Background

Dementia is an overarching term which includes a wide range of neurocognitive conditions, all of which share the same main symptom of declining mental function caused by physical changes in the brain (American Psychiatric Association (APA) 2013, National Institute for Health and Care Excellence (NICE) 2018). The care of people with dementia has changed over the years with increased understanding and awareness of the different types and the needs and experiences of people with dementia and their carers.

Delirium differs from dementia, in that it is rapid in onset, encompasses global cognitive dysfunctions, may fluctuate and can often be prevented and treated (Alzheimer’s Society 2023, NICE 2023). Delirium is identified in the Diagnostic and Statistical Manual of Mental Disorders Fifth edition (DSM-V) (APA 2013) and in the International Classification of Diseases 11^th Revision (ICD-11) (World Health Organization 2022) as a mental health condition often precipitated by a general medical condition, intoxication or withdrawal from intoxicating substances or medicines. Delirium should therefore be regarded as a medical emergency and the care and treatment of a person with delirium should consider any physical symptoms alongside the psychological factors involved (Wick and Zanni 2010, Steis and Fick 2012).

Delirium superimposed on dementia is a complex convergence of the two conditions occurring at the same time (Kolanowski et al 2011a, Morandi and Bellelli 2020). Despite being a potentially fatal medical emergency (Kolanowski et al 2011b), and a relatively common condition (Gibb et al 2020), delirium superimposed on dementia is often missed or misdiagnosed as worsening dementia if the acute presentation of deteriorating cognition or changes in the person’s behaviours are not recognised.

There has been a rapid increase in the availability of tools and scores, such as the 4AT Rapid Clinical Test for Delirium (MacLullich 2023) and the Single Question in Delirium (SQiD) (Sands et al 2010), designed to support the recognition and assessment of delirium in a range of settings and thus reduce the risk of missed diagnosis. However, although nurses’ experience of care may be influenced by such assessment tools or scores, it is also influenced by the way they ‘know’ the people they care for.

Carper (1978), in her influential work Fundamental Patterns of Knowing in Nursing, described four main ways of knowing:

In the UK, people whose main care needs are driven by dementia are often cared for in mental health settings, such as mental health hospitals or specialist care homes in which nurses are predominantly mental health nurses. While this supports the delivery of specialised mental healthcare, it could be argued that, compared with nurses in other fields of nursing, mental health nurses may be less aware of people’s physical health needs and less experienced in addressing those needs. However, in the author’s view, using aesthetic knowing may feel more natural or intuitive to mental health nurses than using assessment tools or scores to recognise, and act on, changes in a person’s condition that may indicate delirium superimposed on dementia.

This article describes one main finding from a study of mental health nurses’ experiences of caring for people with delirium superimposed on dementia and their use of aesthetic ways of knowing in their delivery of care, which was undertaken as part of the author’s PhD (Pryor 2021). The complete study can be accessed at nrl.northumbria.ac.uk/id/eprint/46715/

Aim

To illuminate the experiences of mental health nurses caring for people with delirium superimposed on dementia and to explore how mental health nurses ‘know’ the people they care for using ‘aesthetic ways of knowing’.

Method

Findings

This article discusses one main finding from the original study (Pryor 2021) which suggested that overall, in the context of recognising and caring for people with delirium superimposed on dementia, participants favoured aesthetic ways of knowing.

Discussion

The finding reported in this article emphasises that participants placed greater value on their experiences and on subjective and reflective components of knowledge than on assessment tools or scores and on objective components of knowledge in isolation to recognise delirium superimposed on dementia in their patients. Participants’ practice was informed more by knowledge gained through aesthetic and personal ways of knowing than by knowledge gained through empirical ways of knowing.

In second-generation activity theory, the object is the reason for undertaking an activity (Kaptelinin 2005). The object – in this instance the reason for undertaking a nursing activity – appeared to be motivated by participants’ desire to know people in their care as individuals. Participants demonstrated an affinity with aesthetic and personal ways of knowing, as defined by Carper (1978). These ways of knowing permeated and influenced participants’ care delivery, which echoes Barker and Buchanan-Barker’s (2004) assertion that nurses must have an empathy with, and an awareness of, their patient as a person to provide person-centred care.

Knowing what it is to be that person and taking time to understand them is central to the mental health nursing premise of care (Barker and Buchanan-Barker 2004).

The concept of knowing the person is not new and forms the hypothetical foundation of nursing care. The contemporary nursing ethos has moved away from ‘patient-centred care’, which has connotations of making the patient’s life functional, towards the concept of personhood (Kitwood 1997) and person-centred care, which implies supporting the person to live a meaningful life (Eklund et al 2019). Part of the ethos of person-centredness is to recognise how nurses’ personal attributes, the care environment and activities for people with dementia influence care provision (McCormack and McCance 2006). It could be argued that the increase in the use of assessment tools and scores may detract nurses from using aesthetic ways of knowing to recognise changes in people’s health status. It is essential, therefore, that nurses uphold the principle that care should be individualised and that they value the person receiving care irrespective of their health condition, to ensure people with dementia who are at risk of delirium superimposed on dementia receive person-centred care (Kitwood 1997, Clissette et al 2013).

The finding reported in this article demonstrated that participants had a strong sense of person-centred care and appeared to favour information collected informally through aesthetic ways of knowing to support their assessments and care planning. This supports Delaney’s (2006) and MacNeela’s (2010) assertions that mental health nurses favoured informal information over formal information across a wide range of clinical settings and conditions. In addition, the present study found that participants’ use of formal assessment tools or scores was secondary to their knowledge of the person as an individual. This could suggest that they were uncomfortable with ‘reducing’ a person to a number or score – which removes the focus on the person as an individual – for the purpose of using a clinical pathway.

In the present study there appeared to be low levels of use of assessment tools and scores among participants when they suspected delirium superimposed on dementia compared with using their own knowledge of the person. Assessment tools and scores have a place in high-quality delirium assessment, but the outcome or goal of using such tools must be seen by clinicians as appropriate and useful in supporting care provision (Bryce et al 2018). In a Danish study of 23 hospital nurses’ experiences of using delirium guidelines, participants did not perceive such guidelines as useful and reported feeling frustrated by the organisation’s requirement for habitual screening of patients (Emme 2020). Participants described the guidelines as ‘a paper to make some marks on’ and their use as being mandated by the organisation, rather than dictated by patient need or usefulness (Emme 2020).

Contemporary delirium assessment tools and scores, such as the SQiD (Sands et al 2010) and the 4AT (MacLullich 2023), place an emphasis on recognising and identifying changes in a person’s behaviour or personality, which requires a level of knowledge of the person and not solely relying on clinical tests or laboratory results. However, combining these factors can ensure a robust assessment of delirium superimposed on dementia and subsequent care planning. For example, NICE (2023) advises clinicians to ‘observe, at least daily, all people in hospital or long-term care for recent (within hours or days) changes or fluctuations indicating delirium’. NICE (2023) also states that these observations may be ‘reported by the person at risk, or a carer or relative’ and that ‘if any of these changes are present the person should have an assessment using an appropriate tool’.

The mention of ‘a carer or relative’ implies that a level of personal knowledge is useful in the assessment of delirium, and a parallel can be drawn with the use of aesthetic ways of knowing by participants in this study. Additionally, in contemporary health and social care systems, where nursing teams may include temporary staff, it should not be assumed that all mental health nurses will have personal knowledge of all the people they care for. Participants in this study mentioned the use and usefulness of ‘formulations’ to share knowledge gained through aesthetic ways of knowing across the care team. Such ‘formulations’ may offer one solution to workforce issues, when not everyone on the team has one-to-one personal knowledge of every patient.

While nurses’ aesthetic ways of knowing people is valuable in delirium assessment and care, a balance must be struck between aesthetic and empirical ways of knowing to ensure optimal practice. For example, the minimal use of assessment tools and scores could result in a lack of a ‘shared language’ between the people involved in an individual’s care, such as nurses, doctors, physiotherapists, activity coordinators and family members. If there is no shared language for them to describe their observations, vital information may be missed. It is important that care teams have a shared language to support collaborative working and ensure patient safety (Rabøl et al 2011, Stühlinger et al 2019). This does not mean, however, that nurses should change their method of presenting their assessments. If nurses attempt to ‘medicalise’ the language they use, for example, this could risk losing the quality of understanding of the patient as a person.

Effective prevention, recognition, assessment and care of the person with delirium superimposed on dementia require a comprehensive knowledge of the person as an individual. Therefore, mental health nurses’ knowledge of the people they care for, and their understanding of people’s health status, should be appreciated on an equal level with formal assessment tools and scores.

Conclusion

The study finding discussed in this article suggests that participating mental health nurses’ practice in relation to delirium superimposed on dementia is informed by aesthetic ways of knowing the people they care for. Participants favoured this type of personal and intuitive knowledge over the use of formal assessment tools and scores. However, although aesthetic ways of knowing people should be valued and celebrated, combining these with the use of formal assessment tools and scores can enhance patient safety in the context of assessing people for delirium superimposed on dementia. Mental health nurses may need support to enhance their ability to translate aesthetically gained knowledge within the context of evidence-based assessment tools and scores for delirium superimposed on dementia and to translate the outcomes of such tools within the context of their aesthetically gained knowledge.