regarding length of stay, mortality and further institutionalism (DH 2009, Alzheimer’s Society 2012). In addition, this group of patients place higher demands for nursing care, are more likely to functionally decline during admission and suffer increased rates of delayed discharge. This can result in permanent decline in health and added costs to NHS trusts (Mukadam and Sampson 2011). Though thought by many to be due to their complex health needs (REFERENCE), The Health Foundation (2011) has suggested a significant reason for these poorer outcomes is lack of professional understanding by RGN’s in providing appropriate care.
Improvement in Dementia care is currently a nationwide health initiative reference. National audits over the last 5 years have recommended implementation of dementia services such as dementia lead nurses, standardised assessment and care protocols and compulsory staff training (DH 2009, Harwood et al. 2010, Thompson and Heath 2013, RCP 2013). Yet there are many recent reports of poor and sometimes negligent care suggesting these recommendations have not yet been followed or implemented (Leung and Todd 2010, Francis 2013, RCP 2013). Results from the National Audit of Dementia Care in general hospitals indicated that nurses working on acute wards rated significantly lower adequacy of training than nurses working on care of elderly wards. Other audits such as Counting the Cost report (Alzheimer’s Society 2009) indicated that more than half of nurses had not received any pre or post registered dementia training.
Elliot and Adams (2011) further identify the lack of understanding around Dementia, meaning the needs of older people with Dementia are not addressed in many acute hospital settings. As can be seen, the need for specific training in Dementia care for RGN’s is strong.
There is evidence to support positive influence on effective care with training. The National Audit of Dementia Care in General Hospitals (NAD 2012) was commissioned by Healthcare Quality Improvement Partnership to address the concerns of care for people with dementia (Tadd et al. 2011). These audits aimed to identify hospital’s provision of assessment, care models and staff training. Following the 1st round of audits in 2011 a report by Thompson and Heath concluded that the main barriers to providing good care were lack of understanding of the condition, not enough time to care and failing to communicate with patients. Improvements are not as forthcoming in dementia assessment on admission to acute wards. Results from the 2nd round audit of NAD acknowledge that there had been improvement in implementation of staff training frameworks in hospitals since the 1st round audit and represented an improvement in care as a result (Royal College of Psychiatrists 2013).
The 2nd round report highlighted that approximately 75% of hospitals now provide dementia awareness training to nurses, although almost 50% are still failing to provide dementia awareness training as part of induction programmes. The report suggests that further improvement is required in providing better and more consistent staff training, as despite some progress, there appears to be a gap between actual training and written reports (RCP 2013). As a result, the recommendations outlined and analysed in this Independent project may be of some use in raising positive statistics.

How can the efficacy of training on Dementia care for RGN’s be improved?

It is the evaluation of this evidence which aims to generate key recommendations for provision of Dementia care training.
Elliot and Adams (2011) were able to show improvements in needs met where specific education for RGN’s is provided by a Dementia Nurse Specialist (recommendation number 1). This shows the role of the Dementia Nurse Specialist to be vital in improving the efficacy of Dementia training and infiltrating best possible evidence-based care into clinical practice. However, despite this, the minimal numbers of Dementia Nurse Specialists currently practicing has to be identified as a limiting factor. In many trusts and academic institutions, there is no availability for a Dementia Nurse Specialist to provide training, therefore limiting efficacy even when extensive training is to be provided (Knifton et al. 2014).
In terms of training content, it is well documented that evidence used should be reliable and credibly underpin clinical practice as this promotes evidence –based practice and better health outcomes (Jeffs et al. 2013). Evidence based practice is vital in all nurses’ roles (REFERENCE NMC CODE). REFERENCE suggests up to date qualitative and quantitative research is the only knowledge and information base which should be used to allow best care to be provided, hence placing important value of increased use of evidence based research in training sessions. Currently, Moyle et al. (2008) suggests the lack of research used to underpin Dementia training for RGN’s is limiting ability to not only provide best care but also identify those living with Dementia (Chang et al. 2009) RECOMMENDATION 2. However, barriers to evidence based care remain even when high quality evidence is used to support training. Smith-Strom and Nortvedt (2008) have identified that RGN’s often find evidence difficult to interpret and evaluate while Oermann (2009) suggests very little of the content is retained to be implemented into practice. This suggests RGN’s may also need training on evidence based practice and processing research (REFERENCE). Gerrish (2008) suggested the knowledge and skill of the individual nurse prior to receiving specific training heavily influenced their ability to improve their practice following. This suggests multiple training sessions on Dementia may be needed before practice can be changed and improved (REFERENCE). RECOMMENDATION 3.

What content should be used in Dementia care training?

Tadd et al. (2011) explain that one reason for increased functional decline is that care of patients on acute wards is prioritised from the perspective of the medical condition for which they have been admitted, often overlooking their mental health condition. Most acute wards follow rigid, task driven routines such as drug rounds, meal times and washing, while staff lack the necessary skills required to provide proficient dignified care. This form of nursing can cause increased anxiety and delirium resulting in poorer outcomes for individuals (Tadd et al. 2011, Calnan et al. 2013). Alzheimer’s Society (2009) report that patients admitted to acute hospital wards for longer periods are more likely to suffer from permanent worsened effects of dementia and physical health. They are more likely to receive prescribed antipsychotic drugs and to be discharged to residential care rather than their home (Thompson and Heath 2013).
Leung and Todd (2010) acknowledge that specialist services do exist in some trusts and that training in managing behaviour, using life stories and implementing dementia care mapping are all good techniques that can help nurses to improve quality care. Dementia care mapping is an observational method of recording interactions that take place between individuals and nurses over a period of time (Ervin and Koschel 2012). This enables evaluation of what works and doesn’t work for patients, it is a useful way of tailoring person-centred care to help staff understand the experience of dementia from the patient’s perspective while rating quality of care given (National Institute for Health and Clinical Excellence and Social Institute for Care Excellence 2007) (NICE-SCIE).
Alzheimer’s Society (2013) suggest that nurses must challenge their task driven ward environment and provide a more flexible approach providing care from the patient’s perspective as this is achievable and beneficial to patients. Leung and Todd (2010) reported that most nurses have received little or no training and are ill equipped to deal with the many challenges that face both patients and nurses. Additionally NICE (2013) state that nurses suggest dementia education programmes should include identifying signs and symptoms, communication and person-centred care methods, treatment to include medicine administration and how to monitor side effects, particular emphasis was placed on requirement to assess pan. Nurses also suggested that learning about the impact of dementia on the individual and managing challenging behaviour would be useful. Dementia training is not a compulsory element of the pre-registered nursing curriculum although this has been recommended to the Nursing and Midwifery Council (NMC) by several national organisations. (NICE-SCIE 2007, Alzheimer’s Association 2009, All-party Parliamentary Group on Dementia 2012, Higher Education for Dementia
Network 2014 (HEDN)). The NHS Confederation (2010) recognise that providing dementia training to staff could benefit hospital trusts in several ways. These include nurses being equipped to identify those with dementia, therefore being able to implement care pathways appropriate to patients. Effective management of patients with dementia helps avoid disorientation and anxiousness which could reduce the amount of time spent attending to challenging behaviour and allow staff more time to care for all patients on an acute ward.

What are the barriers to implementation of Dementia care training?

Even when effective dementia training has been provided, barriers to good quality evidence-based care remain and it is important these do not go unnoticed. Identification and knowledge of these barriers alone can minimise their limiting factor (reference). Acute hospital settings pose many challenges to both patients with dementia and the nurses caring for them. Yet Harwood et al. (2011) report that there is little evidence of research aimed at investigating these challenges and the provision of detailed policies on how to deal with them. Patients with dementia are more likely to find an unfamiliar environment unsettling, frightening and confusing due to the nature of impaired cognitive ability (Moyle et al. 2008). This accounts for literature suggesting that an acute ward environment comprised of identical doorways and bed spaces causes added confusion to patients (Reference). This often creates increased disorientation, aggression or withdrawal (Leung and Todd, Thompson and Heath 2013). This further challenges the nurse’s role in maintaining nutritional, personal hygiene and drug administration tasks as individuals can no longer respond to familiar faces, environment and daily routines (Tadd et al. 2011).
Barriers
Overcoming the barriers
The government accepts improvements are needed and is pinning hopes on the £3.8 billion Better Care Fund, which will was launched in April 2015. The pot has been earmarked for joint projects between the NHS and local government to encourage more integrated care.
STUDENT NURSES
2015 report: Dementia education to bestandardised at degree level

some nursing degrees offer only three hours of dementia education throughout the whole three-year course.
How this should change following the dementia core skills framework, but it doesn’t state how many hours students will be required to undertake.
Student nurse attitudes towards working with the elderly

Future plans for RGN’s
HEE 2013 Mandate targets. – ensure that tools and training opportunities in dementia are available to all staff by the end of 2018.
Current training requierments of RGN’s in relation to Dementia training
References
Department of Health (2009) Living well with dementia: a national dementia strategy. The Stationery Office, London.
National Institute for Health and Clinical Excellence/Social Care Institute for Excellence guideline (2006) Dementia: supporting people with dementia and their carers in health and social care. NICE/SCIE, London.