The results of the process evaluation of the care concept are based on 16 participating observations of 49 residents and 76 persons interacting with them on the wards of the SCUs and the NSNHs, three focus-group interviews with 17 nurses, and eleven individual interviews with ward and nursing home managers (Table 1).
Table 1
Data source
|
|
Observed persons (n = 16 observation units (8 mornings, 8 afternoons))
Number of residents focused on in the observations, n
Gender, n women
Age, mean (SD)
MMSE score, mean (SD)
Number of persons observed interacting with the residents focused on in the observations, n
Residents, n
Nurses, n
Visitors (e.g., family members), n
|
49
38
81.7 (7.3)
14.5 (4.2)
76
29
42
5
|
Interview partner (n = 28, 11 individual interviews, 3 focus group interviews with 17 participants in total)
|
|
Gender, n women
Age, mean (SD)
Number of registered nurses, n
Number of nursing assistants, n
Number of home helpers, n
Professional experience in years, mean (SD)
|
26
44.9 (8.6)
16
11
1
16.3 (8.1)
|
The results regarding the mechanisms of impact were organised into three domains and seven themes. In addition, six contextual aspects influencing implementation and mechanisms of impact of the care concept were identified. The first domain, interventions focusing on nurses, included the themes of development of nurses’ skills and knowledge and promotion of a positive work climate. The second domain included the two themes adjusted spatial structures and adjusted personnel deployment strategy of “dedicated time for activities.” The third domain, interventions focusing on residents, included the three themes of promotion of relaxation, promotion of engagement in activities and promotion of engagement in social interaction. The implementation of the interventions and their outcomes are influenced by contextual aspects relating to the (target) population and cultural, organisational and financial features.
The interventions for residents were found to depend on the successful implementation of the interventions for nurses and the spatial and personnel composition of the unit (Fig. 2). This dependency is characterised by the need to develop nurses’ skills and knowledge to empower them to carry out interventions for residents. In addition, a positive work climate and framework conditions, including spatial structures and personnel strategy support, enable nurses to actually provide interventions to residents adequately. In addition, contextual conditions influence the provisioning of the interventions.
Table 2
Mechanisms of impact of the care concept of the SCU
Domain
|
Theme
|
Intervention
|
Mechanism
|
Outcome
|
Impact
|
Interventions focusing on nurses
|
Development of nurses’ skills and knowledge
|
Training team members in validation
|
Shapes the understanding of nursing as well as of dementia and its impact
|
Adjusted care practices towards an adequate response to the needs of residents
|
• Altered prioritisation of care tasks
• Altered time management
|
Discussion in the team of situations experienced as problematic or challenging by individual nurses
|
Enables team members to reflect their experiences together and express their opinions
|
Creative and innovative solutions for situations experienced as challenging
|
Continuous acquisition of competences of the whole team and continuous improvement in self-efficacy of the whole team (positive reinforcing feedback loops)
|
Providing all nurses access to the same training
|
Shapes a shared understanding of and competence in care for persons with dementia
|
• Team competence and self-efficacy: the ability and experience of every nurse to react to changing situations
• Shared and consistent approach to care
|
Flexibility in care
|
Promotion of a positive work climate
|
Joint discussion of situations experienced as problematic or challenging by individual nurses in the team to jointly find solutions
|
• Promotes a mutual understanding and a feeling of being a valued team member
• Makes the nurses feel not to be left alone with a problem
• Enables the provision of good care, also in situations experienced as challenging
|
• Positive work climate
• Provision of good dementia care
• Culture of solidarity: nurses are looking out for and support each other
|
• Promotion of staff retention
• Sustainable implementation of the care concept
|
Informal and formal team gatherings during and after work
|
Promotes mutual appreciation and team cohesion
|
Spatial and personnel composition of the unit
|
Adjusted spatial structures
|
Small-scale, household-like units
|
• Are perceived as spaces with a constant but low level of acoustic and visual stimuli
• Facilitate the fulfilment of the needs of engagement in activities and social life as well as withdrawal
|
• Residents spend most of their time in common areas
• Residents seldom retreat to their bedrooms
|
• Social engagement
• Engagement in activities
|
Adjusted personnel deployment strategy – “dedicated time for activities”
|
Extra nursing shift dedicated to promoting activities
|
• Provides nurses with time to promote activities and social interaction
• Conveys nurses the feeling, that the promotion of activities is part of their job
|
• Establishes an understanding of nursing within the team that includes physical, psychosocial and occupational tasks directed at the individual persons preferences, desires and needs
• Promotion of residents’ engagement in activities and social interaction by nurses of the extra and the “normal” shifts
|
• Social engagement
• Engagement in activities
|
Interventions focusing on residents
|
Promotion of relaxation*
|
Personalised psychosocial interventions directed at the individual persons preferences, desires and needs at an early stage of agitation or to prevent agitation or other challenging behaviour
|
• Leads to relaxation of the specific resident
|
• Relaxed, purposeful actions of the specific resident
• Social engagement
• Engagement in activities
|
• Relaxing, calm, peaceful environment
• Time spent in communal areas
• Work processes of nurses
|
Promotion of engagement in activities
|
Activities offered by nurses throughout the day personalised in content, type, timing, duration and participation mode (single or group, self-initiated with support from nurses, initiated by nurses with active participation, initiated by nurses with active, supported participation or initiated by nurses with passive participation)
|
• Increases the motivation for participation
• Promotes residents` focus on the activity
• Enables residents to use their resources purposefully
• Enables residents to interact meaningfully with the environment and the people in it
|
• Time spent on activities
• Positive experiences
|
• Social engagement
• Relaxation
|
Promotion of engagement in social interaction
|
• Constant, personalised impulses for the social interaction of nurses and the living in a household-like unit
• Active, appreciative communication with family members
|
• Promotes spending time together
• Promotes shared experiences
• Promotes social interaction between residents
• Promotes social interaction between residents and nurses
• Makes family members and loved ones feel valued and welcome
|
• Becoming part of a social community
• Involvement in a fragile, social (sub-)group
• Emotional connections to others
• Relationship with family members and loved ones
|
• Belonging
• Relaxation
• Affection
|
* Definition of relaxation: In the interviews, nurses and managers agreed that relaxation was understood as an opposite state of agitation and in distinction from apathy. They recognise relaxation in a low muscle tone, relaxed neck and face muscles, a focused look, the ability to stay calmly at one place, the absence of repetitive movements and intense (negative) feelings and unmet needs. A significant characteristic of relaxation is seen in the contactability that is described as residents’ ability to react in an adequate way to interactions of others enabling them to communicate with them. |
Interventions focusing on nurses
Development of nurses’ skills and knowledge
The development of nurses’ skills and knowledge is based on the training of all team members and on collective learning through problem discussion and solving within the team and thereby increases team competence and results in altered and shared care practices (Table.
Validation training primarily shapes the fundamental attitude towards care that is expressed by the validation of emotions and enhances the amount of empathy shown during care for persons with dementia. Nurses were seldom observed using validation techniques with agitated residents. The focus group participants considered the validating attitude towards care in combination with systematic biographical work as enablers to recognise residents as persons with individual needs, resources, and preferences. Subsequently, nurses described that they are able to orientate their care on the persons’ needs, resources and preferences and thereby are able to respond adequately to unmet needs. The observations showed that nurses in the SCUs, compared to those in the NSNHs, use their time resources differently by spending more time on the promotion of activities and social interactions and needing less time to respond to distress and agitation.
Apart from formal training, nurses described that they acquire skills and knowledge by discussing challenging situations with their team. This process was regularly observed with residents showing persistent vocalisations or efforts to run away. Nurses from the SCUs and NSNHs outline their experienced difficulties in informal team gatherings, reflect on their experiences together, discuss opinions and find solutions. Therefore, the team continuously expands and revises its knowledge and skills in dementia care. In an individual interview, a manager described this as follows:
“So that (.) if there are any problems that are very stressful, you also include the team, because the solution usually comes from the team anyway, I have to say. Because if it is a larger group and you discuss, for example, any problem that arises, (.) either we or an individual colleague find a solution.” (EI11_58)
As all nurses experience the same development of skills and knowledge, they described that they are more likely to act in synchronisation and thereby offer a consistent approach to care.
“You will make a big leap if you have completed validation training. In addition, above all, as EVERYBODY is trained, we learned to think in the same way.” (GI1_28)
As all nurses are trained, everyone has the capacity to react adequately in changing situations, e.g., when a resident acts like she or he never has before. Residents’ behaviour was observed to change suddenly and unpredictably; therefore, this team skill is especially useful for preventing stress and agitation. However, the observations in the NSNHs with only a few trained team members revealed that stressful situations may be prolonged if the trained nurses are not on-site.
Promotion of a positive work climate
A positive work climate is enhanced by collective problem solving, informal and formal team gatherings and mutual appreciation and thereby contributes to the sustainable implementation of the care concept.
The focus group participants reported discussions of difficult situations with the team to jointly find solutions. The discussions made them feel understood, appreciated and not left alone to deal with a problem. They described formal and informal team gatherings as being important for team building and team cohesion. Both problem discussions and team gatherings contribute to a positive work climate and a culture of solidarity, where team members support each other in particularly challenging situations.
“Well, taking care of each other and reminding each other to take time-outs, for example, helps a lot. If there is someone who says, "Let us go smoke one," this only takes five minutes, and then it’s alright again. Many of us look out for each other.” (EI7_100)
Furthermore, mutual support and jointly developed solutions for particularly challenging situations enable nurses to be more likely to provide good dementia care. The positive climate on the team, the feeling of appreciation and the ability to provide good care reduce nurses’ distress. According to the managers of the SCU, this can be seen in high staff retention rates. Staff retention leads to increased efficiency of training measures and higher team competence, which is essential for the sustainable implementation of the care concept.
Spatial and personnel composition of the unit
The design of the unit and the personnel deployment strategy create spaces, times and an understanding of nursing that promotes activities and social engagement (but also enables privacy and withdrawal) (Table 2).
Adjusted spatial structures
As pointed out in the interviews with the ward managers, the household-like design of the unit offers spaces that support the fulfilment of residents’ needs (e.g., a spatial layout that enables tacit orientation, a patio and a garden with safe walking opportunities, a dining and living area for eating, recreational activities and social life, various sitting options in the indoor patio for tranquillity and resting, a bedroom for privacy). They see a major advantage in the fact that all parts of the unit are in direct sight of the residents and easy to access, thereby enabling residents to autonomously navigate through the unit according to their preferences, desires and needs.
“The background was actually that we can give the residents an intimate space where they can easily find their bearings. That means having FEW people to deal with. In the middle, a living/dining room surrounded by bedrooms. That is, when the resident comes out of his or her bedroom, he is in HIS living room. On a conventional ward, you come into the aisle and must orientate yourself, 'Do I go left, do I go right?' In addition, we just wanted to prevent this additional disorientation.” (EI3_4)
The observations yielded a constant but low level of acoustic and visual stimuli in the small-scale units. In the larger units of the NSNH, however, the level of stimuli (e.g., noise level) was noticeably higher, and residents left situations with extremely high levels of stimuli (e.g., mealtimes) quickly. Residents were seen spending most of their time in areas with a comfortable level of stimuli and with opportunities for the fulfilment of their needs (e.g., social interaction in common areas).
Adjusted personnel deployment strategy “dedicated time for activities”
In addition to the normal nursing shifts, the development team of the care concept established an extra shift, within which nurses’ sole assignment is the provision of occupation either in groups or for individual residents. The individual and focus-group interviews with the members of the SCUs show, especially in contrast to the interviews with the members of the NSNHs, that they integrate not only physical and psychosocial nursing care but also the provision of meaningful activities into their understanding of nursing. The change in the understanding is reflected by nurses who enhance engagement in activities in the extra shift and in the normal shifts.
“Are they going to do something by themselves? No. WE have to give them something and then work with and watch them… (name of resident), for example, she does not stimulate herself, so I sit down, ask her something and she blooms while telling me her stories.” (GI1_43)
An unintended outcome of the personnel deployment strategy is that nurses recognise residents’ great need for engagement in activities and social interaction. The interviewed nurses of the SCUs consider the promotion of engagement in activities and social interaction as their task, and even though they try to use their time optimally, they cannot offer it on an ideal level for all residents. Consequently, they describe having a certain level of distress as they must decide who is going to experience activity promotion and who is not.
Interventions focusing on residents
The promotion of relaxation, activities and social interaction are interlinked intervention complexes that represent the main resident-targeted areas of the care concept (Table 2). On the one hand, they are interlinked because sometimes the same intervention can provide relaxation, engagement in activity and/or social interaction. An example is a group singing activity accompanied by social interaction that promotes residents’ relaxation if it meets their needs. On the other hand, the three complexes are interlinked via their achieved outcomes. In addition, all three intervention complexes are provided in a personalised manner, meaning they are tailored to residents’ needs, resources and preferences.
Promotion of relaxation
For the implementation of the promotion of relaxation (definition in Table 2), nurses primarily use an emotion-oriented approach with psychosocial interventions referring to the individual persons’ preferences, needs and desires. These interventions are provided as soon as nurses detect a potential for stress, agitation or apathy, but they are also applied for de-escalation purposes. Such interventions allow residents to relax, become contactable, and participate in purposeful activities and social interactions.
Subsequently, the interventions support a calm and relaxed atmosphere on the wards, that was only selectively interrupted by arising restlessness during the observations. Nurses reported that residents reflect on the conditions or behaviours, be they calm or agitated, that lead to a reinforcement of the relaxed atmosphere on the ward. A registered nurse described such reinforcement, this time negatively, in the following quote:
“When you come to the ward and you are out of balance, you can be sure that the group is EQUALLY out of balance all day long. They have sensors for that, and if you're having a bad day, you're already screwed. In addition, they notice exactly when you're sad, they look at you and ask, 'What's wrong?' even though you do not do anything differently and think that you're acting quite normal. It works the other way around too; if you come in a good mood, the residents reflect this too." (GI3_161)
The calm atmosphere is reflected by the low acoustic level, calm movement patterns and purposeful actions of the residents. Supporting the assumption that residents like the atmosphere in common areas, residents were observed spending most of their time there, and withdrawal to one’s bedroom was seldom observed in the SCUs. In the NSNHs with a higher noise level, residents with and without dementia tended to seek the quietness of their rooms and use them for relaxation and recreational activities during the observational periods.
The observations in the SCUs that contrasted with the observations in the NSNHs showed the early promotion of relaxation results in a less amount of time needed for calming and reassuring the residents and preventing the development of a negative social dynamic that would in turn affect other residents. Nurses are therefore likely to invest their gained time resources in the promotion of activities and social engagement, which meet residents’ needs and further enhance relaxation. In these situations, a positive social dynamic enhancing relaxation and fulfilment of needs could be observed.
Promotion of engagement in activities
Interventions to promote engagement in activities are provided in organised weekly planned group activities by elder-care staff members and as individual activities by nurses, thereby allowing residents to experience activities throughout the day. During the observations, nurses of the SCUs provided activities to individuals or small groups that were individualised in regard to content, type and duration to meet the physical, cognitive and social abilities, as well as preferences, of the residents. In the interviews, nurses described that this type of activity promotion allows residents to experience activities that they enjoy. This not only creates a positive experience for the residents but also promotes relaxation and focus on the activity, the use of their skills and interaction with their environment.
“They are calmer, they talk much more about it. They also make statements that you would not expect at all, that you do not believe that they still know about. They truly behave differently. They are more communicative, in any case. (.) You have the feeling that they are calmer inside. It is not about their appearance, the fidgeting or something like that, but you have the feeling that they truly give you their full attention and they are calmer for themselves.” (EI4_67)
Nurses reported that the effects of these interventions are limited to the time of the activity. An impact on residents’ mood, in the sense of verbal expressions, facial expressions or behaviour, was only reported in a few cases. It is questionable, however, whether there truly was no change in mood or whether it was difficult to determine because of the impact of dementia on emotional expression. Often, the mechanism of impact is triggered by an interaction initiated by nurses that is modulated on top of an activity, thereby increasing its scope and impact, as described in the following observation protocol:
N12 turns on the TV and helps residents make themselves comfortable in front of it: "What do you say we watch series XY now? Yesterday there was (...); let us see how things go on today. What do you think, (name of R8)? Would you like to watch too, (name of R2)? Well then, come and join us. Shall we bet that they kiss today? All those in favour?” “Sure, they will!” (says R8) Two residents lift their arms. "Who's against it?" (B14_p. 6)
Promotion of engagement in social interaction
Nurses promote engagement in social interaction by starting and guiding conversations or by setting off impulses that are likely to trigger social interactions. Social interaction helps residents to become part of a social community by facilitating a sense of belonging. Becoming part of a social community also happens passively when residents have common experiences that create an emotional connection. This is especially true for residents with advanced dementia, whose opportunities for verbal interaction may be severely limited. The observations made in both settings yielded that the social community is reflected by residents knowing each other and demonstrating behaviours that characterise the social conventions of social groups (e.g., greeting all present when entering the living room, saying goodbye before going to bed, sharing the newspaper and discussing the content, commenting on the weather).
The focus group participants reported that sometimes within the ward, smaller subgroups of two to four people are formed that are primarily based on mutual positive perceptions. The emotional ties of these residents are closer, which is reflected by residents being keen to spend time together (e.g., walking around together, sitting next to each other for certain activities) and by increased interaction between these residents:
“Therefore, for example, we now have a group that has just formed itself. It is an insanely intense group. They're having a great time. Even the residents, who nobody had accepted before. There were always two ladies who nobody accepted. Now suddenly, the group works with six residents at the table. In addition, each of the ladies demands her own topic of conversation." (GI2_186)
In such subgroups, the residents experience mutual affection, which sometimes manifests itself physically through a hug or stroking of the hand. However, the subgroups are described by nurses as fragile entities that “(…) can dissolve unpredictably. In our ward, it went well for a while when two ladies helped to set the table. Then, one of the two ladies got worse and the second one said, ‘Well, I am not going to do that alone.’ And since then, she just sits there and looks. That’s because she did not want to do it alone.” (GI2_76)
The promotion of social interaction includes the facilitation of (close) relationships with family members and loved ones. Nurses promote these exchanges with family members; they openly communicate information about the residents and seek the expertise of family members on, for example, the biography of the residents. In this way, family members feel valued, welcome, and integrated and tend to visit residents more often or for longer periods.
“My experience is that if we take the relatives on board right from the start and we are very open in what we say and do [...], I actually have the relatives very much on board, they help out, they deal with the biographical work of their own dad, mum or whatever. In addition, that leads them to truly deal with them. You see that. They simply visit longer, inform themselves about their family member, what happened, how he is?" (IG_EI1_33)
Contextual aspects
Six aspects within the context features population, cultural, organisational and financial, are found to influence the implementation and outcomes of the care concept. The aspects and corresponding quotes are displayed in Table 3.
Table 3
Contextual aspects influencing implementation and outcomes of the care concept
Context features [21]
|
Topic and its short description
|
Influence on implementation and/or outcomes of the care concept
|
Quotes or/and extracts from observation protocols
|
(Target) Population
|
Persons with severe physical impairments and/or severe dementia live in nursing homes
Living at home even with (more) severe physical and cognitive impairments is possible due to increased care competence of formal and informal caregivers
Leads to later admissions to nursing homes and changes in resident characteristics
|
Increased need for support in physical care needs leaves less time to implement the promotion of activities and social interaction
|
“That is what I believe is the problem, that the residents simply come to us with high physical care needs, that we can no longer promote the resources as it is stated in the care concept. In addition, of course we have enough staff for the way this concept should be, but as it looks now, we do not have it anymore and therefore team members are simply and constantly, massively overloaded and frustrated.” (EI3_89)
|
(Target)Population
|
Constant behaviour changes possible
Persons with dementia unpredictably change their behaviour and reactions to interventions, persons or situations
Nurses must be able to manage changing situations at any given moment and therefore all nurses need to have the appropriate skills and knowledge
|
High need for a stable team competence and early, intensive training of new team members, if this is not achieved implementation of interventions focusing on residents is at risk
|
“With dementia, I will say one thing is that there is no common thread. That is the real tension." (EI2_63)
“When I come in the morning, I never know - yesterday it was great, and today nothing works. You always have to adjust and make the best of it." (IG_GI2_ 75)
|
(Target)Population
|
Family members as advocates
As persons with dementia experience difficulty fully recalling their biography and comprehensively assessing situations, family members take on the role of advocates
|
Need for intensified cooperation with family members, as they have essential information for residents’ care and on the other hand need information to be able to act as advocates, affects implementation of the care concept
|
“My experience is that if we take the relatives on board right from the start and we are very open in what we say and do [...], I actually have the relatives very much on board, they help out, they deal with the biographical work of their own dad, mum or whatever. In addition, that leads them to truly deal with them. You see that. They simply visit longer, inform themselves about their family member, what happened, how is he or she?" (IG_EI1_33)
|
Cultural – attitude of the target population
|
Intolerance of residents towards behaviour that does not meet social conventions:
Residents without, with mild or moderate dementia address behaviour that does not meet social conventions in a punitive manner
|
Intolerance of socially unsuitable behaviour by persons with dementia influences the outcomes of the care concept of belonging to a social community
|
Note at 10:40 a.m.: R14 goes to the next table and drinks from the glass of another resident, whereupon R8 shouts: “Are you stupid? This is not your glass.” […]
Note at 10:55 a.m.: R8 sits down on an armchair that is not his, another resident starts to nudge him with a stick until R8 gets up and leaves grumbling and grumpy. (B3_p. 5)
|
Cultural - belief of the managers and practitioners
|
Empathy as a must-have in the care for persons with dementia:
For the delivery of interventions focusing on residents, empathy is believed to be essential
Empathy is regarded as a characteristic that is difficult to train
|
Conscious recruitment of new team members difficult because of structurally small number of nursing staff on job search and may jeopardise the implementation
|
“When we hire someone new, the most important thing for me is that he or she deals empathically with the residents. We look at this by letting them spend two days on the SCU. The staff then gives me feedback on whether he or she fits into the team. I pay less attention to formalities - everything else can be learned in trainings.” (EI6_34)
|
Organisational
|
Transformational, consistently acting leaders shaping the organisational culture and understanding of nursing
Charismatic leaders convinced of their approach to care were seen to inspire nurses and to empower them to act in the same way
|
Common, person-centred attitude in interaction with each other influences the work climate and care practices
Changes in leaders and personnel may lead to changes in the informal organisational culture and thereby may influence the implementation of the care concept
|
Expression of common person-centred attitude and conformity:
“We try to determine, what resident like. We look at the biography, where were the interests thus far, talk to the relatives, what they did at home until the end, but you are not allowed to forget that people change. If she was knitting for 40 years, then she often does not want to know anything about knitting anymore. ‘I have knitted long enough, yes, I do not like it anymore - I want to do something new.’ Yes, so people with dementia not only want to do the same old things.” (EI1_18)
“Exactly, and our experience is that relatives say in regard to the biography "Yes, they have always loved having children around" and so on, then we ask them, and they can’t stand it. People change, especially with dementia.” (EI3_6)
Example of conformity:
N4: "If you're nervous, it is over."
N6: "If you're having a bad day."
N4: "You're already lost."
N5: "Because they know that [yes], they pick that up right away. Then, your whole day is gone" (laughs).
N4: "They feel that. [Yeah, right]. Sensors they have. Sensors, they already have good ones. Whenever something is..."
N6: "So the feeling." [IG_GI2_161–166]
|
Financial
|
Limited time resources in nursing care:
Time resources are limited and are particularly scarce during holiday periods and periods of high sickness absence
|
Limited time resources influence the implementation of the interventions focusing on residents
Limited time resources sometimes collide with the developed understanding of nursing resulting in a prioritisation of tasks in favour for physical needs and frustration of nurses
|
“The time you need, you should have; it is very important that you can take your time. Good care needs time." (GI1_7)
"Five things are going on at the same time. The bell rings, someone shouts, the ward round comes... In addition, then you cannot arrange anything with the residents with dementia. You cannot say to them, 'Stay here for five minutes, I will be right back.' They do not know what five minutes is. You have to act immediately." [VG_EI6_87]
|
With regard to the target population, the managers of the SCUs and NSNHs reported that the population is changing, with more persons with severe dementia, high levels of physical care needs, (severely) limited mobility and psychological symptoms or diagnoses living in nursing homes. Furthermore, they pointed to the increasing number of persons showing disinhibitory behaviours. This population differs from the target population of the care concept, which was originally developed for persons with moderate dementia who demonstrate challenging behaviours, can move around on the ward independently and perform light household tasks. The managers see possible reasons for these changes in the increased competence in home care, which enables persons to stay longer in their own home. For the SCUs, this means fewer residents who correspond to the defined target group, more time needed for physical care and less time available for the promotion of engagement in activities social interaction. In addition, the increased physical and cognitive impairments hinder the promotion of engagement in activities and social interactions in groups requiring individual, time-intensive offers. Another aspect of the target population reported in both settings is that people with dementia often suddenly change their behaviour, which makes the strict adherence to care plans difficult. Nurses must be able to manage changing situations at any given moment. If nurses lack this competence, the unpredictable actions of persons with dementia result in distress for both nurses and residents. An additional aspect of the target population is that due to their impaired memory and decision-making capacity, family members act as their advocates, which results in intensified cooperation between family members and nurses.
A cultural aspect of the context observed in both settings is the intolerance of residents towards the behaviour of other residents that is perceived as not being in line with certain social conventions. If a behaviour disturbs residents, they comment on it, sanction it and try to stop it. The observations yielded statements that were often coarse, insulting for the persons referenced and sometimes aggressive. Intolerance towards others’ behaviours was observed in persons with no, mild, and moderate but not severe dementia. Another cultural aspect is the belief of nurses and managers of the SCUs that care for persons with dementia requires a basic level of empathy, which is difficult to train and essential for the implementation of care based on a person's needs, resources and preferences.
An organisational aspect of context is the transformational leadership style shown by the SCU managers. They are convinced of their approach to dementia care and live their underlying person-centred values in the interactions with residents and nurses, be it in everyday conversations, in organising roasters or in providing support in stressful times. In the observations and interviews, they showed a strong, charismatic appearance and were perceived by the nurses as figureheads. These leaders shape nurses’ understanding of respectful interactions with each other and of the care of persons with dementia. In the interviews and in the observations, nurses and managers spoke and worked together consistently, and they were convinced of and enthusiastic about their approach to dementia care. This approach influences the work climate and contributes to a stable team that consistently cares for residents with the same attitude in direct care.
A financial aspect of the context under which care in nursing homes takes place is the limited time resources. Nurses describe having an inner conflict when time resources collide with the developed understanding of nursing that is inherent to the care concept. In such situations, nurses are frustrated and prioritise tasks related to physical needs.