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• To identify the importance of optimal knowledge and understanding of dementia among hospital staff
• To learn about nursing students’ experiences of dementia care on acute hospital wards
• To increase your awareness of the need for early socialisation of nursing students in dementia care
Background An ageing population with a range of co-morbidities means the number of hospital admissions of older people with dementia is increasing. People with dementia can find acute hospital settings unsettling and they need to be cared for by a workforce skilled and knowledgeable in dementia care.
Aim To explore nursing students’ experiences of, and socialisation in, dementia care in the acute hospital setting in England through a secondary qualitative analysis of data from a phenomenological study of nursing students’ cultural beliefs around, and understanding of, dementia.
Method Data from ten focus groups with 81 undergraduate nursing students at two universities in the south of England were subjected to content analysis. This was a secondary qualitative analysis of data retrieved from an earlier study.
Findings Two categories emerged: ‘exposure to dementia care’ and ‘socialisation in dementia care’. Participants often felt unprepared to care for patients with dementia and their experiences were negatively affected by staff’s views of patients with dementia, who were often considered challenging to manage. Participants also encountered specialist dementia nurses who enabled them to learn more about person-centred dementia care.
Conclusion Optimal dementia care knowledge and skills can contribute to enhanced patient outcomes and positive attitudes towards older people’s care. To reduce deficits in dementia care education, nurses need regular continuing professional development in dementia care, higher education institutions need to commit to developing dementia care in their curricula, and students need to be socialised in dementia care earlier during undergraduate nurse education.
Nursing Older People. doi: 10.7748/nop.2021.e1312
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Cronin C, Ojo O (2021) Nursing students’ experiences of, and socialisation in, dementia care in the acute hospital setting. Nursing Older People. doi: 10.7748/nop.2021.e1312
Acknowledgements The authors would like to thank the students and site coordinators involved in the primary study
Published online: 05 May 2021
The prevalence of dementia is increasing globally with ten million new diagnoses each year and a predicted 135.5 million people living with dementia by 2050 (World Health Organization (WHO) 2020). In the UK it is estimated that 850,000 people live with dementia and that the figure will rise to more than one million by 2025 (Alzheimer’s Society 2018). Dementia is a progressive terminal condition and an umbrella term for a broad set of signs and symptoms – such as memory loss and challenges with thinking, language and problem solving – caused by a number of diseases (WHO 2020), which include Alzheimer’s disease, dementia with Lewy bodies, frontotemporal dementia and vascular dementia (Alzheimer’s Society 2018). People with dementia require a person-centred approach to their care that maintains their personhood irrespective of cognitive impairment (Kitwood 1997).
In 2017-18, a little more than 40,000 patients with dementia stayed in hospitals in England between one month and one year (Torjesen 2020). Prolonged hospital admission can result in a deterioration of physical health and of the signs and symptoms of dementia (Care Quality Commission (CQC) 2018). Prolonged hospital admissions place a large financial burden on hospitals, while deterioration of mental and physical well-being in patients with dementia often results in discharge to care homes (Dewing and Dijk 2016). In the UK, more than 90% of people living with dementia have another health condition, for example hypertension, diabetes or depression (Browne et al 2017). Common reasons for their admission to hospital include preventable conditions such as hip fracture, urinary tract infection or chest infection (Scrutton and Brancati 2016). The likelihood of nursing students encountering people with dementia while on placement in the acute setting is therefore high.
Dementia education in UK nurse training programmes is guided by the Dementia Training Standards Framework (Skills for Health et al 2018). The framework details the essential skills and knowledge required for dementia care and supports the development and delivery of appropriate and consistent dementia education and training for the health and social care workforce. However, research indicates that, among the UK healthcare workforce, knowledge and skills to care for patients with dementia are inadequate and there is a belief that dementia care is challenging (Baillie et al 2016). Inadequate knowledge of dementia care has been associated with a lack of clinical training hours (Kwok et al 2011).
Early socialisation of nursing students in the workplace is an essential component of nurse education (Young et al 2018). Brim and Wheeler (1966) defined socialisation as ‘processes by which persons acquire the knowledge, skill and dispositions that make them more or less effective members of their society’. In nursing, professional socialisation involves nursing students internalising the profession’s values and norms, such as treating people with kindness, respect and compassion, providing person-centred care and advocating for the vulnerable (Curtis et al 2012). This is an important aspect of nurse education, with practice supervisors acting as influencers (Wilson et al 2017, Nursing and Midwifery Council (NMC) 2018a).
Evidence suggests that nursing students’ negative experiences of caring for people with dementia are linked to unfamiliar placements, unsupportive mentors, and the physical environment and organisational culture of hospitals (Ryan et al 2018). Some researchers have suggested that early placements in care settings for older people, together with dementia training, can positively affect nursing students’ experiences (Robinson and Cubit 2007, Skaalvik et al 2010). However, others have identified that negative attitudes towards people with dementia developed following placements in care settings for older people (Algoso et al 2016). A literature review of undergraduate nursing students’ attitudes to, and perspectives on, working with older people showed that only a minority believed older people’s care was considered an appropriate career choice (Neville and Dickie 2014) and a cross-sectional view of 886 undergraduate nurses from eight Australian universities showed that many would actively avoid that specialty upon qualifying (Neville 2016).
A lack of socialisation in dementia care can result in nursing students developing ageist attitudes and suboptimal experiences during clinical placements can negatively affect the future nursing workforce (Frost et al 2016). Further research is required into how dementia care can be integrated into acute care settings and how nursing students can be socialised in dementia care earlier in their training.
This article reports the findings of a study that explored nursing students’ experiences of, and socialisation in, dementia care in acute hospitals in England. The authors conducted a secondary qualitative analysis of data retrieved from a phenomenological study of nursing students’ cultural beliefs around, and understanding of, dementia on three continents (Brooke et al 2019).
To explore nursing students’ experiences of, and socialisation in, dementia care in the acute hospital setting in England through a secondary qualitative analysis of data from a phenomenological study of nursing students’ cultural beliefs around, and understanding of, dementia.
Data were retrieved from Brooke et al (2019), who had collected data in the UK through ten focus groups with first year (n=54) and third year (n=27) undergraduate nursing students at two universities in the south of England. The focus group interviews lasted approximately 45 to 60 minutes and were conducted at the end of 2016 at the two universities. Five focus groups took place at each university. Focus group participants came from diverse cultural backgrounds. Table 1 shows the number of focus group participants from each university according to study year. Focus groups develop a natural environment in which nursing students can share and discuss their experiences with their peers (Kitzinger 1994).
| Study year | Number of participants | ||
|---|---|---|---|
| University 1 | University 2 | Total by study year | |
| First | 7 | 10 | First year: 54 |
| First | 7 | 7 | |
| First | 8 | 7 | |
| First | 0 * | 8 | |
| Third | 9 | 11 | Third year: 27 |
| Third | 7 | 0 * | |
Originally, 12 focus groups were planned but only ten took place (Brooke et al 2019)
The authors of this article used content analysis to undertake a secondary analysis of UK data retrieved from Brooke et al (2019). Secondary analysis enables further exploration of a dataset by investigating an emergent issue (Long-Sutehall et al 2010). Content analysis is a systematic process comprising decontextualisation, recontextualisation, categorisation and compilation (Bengtsson 2016). Each stage is performed numerous times to interpret data and preserve the quality and trustworthiness of the process (Silverman 2015).
For this secondary qualitative analysis, data from the ten focus groups were extracted from the primary dataset (Brooke et al 2019) and analysed using content analysis to maintain quality, transparency, consistency and meaning (Silverman 2015). The transcripts were reviewed independently line by line to identify data relating to each category. This systematic process produced a descriptive account from participants (Patton 2014). Emerging themes were developed methodically, categorised and coded. Each category was reviewed with illustrative narratives to describe and interpret the lived experiences of participants. To increase validity, each author was separately involved in the analysis and the two authors subsequently discussed their findings to reach consensus.
Ethical approval for the primary study (Brooke et al 2019) had been obtained from the participating universities’ research ethics committees. Nursing students had received information sheets, had been given time to discuss the study before signing a consent form, and the voluntary nature of participation had been emphasised. Confidentiality and anonymity had been maintained, except when there might have been concerns about the safety of students or patients.
Content analysis identified two overarching categories with two subcategories each:
Narratives from participants are used below to illustrate each category and subcategory.
Participants believed they had a general awareness of what dementia was, but often felt unprepared to care for patients with dementia. They observed how unsettled patients with dementia were and the effects on patients of being in a different environment than their home. They witnessed how busy nurses were and how little time there was to spend with patients with dementia on acute hospital wards.
Participants discussed how patients with dementia were cared for on an individual basis because they were perceived as being ‘at risk’ since they ‘get up and they would like to walk’ (focus group 1, Participant 5). Participants regularly mentioned a lack of interaction between patients with dementia and nurses, and noted that healthcare assistants or nursing students with little or no training in dementia care were often left to care for these patients:
‘They [staff] just sat there reading a magazine and completely ignored the patient.’ (Focus group 1, Participant 5)
‘They [patients] are put with someone that probably has not been trained who just stays with that person.’ (Focus group 3, Participant 3).
Participants discussed how all staff needed more skills in dementia care and awareness of dementia in acute hospital settings. Participants spoke confidently about the interventions they provided, but were frustrated by the lack of amenities to support interactions with patients:
‘I think a lot of wards I have been on do not actually use a lot of dementia interventions such as those muff things.’ (Focus group 1, Participant 2)
‘I do find it frustrating that in a lot of wards they don’t find ways to interact with patients with dementia. If you ask for a rummage box, they would not know what it is or they would say “It’s been taken and not replaced”. There was no facility to interact on any level or just think outside of the box, eg pictures, names, dancing.’ (Focus group 1, Participant 1).
One participant expressed the idea that nursing students had the advantage of having received more education in dementia care and that, because of their education, they could act as champions for patients with dementia. Participants believed that having knowledge of dementia influenced the care provided and found that, on dementia-friendly wards, care was person centred:
‘We are taught the difference between dementia, delirium and depression and what to look for… we are taught it is not conducive for all patients with dementia to be on an acute ward.’ (Focus group 1, Participant 1)
‘They used a “forget me not” symbol with every patient admitted who had dementia as soon as they came in. I thought that the care was really good for patients with dementia.’ (Focus group 2, Participant 6).
A recurrent theme was the lack of time and resources such as staff, equipment and space, which negatively affected patient care. Participants commented on how nursing staff they worked with had little or no time to spend with patients with dementia and moved from one patient to the next prioritising care tasks:
‘Qualified staff don’t have the time, do they, and I think that is where the frustration comes in and that frustration rubs on the patient and then the patient becomes agitated and it is like a vicious circle.’ (Focus group 2, Participant 1)
‘I have got 20 other patients who I have got to do this for, which is horrible, it is a horrible way to see it, but I think that might be how it is in some cases.’ (Focus group 2, Participant 3).
A phrase used by participants when discussing socialisation in dementia care was ‘dementia is not seen’. Participants’ perceptions were that nursing staff had negative views of patients with dementia, who they often considered challenging to care for and felt they did not have time to spend with. These negative views negatively affected participants’ experiences while on placement.
Participants discussed how dementia is perceived by staff in hospitals. One described ‘pre-empting’, whereby all patients with dementia are believed to be, or described as, for example, aggressive. With pre-empting comes stigma and labelling, which can remain attached to patients during their whole hospital stay:
‘I have noticed as well, along with the eye roll, the stigma because they will say “Oh yeah, they have dementia and they are very aggressive make sure you watch them, make sure you double up”.’ (Focus group 1, Participant 1)
‘I spoke to one of the nurses about it on my ward and she said that once you put that label on someone it travels with them.’ (Focus group 3, Participant 2).
Participants extrapolated nurses’ beliefs about dementia from the way they described patients with dementia. Participants perceived that nurses did not understand that patients’ behaviours were due to their condition:
‘So and so from this ward said, “They are not that bad, but look at them, they are wandering all over the place”.’ (Focus group 4, Participant 2)
‘The night shift had told me how bad he had been and how aggressive he had been, but it turned out nobody had actually listened to him, he thought he had to go for a job interview.’ (Focus group 4, Participant 3).
Participants shared typical experiences of how nurses discussed patients with dementia, often in a negative manner, for example describing them as ‘blocking beds’ or ‘being high risk’. Nursing students seldom found positive role models:
‘I do think some nurses see it [dementia] as […] especially in general wards not focused on dementia and see it as a burden.’ (Focus group 2, Participant 1)
‘A lot of the time you find that a patient with dementia automatically gets put on the falls risk.’ (Focus group 2, Participant 3).
Nurses’ perceptions of patients with dementia could affect nursing students’ experiences during placements. Typically, patients with dementia were labelled negatively and nurses made assumptions about them, using non-verbal communication to display their feelings. During handovers, it was often the patient’s condition that was identified, not the person or their care needs:
‘Some of the nurses just assumed if they [patients] had this type of behaviour, then this person had dementia and I think this is really bad.’ (Focus group 1, Participant 1)
‘I have seen some handovers where they have said “Bed seven has got dementia” and the eye roll.’ (Focus group 1, Participant 9).
Participants regularly encountered patients with dementia who had been in hospital for a long time and were waiting for a long-term care placement, for example in a nursing home. This was an aspect of care they believed was failing people with dementia:
‘They [patients] are stuck in hospital waiting for social placement which goes on for weeks and they are very nice people but come the third week they just want to go home, and I think that is what is letting people with dementia down.’ (Focus group 4, Participant 2).
However, participants also reported examples of effective practice and encounters with specialist dementia nurses who gave them opportunities to learn more about dementia, provide person-centred care and use specific and appropriate interventions:
‘I think it depends on the ward … they have on the board with the patients’ names on a symbol, a little flower, that tells us that there is a dementia patient.’ (Focus group 1, Participant 2)
‘I think it is different when you have a specialised dementia nurse. They are used to the ways and the behaviours and they have time. They have time to sit down with the patient and have time to get to know the mannerisms.’ (Focus group 2, Participant 3).
Participants’ experiences were directly influenced by their placements. However, despite some challenging experiences, the findings of this secondary data analysis appear to contradict those of other international studies in which nursing students described older people’s care as less desirable than other areas of nursing (Smith et al 2017), repetitive and unchallenging (Gould et al 2013) or undemanding and depressing (Carlson and Idvall 2015). Participants in this study took every opportunity to undertake additional education and attend dementia awareness training. They described themselves as having the advantage of having received more education in dementia care than their qualified colleagues. This supports the call for enhanced training in dementia care for the existing healthcare workforce and for significant changes in the environment and organisational culture of acute care settings (Digby et al 2017).
Participants described a lack of resources to support patients with dementia in acute care settings. This is supported by the existing literature, in which time constraints and lack of staff, equipment and space are often cited as issues when caring for patients with dementia in acute hospitals (Ryan et al 2018). Additionally, nurses often feel frustration and exhaustion when providing care for patients with dementia, which can lead to suboptimal job satisfaction and potentially burnout, resulting in inadequate patient outcomes (Brown and Bright 2017). ‘Enriched’ work environments where older people’s care is valued can promote a sense of belonging, purpose and community among staff (Brown and Bright 2017), while ‘impoverished’ work environments can lead to suboptimal standards of care and negative perceptions of older people (CQC 2018). Participants described acute hospital settings as ‘completely different’ for patients with dementia from clinical areas that specialise in dementia care and as much less conducive to optimal care. Hospitals are busy environments and ‘occupancy targets’ contribute to high patient turnover, which is unsettling for patients with dementia (Digby et al 2017). The physical environment and organisational culture of acute hospitals, deficits in knowledge and skills, and negative attitudes of staff can lead to nursing students struggling on placements (Baillie et al 2016).
Participants perceived that nurses dealt with the issue that had prompted the patient’s admission instead of considering the person themselves, describing this as ‘dementia is not seen’. The lack of time and the pace of work, combined with the tension caused by trying to prioritise acute care tasks, mean that person-centred dementia care is often lacking; it is also complicated by a lack of knowledge of what dementia is (Dewing and Dijk 2016). This can result in negative experiences for patients with dementia during their hospital stay, with staff not respecting their preferences and needs (CQC 2018). Observing such practices during placements can negatively influence nursing students’ attitudes towards patients with dementia.
Many patients with dementia lose their independence during a hospital stay and are unable to return home, which can be challenging for families while also resulting in a heavy burden for the health and social care system (Waller and Masterson 2015). Participants described how qualified staff on acute hospital wards considered patients with dementia as being challenging to manage, requiring longer hospital stays and lengthy discharge planning. This is supported by Digby et al (2017), who interviewed 29 nurses working with patients with dementia in geriatric rehabilitation hospitals in Australia. Digby et al (2017) found that nurses viewed that group negatively when they were awaiting social care and considered them ‘unworthy’ because their discharge was delayed.
Nursing students require early preparation for dementia care and need to be supported by informed staff in practice (Baillie et al 2016). In addition, dementia-friendly environments can improve patient care in acute hospital settings (Waller and Masterson 2015).
Cherry et al (2016) found that early encounters of adolescents and adults with older people encourage positive attitudes towards ageing. Carlson and Idvall (2015) and Brooke et al (2017) recommended that nursing students should be exposed to older people’s care during undergraduate education, and Neville (2016) argued that exposure to older people’s care is needed in education and clinical practice to enhance positive ageism. In its standards of proficiency for registered nurses, the NMC (2018a) states that ‘registered nurses provide leadership in the delivery of care for people of all ages and from different backgrounds, cultures and beliefs’ and that ‘they provide nursing care for people who have complex mental, physical, cognitive and behavioural care needs, those living with dementia, the elderly, and for people at the end of their life’. However, the dementia content of nurse training programmes is variable and in-depth coverage often relies on the presence of experienced and committed lecturers (Collier et al 2015).
Some authors still report that dementia education in preregistration healthcare programmes is inadequate (Alushi et al 2015). While there are many challenges, such as overloaded curricula and a lack of lecturers in older people’s care, higher education institutions need to commit to enhancing dementia education for preregistration nursing students (Collier et al 2015).
Participants believed they had adequate knowledge of dementia and considered themselves as ‘champions’ for patients with dementia on acute hospital wards. However, the literature continues to report a lack of education and training for nurses working with older people (Faronbi et al 2017), negative attitudes towards older people’s care (Oyetunde et al 2013) and nursing students’ bias about caring for this population (Cronin and Brooke 2019).
To enhance the understanding of the ageing process and of dementia, dementia education and early socialisation in dementia care need to be embedded in undergraduate nurse education programmes, both at university and in clinical practice. The stereotypes and stigma attached to dementia (Alzheimer’s Society 2018) need to be addressed in nurse education and practice (Cronin and Brooke 2019). An optimal knowledge of older people’s care can positively influence nursing students’ perceptions and attitudes (Faronbi et al 2017), while mentors and peers can be important positive role models in promoting that specialty as a career choice (Wilson et al 2017).
Preparing nursing students to meet the needs of the growing number of older people is one of the main challenges for nurse education. If nursing students are provided with relevant preparation and support, they can have richer learning experiences, deliver better quality care and develop more positive attitudes towards older people’s care (Koh 2012).
While undergraduate nursing curricula place more emphasis on acute and critical care, the NMC (2018b) states that its registrants are expected to prioritise people, ‘make sure that people’s physical, social and psychological needs are assessed and responded to’ and ‘pay special attention to promoting wellbeing, preventing ill-health and meeting the changing health and care needs of people during all life stages’. Garbrah et al (2017) suggested that there is a need for age‐friendly curricula and for nurses who specialise in gerontology to act as mentors and role models. There is also a need for a greater understanding of the culture of the nursing workforce and of dementia care (Brooke et al 2017).
Enhanced liaison with stakeholders is needed to develop clinical placements that can offer time and supervision to support nursing students to be socialised in dementia care. This is identified by professional bodies such as the NMC (2018a), which has made dementia training mandatory in nursing curricula, although there is still variation in the quality and depth of its delivery (Baillie et al 2016).
Despite the transparent research process, the study findings cannot be generalised. Data were originally collected for a primary study and may provide limited answers in this secondary analysis. The findings may have been influenced by the original question schedule and participants’ interest in dementia research.
Descriptive accounts of nursing students’ experiences of socialisation in dementia care in acute hospital settings show that some students feel unprepared and unsupported to care for patients with dementia. People with dementia and co-morbidities can find acute hospital settings unsettling and they need to be cared for by a workforce skilled and knowledgeable in dementia care. Nurse education and practice leaders need to support the socialisation of nursing students in dementia care earlier in their education to ensure that dementia care knowledge and skills are embedded in their practice.
• An optimal knowledge of dementia can contribute to the development of positive attitudes towards older people’s care
• Nursing students need to be socialised in dementia care earlier during undergraduate nurse education
• Higher education institutions need to commit to developing person-centred dementia care in their curricula
• Regular continuing professional development in dementia care and dementia-friendly environments would enhance dementia care in acute hospitals
• Positive role models for patient-centred dementia care are needed on acute hospital wards
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