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• To understand how time spent with a person with dementia provides added value within a care setting
• To recognise how environmental factors can reduce the quality of the time spent with a person with dementia
• To learn about techniques that nurses can use to be more ‘present’ with people with dementia
Spending time with a person with dementia to develop a rapport is vitally important for nurses who are attempting to deliver high-quality care. However, finding opportunities to spend meaningful time with a person with dementia can be challenging due to the nature of busy clinical environments. Further, spending time with people may be considered a non-essential use of a nurse’s time by some colleagues. These factors can result in inadequate outcomes for both the person with dementia and the nurse providing the care.
This article outlines a rationale for reframing the time nurses have available to spend with people with dementia. The author explains the concepts of ‘ways of being’ and ‘mentalising’ and how these can assist nurses to provide a more authentic presence during their interactions with people with dementia.
Nursing Older People. doi: 10.7748/nop.2022.e1402
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Krohne J (2022) Reframing nurses’ time to enhance interpersonal interactions in dementia care. Nursing Older People. doi: 10.7748/nop.2022.e1402
Published online: 10 August 2022
The Nursing and Midwifery Council (NMC) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates requires nurses to listen to patients and their preferences, concerns and needs (NMC 2018). In addition, the provision of high-quality care for people with dementia is fundamentally dependent on effective, competent and compassionate communication from all staff involved in their care (Naughton et al 2018). Patients with cognitive impairment often require significant attention from nurses, but there can be very limited time to provide this (Nilsson et al 2016). This can lead to nurses struggling to find a balance between fulfilling their institutional role and the need to provide emotional support to the person with dementia (Dooley et al 2015).
Maintaining a compassionate relationship with patients is one of the most challenging aspects of nursing in a complex practice environment (Dewing and McCormack 2017). A lack of time means that nurses sometimes find it difficult to adopt the appropriate approach when engaging with people with dementia (Juhasz 2016). Nurses can spend as little as 20% of their time providing direct care (Michel et al 2021), often leading to a disconnect between the person-centred care that they would like to practise and the reality of the care they are actually able to provide (Prato et al 2019). In addition, healthcare settings are often affected by endemic staff shortages (The King’s Fund 2022), so it is essential that the time available to nurses to spend with people with dementia is used as effectively as possible. There is also evidence that the lack of time available to spend with patients can have a detrimental effect on nurses’ own well-being (Bright 2012).
This article examines the concept of time within dementia care. The author argues that a cultural change is needed when considering the value of the nursing time allocated to people with dementia. The concepts of ‘ways of being’ and ‘mentalising’ are explained, an understanding of which will enable nurses to use their time effectively and provide an authentic presence for people with dementia.
Person-centred care and communication are crucial elements of an effective workplace culture (Manley et al 2019) and fundamental to ensuring optimal health outcomes (Kwame and Petrucka 2021). However, when under pressure, for example because of staff shortages, nurses may have less time to consider patients’ emotional welfare and may attempt to meet patients’ needs in rote fashion with little or no therapeutic interaction (Theodosius 2008, Boeck 2014). In addition, feeling hurried, impatient and overwhelmed with clinical tasks can negatively affect a nurse’s compassion for a person with dementia (Bickford et al 2019), leading to some nurses not demonstrating an appropriate level of care (Davies et al 2017).
As well as negative effects on the person with dementia, this focus on tasks and supporting the healthcare system rather than the patient can have negative consequences for nurses, including feelings of guilt, shame, anger and depersonalisation (Bright 2012). These feelings are linked to burnout for nurses, which is characterised by increased emotional exhaustion, disengagement from those they care for and a reduced sense of personal accomplishment (Smythe et al 2020). This experience of burnout will further reduce nurses’ interactions with people with dementia (Kokkonen et al 2014). Burnout can also contribute to the development of an ‘empathy wall’, described by Hochschild (2016) as an obstacle to gaining a deeper understanding of other people.
These symptoms of burnout also contribute to nurses leaving the profession, leading to additional workforce shortages which in turn have a direct effect on the quality of care (The King’s Fund 2022). These workforce shortages exert increased pressure on a depleted and exhausted workforce, further reducing the time nurses have to spend with people with dementia (Care Quality Commission 2021).
Resilience refers to the ability of an individual to cope effectively with adverse circumstances (Rutter 2008). Being present with patients can result in enhanced mental well-being for nurses (Bright 2012) and could be considered a protective factor, supporting nurses’ resilience and assisting them to manage workplace stressors (McAllister and Lowe 2011, Stephens 2013). Therefore, reprioritising the use of nurses’ time and releasing them to spend more time with people with dementia could assist in addressing negative factors such as burnout.
• The ability to be ‘authentically present’ with a person is the essence of nursing as a caring practice
• Developing a rapport with a person with dementia must be regarded as a positive use of a nurse’s time
• Spending meaningful time with people with dementia can reduce the emotional demands of the caring role for nurses
• Nurse managers should develop a culture where time spent with a person with dementia is regarded as positive
Time in healthcare settings is a sensitive and valuable commodity. Healthcare tasks are allocated according to whether they are considered a positive use of time (value-adding activities) or a potentially negative use of time (non-value-adding activities). Value-adding activities have been defined as those that directly benefit patients, such as the time nurses spend carrying out clinical tasks (Dearmon et al 2013), as opposed to non-value-adding activities, such as attending meetings which might be considered a waste of nurses’ time (Storfjell et al 2009, Antinaho et al 2015).
Another example is where nurses are encouraged to report an adverse incident whether or not it results in harm. The time involved in completing such reports is regarded as value-adding because it enables the NHS to learn from mistakes and take action to keep patients safe (NHS England 2022). Conversely, taking a similar amount of time to sit with a person with cognitive impairment may not fit into a ward’s busy routine (Prato et al 2019), so could be regarded as a non-value-adding activity. This is despite evidence that providing care to a person with dementia requires more time and commitment from the nurse compared with other tasks (Kang and Hur 2021).
Those in positions of power can decide if time spent with a person with dementia is regarded as a positive or negative use of time. Decisions concerning the allocation of time are likely to be subjective and decided by those with authority in specific healthcare environments (Engleberg and Wynn 2010). Similarly, the use of time in healthcare teams is often governed by socially constructed formal and/or informal rules, which can have an important role in how a nurse’s work is perceived (Jones and Yoder 2015). For example, if a nurse completes a task within the allotted time they are likely to receive positive feedback from senior colleagues, reflecting the concept of ‘reward power’ outlined by French and Raven (1959). Conversely, if the task takes longer than the allotted time then the nurse is likely to receive a negative response. Such negative responses reflect the concept of ‘coercive power’, which involves the power to sanction others (French and Raven 1959).
Healthcare teams with a caring outlook can ‘set the mood’ for what an effective healthcare workplace culture should ‘look and feel like’ (Cardiff et al 2020). If nurses are to enhance the care provided to people with dementia and change the overall culture within dementia care, they need to be supported by their managers to reframe what is considered positive and negative use of time. This reframing involves regarding the time spent developing rapport and providing person-centred care to people with dementia as positive rather than negative. In turn, this reframing of the nursing workload can enable nurses to provide sufficient care without feeling pressured (Kang and Hur 2021).
Where nurses have only limited time to engage with people with dementia, it is important that they make those moments count. Krohne and Milburn (2019) provided a simile for these types of positive interactions, stating that they are like ‘dropping a stone into a pond’ with the consequences spreading outward like ripples. This simile emphasises how the positive or negative actions a nurse takes at the outset of a clinical episode can have a significant effect on how their relationship with the person with dementia will develop in the longer term (Krohne and Milburn 2019). Care interactions are more effective when people with cognitive impairment are given adequate time to engage in their care; however, when they are rushed or not listened to, or where healthcare staff focus only on clinical tasks, this can have a negative effect on the person’s emotional memory (Juhasz 2016).
It is important for nurses to remember that taking a few extra moments to consider the approach they need to take before starting any interaction can enhance the care experience for the person with dementia (Krohne and Milburn 2019). Furthermore, when the nurse takes a little more time to consider their approach, the person with dementia can become increasingly engaged, leading to a more effective interaction (Juhasz 2016).
Although there is a physical element to spending time with a person, being fully present is a unique skill that involves empathy and a caring attitude (du Plessis 2016). Empathy is defined as a person’s ability to be present with ‘what’s really going on’ for another person or themselves in the moment (Graham 2019). Benner and Wrubel (1989) argued that an individual’s ability to be present with another person and to acknowledge their shared humanity forms the basis of nursing as a caring practice.
In their daily work, nurses are subject to conflicting priorities which can interfere with their efforts to be truly present with patients (Norman et al 2016). Often it is the nurse’s own concerns and preoccupations that limit their ability to have an empathic understanding of another person (Kitwood 1997). However, providing an authentic presence does not have to be overly time-consuming (Boeck 2014). Using the technique of ‘centring’ before engaging with a person with dementia can enable the nurse to set aside clinical tasks or concerns and focus on being attentive to the person’s needs (Boeck 2014, Norman et al 2016). Centring involves taking a moment to close one’s eyes and take a few deep breaths before making contact with another.
Where the nurse is able to provide an authentic presence when caring for a person with dementia, this can promote a human connection, demonstrate sensitivity and openness and enable the focus of the interaction to be on what matters to the person (Watson 2008).
Buber’s (1970) ‘ways of being’ theory outlined two ways of relating to others – ‘I-It’ and ‘I-Thou’ – which, if applied appropriately by nurses, can contribute towards the development of an authentic presence. Kitwood (1997) examined these two ways of being in the context of dementia.
The I-It way of being implies coolness and detachment. I-It involves the nurse engaging with a person with dementia in a distant, non-involved way that does not fully recognise their individuality (Dewing 2019). This I-It way of being reflects elements of Kitwood’s (1997) malignant social psychology theory, which includes the concept of objectification whereby a person with dementia can be treated as if they were a ‘lump of dead matter’. Kitwood’s (1997) theory also includes the concept of invalidation, meaning undermining the person with dementia by failing to acknowledge the subjective reality of their experience, especially what they are feeling, thereby reinforcing their anonymity.
When a nurse does not value a person with dementia and does not communicate effectively with them, this has a negative effect on the person’s experience (Prato et al 2019). This can contribute towards Bandura’s (2002) theory of moral disengagement, where nurses start to ‘reconstruct’ their conduct and justify negative actions by blaming environmental factors, such as low staffing levels or lack of equipment. In addition, this reconstruction of their conduct can cause nurses to dehumanise people with dementia, treating them more ruthlessly than those that they consider have ‘more human’ qualities (Bandura 2002).
Social interactions support the development of meaningful relationships (Chenoweth et al 2009). The I-Thou way of being involves ‘reaching out’ towards the other person and is the foundation of treating others as people rather than objects (Kitwood 1997). Taking an I-Thou approach means attempting to relate to the other person in a genuine human exchange (Dewing 2019) and reflects Kitwood’s (1997) notion of ‘validation’, which seeks to understand another person’s frame of reference and gain an empathic understanding of them. This kind of positive communication with nurses adds immeasurably to the experience of a person with dementia (Prato et al 2019). The person with dementia can make a new memory that a particular person was kind, even if their ability to recall the precise details of the encounter is not intact (Sabat 2019). Using the I-Thou approach can enhance this process and have a positive effect on the well-being of the person with dementia.
Mentalising develops the concept of I-Thou and is the process by which people use subjectivity and mental processes to make sense of each other and themselves (Bateman and Fonagy 2010). The technique of mentalising has most commonly been used in people with mental health issues, such as personality disorder, anxiety and depression (Bateman and Fonagy 2010, Lemma et al 2011), but more recently it has started to be used in dementia care (McEvoy et al 2019).
Mentalising enables the nurse to be more ‘in touch’ with what they are thinking and feeling and to take note of how the environment, time pressures and the behaviour of the person with dementia may be affecting the nurse’s interaction with them (Bray and Janner 2014). The nurse can then adapt their approach to ensure the time they spend with the person is not affected in a negative way by their thoughts and feelings. They can do this by pausing, reflecting and reconnecting with their own ‘state of mind’ (McEvoy et al 2019) and by being attentive to the mental state of the person with dementia (Bateman and Fonagy 2010). By attempting to understand what a person with dementia may be thinking or feeling, the nurse will be in a better position to appreciate the person’s perspective and work out how best to resolve any situation (Bray and Janner 2014). This is particularly important when the person with dementia is trying to communicate an unmet need (Cohen-Mansfield et al 2015).
Using this mentalising approach can enhance the nurse’s ability to deliver personalised care in a nuanced way (McEvoy et al 2019). An understanding of the mentalising approach is essential in nurses’ interactions with the person with dementia, particularly when these are likely to be time limited. Conversely, non-mentalising responses may be a cause of misunderstanding and emotional disengagement between the nurse and the person with dementia (McEvoy et al 2019), with the nurse’s negative emotions acting as a barrier to compassionate care (Bickford et al 2019).
Time is a valuable commodity in dementia care. A nurse’s ability to provide high-quality care to people with dementia can be affected by time-related environmental factors. Nurse managers need to develop a culture where time spent with a person with dementia is regarded as positive and value adding. To maximise the time spent with a person with dementia, the nurse should incorporate the principles of the I-Thou way of being and the concept of mentalising into their practice. Using these approaches to create an authentic presence will enhance the experience for the person with dementia and the nurse’s emotional well-being.
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