Nursing Standard

evidence & practice / researchdementia

Care of patients with dementia in an acute trauma unit[Q please note – title altered for space and in accordance with our house style – is this ok?] yes this is fineMcCorkell G, Harkin D, McCrory V et al (2017) Care of patients with dementia in an acute trauma unit. Nursing Standard.Date of submission: 30 July 2015; date of acceptance: 1 June 2016. doi: 10.7748/ns.2017.e10250

Gillian McCorkell

[Q please add your job title]Lead Nurse Research and Development Western Health and Social Care Trust, Londonderry,

Northern Ireland

Deirdre Harkin Staff Nurse Trauma and Orthopaedics Acute Services ,Altnagelvn Hospital, Londonderry

Victoria McCrory Staff Nurse Trauma and Orthopaedics Acute Services, Altnagelvn Hospital Londonderry

Mary Lafferty Assistant Nursing Manager Trauma and Orthopaedics, Acute Services Altnagelvn Hospital Londonderry

Vivien Coates

[Q please add the job title, place of work and location for each of your co-authors] Florence Nightingale Foundation Professor Clinical Nursing Practice.Joint appointment: Ulster University & Western Health & Social Care Trust

Correspondence

gillian.mccorkell@westerntrust.hscni.net

[Q please check your details are correct and confirm if you are happy for your email address to be published for correspondence purposes. Also, add your twitter handle if you have one. Thank you] details are correct , happy for email address to be published to twitter handle.

Conflict of interest

None declared

Peer review

Online

Abstract

Aim

The aim of this research project was to raise awareness of the needs of patients with dementia in the trauma and orthopaedics unit of an acute hospital, and to work with staff on the unit to identify ways to improve the care experienced by these patients and their families.Method

An action research approach was used and several cycles were completed. Data were obtained retrospectively from 20 patients with trauma and dementia who were admitted to the trauma and orthopaedics unit for treatment before implementation of the toolkit. Deficiencies in the care of patients with dementia on the unit were identified, nurses' awareness raised, the toolkit developed by nurses and then used. Findings

Comparison of the results pre and post-implementation indicated a significant improvement in all aspects of care for patients with dementia in the trauma and orthopaedics unit. Conclusion

The involvement and inclusion of staff in practice i.e. 'grass-roots' practitioners [Q ok to change to staff on the unit, or staff in practice? It may be unclear what grass-roots refers to, particularly to international readers] in determining what change was needed, how this was to be carried out and the positive impact that these changes have made, demonstrates how the principle of action research has informed and improved clinical practice.

Keywords

action research, delirium, dementia, older adults, research, trauma

THE TERM ‘DEMENTIA’ is used to describe a syndrome that may be caused by a range of illnesses in which there is

progressive decline in multiple areas of function, including memory, reasoning, communication skills and the ability to carry

out daily activities (Wilson et al 2011). Alongside this decline, individuals may develop behavioural and psychological

symptoms such as depression, psychosis and aggression, which may complicate care and which can occur at any stage of

the illness (Department of Health 2009).

The most common types of dementia are Alzheimer’s disease and vascular dementia. Other forms of the disease include

frontal-temporal dementia and dementia with Lewy bodies (Takeda et al 2012). Dementia is a progressive condition, thus

symptoms are likely to get worse over time. Progression will vary from person to person, and each will experience

dementia in a different way. It is unclear why dementia develops, and once cognitive impairment begins, there is little

that can be done to arrest its decline (Wilson et al 2011).

BackgroundAcute hospital wards are busy settings. Admission to hospital can be stressful for any patient, and can be particularly

difficult for patients with dementia because of cognitive impairment. Distress, confusion and the difficulties experienced

meeting fundamental care needs often leads to a longer admission and suboptimal outcomes. Patients with dementia

often require a level of care that requires more time and specific attention when they are admitted to hospital (Van

Hunen Bos 2011) [Q sentence added from the conclusion, since new information should not be added in the

conclusion. Is this ok?]. YES

Up to 70% of acute hospital beds are occupied by older people, approximately 40% of whom have dementia

(Alzheimer’s Society 2009). Although dementia may not be the primary reason for the patient’s admission, those who

have dementia experience increased care complications such as pressure sores, falls and incontinence (RCN 2013).

Studies also show that the average length of stay of a person with dementia in an acute hospital is longer than for

someone without the condition (Johnston et al 2011 [Q 1987?] ). NO 2011 is the correct date of this publication Overall,

patients with dementia typically stay 25% longer, and in some places up to 85% longer, than people without dementia

(CHKS 2013). Patients with dementia are also at greater risk of delirium, with an estimated 90% developing the

condition following hip surgery (Björkelund et al 2009). All older patients should be assessed for delirium, especially

those with dementia. If delirium is not treated, individuals can develop additional complications that may result in poor

outcome such as delayed discharge [Q what is meant by poor outcomes in this context? Could you give an

example?] or death (Hasemann et al 2016).

In acute care settings, the focus is usually on the patient’s presenting condition, for example a fracture following a fall.

Staff treating these patients will have the knowledge, skills and expertise to treat the patient in their respective specialty;

however, the patient’s diagnosis of dementia is often overlooked. The care of patients with dementia can be difficult and

challenging for generalist clinicians and evidences suggests that nurses in the acute care setting may lack the specialist

knowledge, skills and confidence required to provide this care (Surr et al 2016). Issues relating to communication, nutrition

and pain management have been identified as priority areas for improving the care of patients with dementia in the acute

hospital setting (Alzheimer’s Society 2009, Department of Health, Social Services and Public Safety 2011).

AimThe aim of this research project was to raise awareness of the needs of patients with dementia in the trauma and

orthopaedics unit of an acute hospital, and to work with staff to identify ways to improve the care experienced by patients

and their families.

MethodAn action research approach was used, which is the systematic development of knowledge rooted in experience with

the purpose of generating new forms of understanding among individuals and groups of inquiry (Williamson et al 2012).

It is conducted by practitioners who are working in an area in where they have recognised a problem and is often

referred to as practitioner research. Action research typically involves [Q identifying a problem, then ?] OK engaging

in cycles of planning, action, observing and critical reflection [Q ok to add ‘to overcome the problem’ ?] OK (Koshy et

al 2010).

Figure deleted

[Q where is this figure from? Do you have permission to reproduce it?]

One of the attributes of action research is the focus on day-to-day practice and the work context, since it involves

thinking about and reflecting on work; it is a form of self-reflective practice (McCormack 2009). Self-reflection was a

central to this project. Staff on the trauma and orthopaedics unit had the potential to realise themselves how their

attitudes, values and behaviours may be hindering changes to the care of patients in the unit who have a diagnosis of

dementia.

FindingsThree action research cycles were completed. The first action cycle was undertaken to address the problem

of inadequate care for patients with dementia on the trauma and orthopaedics unit. [Q ok to add this here?] Yes

Cycle 1: planningThe first action research cycle began with the ‘planning’ stage, to overcome the difficulty or to explore the problem

identified. During a clinical supervision session, two staff nurses observed that the patients with dementia admitted to the

unit for acute trauma care were not receiving the standard of care recommended by the regional strategy (Box 1)

(Department of Health, Social Services and Public Safety 2011) and that [Q nursing?] staff on the unit felt stressed when

caring for such patients. It was acknowledged that it can be difficult for staff to identify and provide the extra assistance

and support required by patients who are cognitively impaired in a busy ward. The [Q trauma and orthopaedics ?] OK

unit manager was supportive [Q of the project ?] OKand encouraged the staff with its application and implementation at

each stage.

Box 1. Recommended standard of care as recommended by the regional strategy

A person-centred and multidisciplinary approach Provision of information to the person and their family Improving staff knowledge and skills Preserving patient function and skills and preventing decline Appropriate use of medication and other interventions Environmental design(Department of Health, Social Services and Public Safety 2011)

The next step was to assess the extent of the problem (Parahoo 2014), since this informs the planning stage. An audit

was undertaken of the care of 20 patients admitted to the trauma and orthopaedics unit for orthopaedic treatment, but who

also had an underlying diagnosis of dementia. This was to gather baseline data to determine the standard of care they

received in relation to nutrition, communication, management of pain and recognition of delirium. The case notes were

retrospectively drawn [Q ok to change to selected?] OKat random for patients discharged during 2013.

The results of this audit indicated that:

A total of 25% of patients did not have the type of dementia they had documented.

Pain was not adequately assessed using an observational pain assessment tool, which mean that pain relief was not

administered regularly or appropriately for any patients.

Minimal notes about communication with the patient’s family were documented. For example, information about the

patient’s particular individual needs was documented in only 45% of the case notes reviewed.

The audit indicated that improvement in communicating with patients with dementia and their families was

required. It also showed that it was necessary to improve pain management and the identification of delirium in patients

with dementia.

Cycle 1: actionThe second stage of the research action cycle is action (Figure 1). In this project, the action stage involved two staff

nurses requesting a meeting with their [Q nursing ?] OKcolleagues to inform them of the audit results and plan how care

could be improved. The nursing team made suggestions regarding what would help them when caring for patients with

dementia. It was agreed that a toolkit should be designed that would include information, charts, documents and advice to

help overcome the deficiencies in care that had been identified by the audit. The [Q two ?] OKstaff nurses took the lead on

this work and developed a [dementia?]OK toolkit to raise awareness, provide assistance and also discreetly communicate

that a patient has dementia to all members of the multidisciplinary team.

On the trauma and orthopaedics unit, patient documentation such as fluid balance and clinical observation charts,

are usually held in a black folder at the end of the patient’s bed. For patients with dementia, the colour of the folder was

changed to purple, since this is the international colour for dementia (Alzheimer’s Society 2016). [Q is the purple folder

with the additional documents known as the ‘Dementia Toolkit’ Suggest identifying it as such to distinguish

from other tools and for clarity] OK In addition to the standard ward documentation, the purple toolkit contains: a

letter to the patient’s family members explaining that the unit is a dementia friendly ward; advice for

communicating with patients with dementia; a traffic light communication system form; the Bolton Pain

Assessment Scale; and the delirium pathway [Q ok to add this sentence?].OK

Letter to the patient’s family members explaining that the unit is a dementia friendly ward

Knowing as much as possible about the patient is central to successful person-centred communication (RCN 2013). It is

important to learn from carers about the person with dementia and how they function best in everyday life. Working in

partnership with the patient’s family, carers and friends is not only important for delivering the right care, but also can be

helpful for staff. Families often have valuable information about the patient that can support staff to make accurate

assessments, provide care that meets the patients’ needs, and enable effective discharge planning. The letter helps to initiate

such conversations [Q with families?].OK

[Q please note – this letter would be difficult to reproduce in print so will have to be cut] OK

Communication

Effective communication is essential in supporting the well-being of patients with dementia and preventing stressful

situations developing (RCN 2013). It may take someone with dementia longer to understand what is being said to them,

and the unfamiliar people and routines in the hospital ward setting, along with the effects of acute illness, often

exacerbate such difficulties. As a result, patients with dementia in hospital may be unable to understand explanations,

follow directions, report their symptoms and needs, ask for help, and develop and maintain relationships with staff that

would support their treatment and care. These problems have significant implications for patient care and outcomes

(Eggenbergera, Heimerla and Bennetta 2013 [Q please add to references list] ).added

In addition to assessing the patient’s language deficits and communication patterns, nurses should also gather other

information from family or carers that will help staff communicate with the patient with dementia in a person-centred

way, enabling better interpretation of unclear vocalisations, and better anticipating their needs. Such information may

include: the patient’s preferred name and the names of their immediate family members; their daily routine, including

eating, sleeping, leisure activity, and toileting patterns; potential situations they might find upsetting; potentially calming

interventions; how they may exhibit pain; and sources of comfort and reassurance. Information about how to

communicate effectively with patients who have dementia was included in the Dementia Toolkit (Box 2).

Box 2. Advice for communicating with patients who have dementia

Where possible, approach the patient from the front Ensure that you have the patient’s attention by minimising other distractions

Help the patient’s focus by maintaining eye contact – try to be at their eye level. Standing over someone can be intimidating

As much as 90% of communication is non-verbal. A patient with dementia will read your body language and your tone of voice

Speak clearly and calmly. Make sentences short and simple. Make one point at a time Avoid asking the patient questions that require complicated answers Processing information will take the patient longer than usual, so be patient Listen carefully and read the patient’s body language People with dementia can become confused. Even if the patient says something you know isn’t

true, try to avoiding contradicting them or arguing Never speak down to or over a patient with dementia or treat them like a child(Adapted from Alzheimer’s Society 2016) [Q please add to references list]added

‘Traffic light’ communication system for patients with dementia

Time in hospital can result in the deterioration of daily living skills, confidence and independence for all patients.

While the effects of a dementia cannot be ignored, it is essential for staff to acknowledge the multiple abilities and needs

of these patients (RCN 2013). To prevent excess disability compounding functioning that is already compromised, care

should proactively promote re-enablement and rehabilitation to optimum of the patient’s potential. This individual

patient assessment is completed on admission, using information gained from a family member, to ensure an accurate

record of the patient’s ability in carrying out the many activities of daily living, such as eating and drinking, mobility and

elimination. The assessment depends on knowing not only what the patient's present state is, but what their functional

ability was in better health, before the hospital admission. The aim is to restore and maintain the optimal level of

function before discharge. The traffic light communication system is specific to nutrition, continence and mobility, and

has a communication sheet for relatives to add further relevant information about the patient [Q ok to add this

here?] (Figure 2).ok to add

Figure 2. ‘Traffic light’ communication system for patients with dementia

Developed by authors

mobile with assistance of two people and aid

Mobile with supervison on one person

[Q please note: we will ask our design team to redraw this figure, in accordance with our house style. Where

did this figure originate from – was it developed by yourselves, or Western Health and Social Care Trust? Do

you have permission for it to be reproduced?

Also please clarify – what does assistance ‘of two’ and supervision ‘of one’ mean? Does it mean of one / two

members of staff?] as above

Bolton Pain Assessment Scale

In the trauma and orthopaedics unit, most patients will experience pain of some degree during their stay. Suboptimal

pain management may lead to the patient experiencing unnecessary pain, difficulty mobilising, increased agitation,

increased risk of developing delirium and a longer stay in hospital (Achterberg et al 2013). Patients with dementia are

especially vulnerable to unmanaged pain as a result of communication problems (Regnard et al 2003), since they may not be

able to report their pain. As a result, despite being equally susceptible to painful conditions, patients with dementia receive

fewer analgesics than their patients who are cognitively intact (McLachlan et al 2011). Pain assessment tools, particularly

observational or behavioural tools, such as the Abbey Pain Scale [Q please add a reference for the Abbey Pain Scale –

see references list for suggestion] or the Pain Assessment in Advanced Dementia scale (PAINAD) [Q please add a

reference for the PAINAD scale – Lichtner et al appears to be a secondary reference. See references list for

suggestion] all ok to add help to identify pain-related behaviour (Lichtner et al 2014). However, these two tools are

more effective in long-term care settings than in acute settings.

The Bolton Pain Assessment Scale (BPAS) was developed for use in an acute hospital setting (Gregory 2011), and was

therefore selected as the most appropriate measure for the trauma and orthopaedics unit. BPAS is a combination of the

Abbey Pain Scale and PAINAD scale, and has an additional section for the patient’s family to provide pain behaviour

information about the patient with dementia. This measure enables staff on the unit to undertake a wider assessment of the

patient, rather than simply asking ‘are you in pain?’ As with other observational pain assessment measures, the nurse or

healthcare professional observes for visual signs in the patient’s facial expressions and speech, for example if they appear

relaxed, quiet and smiling, or if they are tense, groaning or crying out.

The BPAS also includes other physical signs of pain, such as fidgeting, fist clenching or changes in the patient’s usual

eating patterns. The patient’s reactions to others, including pulling, pushing away and striking out is also assessed as

possible manifestations of pain and/or discomfort. These signs are scored from 0 (absent) to 3 (severe) [Q ok to add?],

ok to add then the scores are totalled to give an overall pain score, which indicates if the patient has no pain, mild,

moderate or severe pain. Analgesics are then prescribed and administered accordingly. Permission was received from the

team at Bolton to adapt this tool for use in our wards [Q is this referring to hospital wards in the trust, or the T&O

unit specifically?]. ( BOTH)

Figure 3. [Q please clarify – the figure below is titled ‘Cognitive Impairment Pain Assessment Scale’ but this is referred to as Bolton Pain Assessment Scale (BPAS) in the rest of the article. Which was included in the toolkit? If this is an adaptation of the BPAS, can this wording be changed, and who adapted the toolTHE AUTHORS ? Do you have permission from the trust to reproduce this figure YES?] titled ‘Cognitive Impairment Pain Assessment Scale’ ADAPTED FROM Bolton Pain Assessment Scale (BPAS)

[Q what does H&C stand for?]Health and Social Care

Delirium prevention and management care pathway

Delirium is a sudden deterioration in mental functioning, which is caused by acute illness, acute injury or drug

intoxication (Siddiqi 2011). As many as 1 in 8 hospital patients may be affected and is the most common complication

experienced by elderly people when in hospital (Siddiqi 2011 )[Q what is the reference for this figure?].

Delirium can be caused by various factors such as unfamiliar surroundings, pain, dehydration, electrolyte imbalance,

constipation and infection. By recognising the difference between dementia and delirium [Q not sure what the

difference is between here – does this mean recognising the cause?] and managing delirium promptly and

appropriately the patient experience [Q what is meant by outcome here? Symptoms can be greatly improved?]

( deleted) can be greatly improved. A flow chart to assist with the recognition and management of delirium was added to

the toolkit.

(Insert Figure 6 about here) [Q please note - this figure will have to be cut for space – suggest adding a sentence

with a link to it, or if a link is not available, stating it is based on the NICE (2010) guidelines for delirium?]OK TO

DO THIS

Cycle 1: observing

The next stage of the cycle is observing the effects of the action, in this case the use of the toolkit in practice. On an

agreed date, the first version of the ‘Toolkit’ was introduced and used in practice. While the toolkit was used for some

patients, it was not applied appropriately across the nursing team [Q how was this determined?] and in the fourth

stage, ‘Critical Reflection’, it was felt that staff required further education on the use of the toolkit [Q rephrase

ok?]. This led into the next of the action research cycles.

[Q does a more information need to be added here for the fourth stage of the action research cycle – Critical

reflection?] DUE TO WORD LIMIT SUGGEST KEEP IT AS IT IS

Cycle 2 – staff educationA problem identified was the lack of [Q staff?] OK education about the effects of dementia, the onset of delirium and

the use of the toolkit, so a second action research cycle commenced. The planning stage of this cycle related to providing

further education to enable changes to become embedded into everyday practice. Staff in the trauma and orthopaedics

unit needed to know not only about what practices were to change, but also how best to implement the changes. It was

important for the ward staff to be aware of the rationale for the contents of the toolkit to enhance its effectiveness. This

is an ongoing process since the ward environment is not static [Q dynamic?]. OK

The action stage of this cycle focused on teaching and training sessions supported by the nurses who had designed

the toolkit. These sessions were held at lunchtime, or on an ad hoc individual basis when the opportunity arose, with all

members of the ward team with the purpose of working towards improving the care for patients with dementia and

their families. Further versions of the toolkit [Q please clarify – was this the same toolkit as used previously,YES

or were these further versions amended in any way?] were made available following this education and were to be

used by all nurses on the unit when a patient with dementia was admitted.

The third stage of this cycle, observing, involved undertaking a repeat audit six months after the toolkit was

implemented [Q was this of 20 patients in the T&O unit with dementia, as before?]. YES Comparison of the results

pre and post-implementation of the toolkit indicated significant improvements in all aspects of care of patients with

dementia. Pre-implementation data indicated that a recognised dementia pain assessment tool was not used for any of

the patients with dementia. However, the post-implementation data indicated the BPAS [Q please confirm – was this

the BPAS or the adaptation shown in Figure 3 – the Cognitive Impairment Pain Assessment Scale?] was used in

95% (n=19) of patients. Evidence of regular pain relief prescribed was only documented in 30% (n=6) of patients pre-

implementation, whereas this increased to 90% (n=18) of patients post-implementation.

Table 1. Audit results for the care of patients with dementia admitted to the trauma and orthopaedics unit

[Q please add number of patients for each of the percentages in Table 1]

Before

implementation of

the toolkit (%)

(n=20)

After implementation

of the toolkit (%)

(n=20)

Type of dementia

documented

25 (5) 55 (11)

Communication sheet

completed

45 ( 9) 100 ( 20)

Recognised dementia

pain assessment tool

used

0 ( 0) 95 ( 19)

Evidence that regular

pain relief was

prescribed from

admission

25( 5) 95 ( 19)

Evidence that

analgesics were

prescribed when

required

70 ( 14) 100 ( 20)

Regular pain relief

administered from

time of admission

30 ( 6) 90 ( 18)

Evidence that family

members were

updated on the

progress of the patient

0 (0) 80 ( 16)

Cycle 3 - sustainability[Q can this section be clarified/expanded on – what was the problem identified, and what happened during

the planning, action, observing and critical reflection stages of this action research cycle?]

Several ‘dementia champions’ have been selected to attend [Q suggest rephrasing for clarity – ‘Several members of

staff on the unit have been selected to become ‘dementia champions’, attending…’] ok The Best Practice in

Dementia Care learning programme provided by the University of Sterling (Dementia Services Development Centre 2007).

These dementia champions have been equipped with workbooks and resources and have each facilitated the

development of up to eight further dementia champions on the unit over six-months, using a cascade approach [Q

rephrasing ok?]. ok This cycle is ongoing, but preliminary results and feedback from staff and families are extremely

positive. It is envisaged that the Dementia Toolkit will eventually be implemented in all acute and older adult wards in the

trust.

DiscussionIt is evident from the data collected and results of the audit that the implementation of the toolkit has made

significant changes to the care of patients with dementia in a busy acute hospital ward.

When a patient with dementia is admitted to an acute hospital ward, effective communication is an important aspect of

their care. The unfamiliar hospital environment can be overwhelming for these patients. Previous studies have established

for these patients, their dementia is often seen as secondary to the reason for their hospital admission, thus meeting the

needs that this creates may be considered a low priority and requiring time, which takes nurses away from their primary

purpose of delivering acute medical or surgical care (Moyle et al 2011). In addition, staff on acute hospital wards may have

an acute care ‘mindset’ that does consider the specific needs of patients with cognitive impairment (Eriksson and Saveman

2002). Part of the complexity of caring for people with dementia in acute hospital wards results from an acute care focus

on the patient’s physical diagnosis, whereas patients with dementia require highly skilled assessment and care planning

designed to coordinate their physical and mental health needs (Bezzant 2008). Caring for these patients may be physically

and mentally demanding (Eriksson and Saveman 2002), and often takes place in areas with high workloads, insufficient

staffing levels and inappropriate physical environments (Dean 2011). The toolkit has enabled staff to address previous

concerns such as difficulties in communication, managing pain and managing other challenging behaviours (Alzheimer’s

Society 2009).

Communication and managing painRecognising the need to address the extra assistance and support required to be effective in terms of communication,

pain assessment and pain relief has been paramount. Effective communication techniques are essential when assessing

pain. The nurse has a central role in identifying and appropriately assessing pain to provide effective treatment (Buchanan

et al 2014). Pain is often not recognised and undertreated in patients with dementia (Reynolds et al 2008), with patients

losing the ability to self-report pain (Herr et al 2006). According to Riva et al (2011), unrelieved pain can result in an

individual experiencing cognitive impairment, such as disorientation, mental confusion and reduced concentration. For

individuals with dementia, the experience of pain can manifest as behavioural disturbances such as agitation and

aggression (Cohen-Mansfield 2014). A previous study found that among postoperative hip-fracture patients, those who

were cognitively impaired received only one third of the opioid analgesics administered to patients who were cognitively

intact (Eide and Forman 2008) [Q ok to change reference to Morrison and Siu (2000), since this seems to be the

primary reference? https://www.ncbi.nlm.nih.gov/pubmed/10799790 ]. These study results are comparable to the

data that was collected before the use of the Bolton Pain Assessment Scale within the toolkit. Overall, effective management

of undiagnosed pain can reduce behavioural disturbances and distress (Ahn and Horgas 2013). Staff in the trauma and

orthopaedics unit are now aware that they cannot rely on usual pain assessment tools for patients with dementia; instead,

they should consider pain indicators such as changes in mood and behaviour to provide an accurate assessment and to

distinguish between pain and other problems such as delirium.

Staff trainingIt has been suggested that conventional didactic classroom approaches to training do not improve knowledge

sufficiently to support changes to clinical practice (Ballard and Aarsland 2009, Smythe et al 2015). Staff often have little

opportunity to leave the clinical environment for training, or to meet as a team to reflect and learn together (Smythe et al

2015). Therefore, training delivered in the clinical setting may be more feasible and might have greater potential to

enhance practice. It was necessary to involve and include ‘grass-roots' practitioners [Q ok to change to staff on the

ward / in practice?]OK to determine what changes to care were needed, how this was to be carried out and the

positive effects that these changes have had, demonstrating how an action research approach can inform and enhance

clinical practice.

ConclusionWhen a patient with a diagnosis of dementia is admitted to an acute hospital ward, all members of the healthcare

team should be made aware of their condition, because the patient will often require a level of care that requires more

time and specific attention (Van Hunen Bos 2011). It can be difficult on a busy ward for staff to immediately identify the

patient’s need for additional assistance and support because of the cognitive impairment associated with dementia. The

toolkit has been implemented in the trauma and orthopaedics unit as an integral part of the care pathway for people

with dementia.

While an acute care setting is not ideal for patients with dementia, many will require this type of admission when

presenting with acute comorbid conditions [Q or acute trauma ?], therefore effective training for staff is essential.

Staff in acute care settings should have appropriate knowledge and skills to better meet the needs of patients with dementia.

The toolkit is a discreet, subtle and inexpensive way of improving care for patients with dementia and their families, and

supports the development of person-centred culture care on the ward, which can result in significant improvements to the

patient’s care experience.

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