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Title

Being a dissertation submitted in partial fulfilment of the

requirements for the degree of
Bachelor of Science in

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For module Click or tap here to enter text.

in the University of Hull, Faculty of Health Sciences

by

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Month Year
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Acknowledgements
2-3 paragraphs to acknowledge those who supported you. If you only acknowledge one person,
change the heading to Acknowledgement.
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Abstract
The current paper is segmented into three sections wherein the first section focuses on

offering a critical review of academic literature regarding how nurses care for patients with

dementia and how this treatment can be improved. In reviewing numerous literary works,

research evidence was able to recommend best practices for how nursing practice can be

improved concerning individuals who experienced dementia. This first section helps answer

the research question at the start of it, which questions the conditions and knowledge needs

of nurses who care for individuals with dementia. The second portion of the current

dissertation then offers a critical discussion of the obstacles in the way of such

recommendations. This critical discussion is followed up with strategies on how resistance to

change being implemented can be overcome utilizing change management models. The last

section, Part C, offers a critical self-reflection on what the authors have learnt through the

course of this literature review and discussion as well as how the teachings of the module

have impacted them.

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Contents
Acknowledgements............................................................................................................................i

Abstract.............................................................................................................................................ii

Contents..........................................................................................................................................iii

Part A: Critical appraisal of literature using a systematic approach.......................................................I

A.1 Introduction................................................................................................................................I

A.2 PICO Framework.....................................................................................................................II

A.3 Research Question..................................................................................................................II

A.4 Search Strategy.......................................................................................................................II

A.5 Background.............................................................................................................................VI

A.6 Nursing.....................................................................................................................................VI

A.6.1 Nursing Dementia...........................................................................................................VII

A.7 The Nurse's Knowledge and Responsibility......................................................................VIII

A.7.1 The Specialist Nurse's Knowledge and Responsibility...............................................IX

A.7.2 The Specialist Nurse's Core Competence - Theoretical Starting Point.....................X

A.8 Nurse Who Cares for People with Dementia....................................................................XIII

A.9 Conclusion................................................................................................................................XIV

A.10 Recommendations..................................................................................................................XV

A.10.1 Need for Knowledge Development.........................................................................XVIII

Part B: Implementation of an evidence-based recommendation with application of theoretical

perspectives on managing change......................................................................................................XX

B.1 Rationale.................................................................................................................................XX

B.2 Organizational Structure.......................................................................................................XX

B.3 Change and Improvement Work.........................................................................................XXI

B.4 Team Collaboration............................................................................................................XXIII

B.5 Problems Nurses Face.......................................................................................................XXIII

B.5.1 Experience of Uncertainty..........................................................................................XXIV

B.5.2 Communication............................................................................................................XXVI
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B.5.3 Knowledge....................................................................................................................XXVI

B.6 Conclusion..........................................................................................................................XXVII

Part C: Critical reflection on peer teaching and evaluation of learning from the module................XXIX

C.1 Introduction............................................................................................................................XXIX

C.2 Conducting a Literature Review...............................................................................................XXX

C.3 Conclusion............................................................................................................................XXXIII

Reference list.................................................................................................................................XXXIV
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Part A: Critical appraisal of literature using a

systematic approach

A.1 Introduction

Nursing is a highly complex professional practice that necessitates specific attention

to not only the unique needs of each patient but also considerable competence, skill, and

knowledge from the professional in question – in essence leading the professional to abide

by the NMC Code (2019) which encourages prioritizing people, promoting trust and

professionalism, preserving safety, and practicing effectively. The current section, one of

three, offers a critical appraisal of the literature utilizing a systematic approach. The focus of

this work is the nursing care of people with dementia. In this regard, it should be noted that

nursing is integral to the healthcare system at large with the disease in focus, dementia,

affecting about fifty million individuals around the world with ten million new cases arising

every year, according to the WHO (2020). With such a large portion of the world population

being affected per year, it is important to understand how these individuals can be cared for

and supported and the factors that further complicate their illness.

Dementia is a collective name for several diseases where the common symptoms

stand for a clear deterioration of thinking ability and memory. The term dementia is only used

when these symptoms are persistent and have been present for at least six months and that

a dementia investigation has been performed (Thorogood, et al. 2018). Which symptom

develops depends on which parts of the brain are affected, therefore different dementia

diseases may have similar symptoms. Nine out of ten people experienced behavioral and

mental symptoms, Behavioral and Psychological Symptoms in Dementia (BPSD), at some

point during the disease, which means that such symptoms are common in all forms of

dementia (Livingston, et al. 2017).

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Compassion and understanding are the foundations of care. This is true in all

interactions between people, but dementia caregivers may find it particularly important.

Dementia patients, for instance, are concerned about losing track of their surroundings as

well as the time frame in which they have been living. Consider why you would feel and also

how you would like being handled if you were unexpectedly bewildered in a strange area,

unsure of year or even your own identity.

Nursing for dementia sufferers may be physically and mentally exhausting. The

importance of self-care cannot be overstated. It's crucial to share the load, delegate duties,

and take mental and physical breaks. It is critical to renew the soul to continue working and

delivering great care.

A.2 PICO Framework

P: Carers of people with dementia.

I: Cognitive-behavioural therapy counselling/case management general support training of

caregivers.

C: Relative to the traditional approach of nursing in a healthcare setting.

O: Improve patient outcomes but not remarkable change.

The above PICO framework acted as the basis for the research question presented below.

A.3 Research Question

The current review of academic literature was performed so as to answer the

research question that follows: How nurses’ practice can help patients who experience

dementia be improved?

A.4 Search Strategy

The current work was based on an extensive search of the literature in which a

number of academic databases were accessed. These databases included Google Scholar,

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JStor, PsycINFO, NCBI, MEDLINE, and CHINA wherein a combination of the following

keywords was used, with the Boolean operator AND being used to combine them into

various combinations:

 Nursing

 Healthcare

 Dementia

 Care

 Patient-Centered

 Collaboration

 Hospital

It should then be taken into account that these keywords, in spite of them being

segmented as such, were all combined with the term nursing – as this profession was the

primary point of focus of the current review. However, truncation was not used. Additional

searches were performed on the WHO’s website from which a single article was used. This

article, as it was not used as a primary portion of the literature review and was mainly used

to assess statistical information regarding the subject matter, was not included within the

below PRISMA chart. As continued searches were performed, a total of nine articles

appeared twice, due to which the overall number of articles gathered went from 79 to 70.

This was followed by the inclusion criteria being applied to the works gathered following

which only 45 remained, not accounting for the single article attained from the WHO’s

website.

Articles that were deemed suitable for the current study were synthesized with their

abstracts, introductions, methodologies, results, conclusions, and recommendations (if any)

being overviewed to see if these works could add meaningful information to the current

review at hand.

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n
Records identified through Additional records identified
tio
database searching(93,600) through other sources(18)
ca
tifi
en
Id
Records after duplicates
removed(93,591)

g
in
en
Records screened(70) Records
re
excluded(93,521)
Sc

Full-text articles Full-text articles

assessed for excluded, with
ity eligibility(45) reasons(25)
bil
gi
Eli Studies included in
qualitative
synthesis(36)

ed Studies included in
ud the quantitative
cl synthesis (9)
In

Figure A.1 PRISMA Flow Diagram (based on: Moher et al., 2009)

The above PRISMA Flow Diagram illustrates the overall number of studies searched

and excluded as well as those included. In this regard, it needs to be understood that the

inclusion criteria for the current work were as follows:

 Articles published within the last five years (2015 to 2020) in order for the author to attain

the most recent and up-dated information possible.

 Articles must be available in English.

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 Focus on or be relevant to the subject matter (Must match or appear when a varied

combination of the following keywords is used: Nursing, healthcare, dementia, care,

patient-centered, collaboration, or hospital).

 Peer-Reviewed.

 Be available for free.

These studies were determined by the author to be worthy of inclusion as they met all

except one of the five above-listed criteria. The works appraised had their titles and

abstracts synthesized and should the information be relevant then the author attained full-

print versions of these works to extract information from them and include them in the

current paper.

Table 1: Inclusion/exclusion criteria (database search)

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A.5 Background

Alzheimer's disease is the most common dementia disease and accounts for 60 to

70 percent of disease states (Thorogood, et al. 2018). Dementia is a chronic disease which

means that it cannot be cured but only alleviated. The life of a person with dementia is

facilitated with good treatment as continence care. Primarily dementia is treated with nursing

measures for the person to achieve as good a quality of life as possible despite their illness

(Thorogood, et al. 2018). Treatment options that are a second choice are pharmacological,

in the form of various symptom-relieving drugs. The symptom-relieving drugs are disease-

related, so it is important to get a diagnosis to get the right help. The biggest risk factor for

dementia in old age as older populations are more likely to be inflicted by this ailment, but

there is also a risk of being affected from a genetic perspective (Livingston, et al. 2017). As

described above, the term dementia is a collective name for several different diseases. A

common division of dementia diseases is primary degenerative, vascular, secondary, and

various mixed forms (Livingston, et al. 2017). Nurses play a central part in providing care for

people with dementia, which includes not only specialist nurses but also all nurses in

hospitals, community, and care homes caring for these individuals.

A.6 Nursing

Nursing means giving care to someone else, it is the nurse's area of responsibility

and it should be conducted close to the patient (Fukada 2018). Nursing is given and decided

together with the individual to maintain good health and quality of life, regardless of whether

the individual is healthy, sick, or in need of support before death. Nursing should have a

clear holistic perspective on the human being, where the main focus is the individual's well-

being (Fukada 2018). Nursing can take place at different levels, general nursing and specific

nursing. General care is at a basic level and independent of illness, the care can be

performed by all care staff but also by relatives and other people in the community. Specific

nursing is performed in the case of illness where there are state guidelines to relate to

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concerning the individual's disease. Conducting specific nursing requires specialist

knowledge (Cations, et al. 2018).

A.6.1 Nursing Dementia

How nursing should be designed and conducted varies slightly depending on state

regulations; and nursing care for individual patients, such as those with dementia, is

specified in said regulations. Assessing and describing what quality of life / good standard of

living is in dementia can mean difficulties, when estimating someone else's well-being there

is always a certain subjectivity. For people with dementia to experience the highest possible

quality of life, the care should take place with the individual at the center. To be able to

achieve this, cooperation between a nurse, care staff, and relatives is required to be able to

obtain a good overall assessment and reduce the difficulties with subjectivity (Bruun, et al.

2018).

A.6.1.1 Person Centered Care

In person-centered care, the individual is in focus and the work is built up with the

help of a team. The team can include several different categories of care staff, the important

thing is that the person the team affects and the person's relatives are part of the team and

actively participate in their care. Person-centered care abides by NMC Code domains with

professionals being tasks to treat patients as individuals whilst upholding their dignity,

listening and responding to their concerns and preferences, making sure that their

psychological, social, and physical needs are met, acting in their best interests, and

respecting their right to confidentiality and privacy (Kim and Park 2017). Person-centered

care requires all care staff to be sensitive and compliant as well as a good ability to be able

to see what is not seen and hear what is not said. This emphasis on the psychological

aspects is what characterizes good person-centered care (Manthorpe and Samsi 2016).

A.6.1.2 Person-Centered Care for Dementia

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Carl Rogers' approach, which was influenced by human experience as the

foundation and benchmark for life and therapeutic impact, gave rise to the phrase "person-

centered treatment." In 1988, Tom Kitwood has been using the phrase to separate a certain

form of dementia treatment from more cognitive and psychiatric methods. he phrases to

describe a collection of concepts and working methods that prioritized communication and

connections. Dementia, according to Chenoweth et al. (2019), is best viewed as a

combination of neurological dysfunction and psychosocial variables, such as health,

psychology and culture, and the community, with a focus on social context. He thought that

the environment influences the brain just as much as the brain influences a person's talents.

The rejection of the conventional medical approach to dementia, which centered on strictly

treating an illness, was central to Kitwood's thesis. He thought that the underlying premise of

dementia in medical research had much too detrimental and predictable consequences for

the nature of caregiving.

Early studies on person-centered care had observable outcomes. Brooker and

Latham (2015) cited much research that found benefits from applying person-centered care

methods, such as better quality of life, less tension, enhanced sleeping habits, and self-

esteem preservation. Chenoweth, et al. 2019; Du Toit, Shen, and McGrath 2019). Keeping

shower rooms warm, for example, can improve residents' bathing experiences, minimize

staff stress, and save time (Chenoweth, et al. 2019; Du Toit, Shen, and McGrath 2019).

Several research methods also show the relationship between effective organizational

behavior and human resource performance, providing credence to culture-change

advocates' desire for organizational redesign.

A.7 The Nurse's Knowledge and Responsibility

Nurse responsibility includes planning, leading, implementing, and evaluating

nursing. The nurse's professional responsibility also includes working preventively / health

promotion and teaching and imparting knowledge to patients, relatives, employees, and

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students. All these components contribute to good and safe nursing being achieved in

clinical practice (Yamaguchi, et al. 2019). Nursing is the basis of the nurse's professional

responsibility to see nursing as a theoretical concept and not only as a physical act.

Moreover, for nurses to be responsible, they have to abide by a set code of ethics. In this

regard, it should be noted that there is an international code of ethics for nurses set out by

the International Council of Nurses (ICN) (Cations, et al. 2018). The most prominent

amongst this code is that of the principle that nursing should aim to "promote health, prevent

disease, restore health and alleviate suffering" (Yamaguchi, et al. 2019).

For the outcomes,

A.7.1 The Specialist Nurse's Knowledge and Responsibility

To be able to provide good and knowledge-based nursing and to carry out

development work based on evidence, a higher academic level is required (Harrison Dening,

et al. 2017; Handley, Bunn and Goodman 2019). Specialist education at the international

level should be based on theoretical knowledge, relevant research, and clinical education

being woven together to achieve high quality, which leads to both an academic degree and a

vocational degree (Harrison Dening, et al. 2017; Handley, Bunn and Goodman 2019). Being

a specialist nurse means working at an advanced level with different nursing situations

(Harrison Dening, et al. 2017). An undergraduate nurse lacks sufficient knowledge in their

education to be able to work independently in different nursing areas with a specialist focus

(Handley, Bunn, and Goodman 2019). Being a specialist requires not only a clinical eye but

also a high level of emotional knowledge - to be able to read and understand complex

nursing situations according to Yamaguchi, et al. (2019).

For the outcomes, It was discovered that the breadth of the practice of primary care

nurses found it challenging to synthesize the data and draw conclusions. The findings

provide valuable insight into the features of tasks performed by nurses in general practice

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settings, which might be useful to persons living with dementia and their caregivers. Access

to the Practice Nurse for patients, early prevention and diagnosis of cognitive abnormalities,

care management, and teamwork with the General Practitioner were among them. Practicing

Nurses' ability to provide dementia care was limited by a lack of description of the job,

insufficient dementia additional skills, time limitations, and poor communication.

A.7.2 The Specialist Nurse's Core Competence - Theoretical Starting Point

The specialist nurse's core competence is based on six core competencies.

According to Fazio, et al. (2018), these needs to be followed to drive health care forward.

The six core competencies are the following:

A.7.2.1 Person Centered Care

Fazio, et al. (2018) present person-centered care as a central concept regarding

attitudes and working methods for specialist nurses. According to Håkansson, et al. (2019),

nurses believe that it is desirable that care and development work is conducted in a person-

centered way, that they see again in the person-centered way of working. With an increased

understanding of the individual behind the disease, but also a structure for the practical work

in their business (Cations, et al. 2018). For it to be feasible in clinical activities, nurses with

competence for the assignment are required (Håkansson, et al. 2019). It is the responsibility

of specialist nurses with their in-depth competence to drive nursing forward (Fazio, et al.

2018). For specialist nurses to have the opportunity to implement it, clear strategies are

required for person-centered care, so that it maintains good quality (Håkansson, et al. 2019).

Fazio, et al. (2018) state that closely focusing on patients and ensuring high quality of

care as well as the competence of the nurse increase disproportionately with care time,

financial cost, and rate of death. This means that the more focus placed on patients, the

higher the quality of care and the more competent the nurse, the fewer patients, and their

families have to spend on healthcare and the less likely are the chances of the patient dying

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and them being in care for the long-term (Fazio, et al. 2018). For good person-centered care

to be achieved, collaboration in teams is required (Fazio, et al. 2018) as people with

dementia present complex physical, psychological, and behavioral states.

A.7.2.2 Safe Care

Safe care includes several different parts and to achieve good patient safety, not only

organizational safety but also competence safety is required. This means that the care

provided corresponds to national guidelines and laws such as the HITECH ACT, the

EMTALA Act, the ACA, the CARE Act, and so on, but also that the level of care provided is

exercised by nurses with current qualifications (Evans, et al. 2018). Evans, et al. (2018) state

that the care provider, as well as the nurse, must have the right competence for the

assignment. It is therefore the specialist nurse's task based on their cutting-edge

competence to ensure the care provided within the chosen specialist area is done so in a

safe manner (Evans, et al. 2018).

A.7.2.3 Informatics

The specialist nurse is involved in communication and information being carried out

and reported. Good communication and information are prerequisites for the care to be

conducted (Brown, Agronin, and Stein 2019). The nursing perspective should permeate the

information and communication performed by nurses and nursing staff, for example, to

create good knowledge-based care with support from the nursing process. Technology is

driving healthcare forward, today patients have a greater role than before regarding their

care, for example in the use of various internet / online services. These services can be

anything from booking an appointment, renewing prescriptions, seeing a doctor, or reading

your medical record. The specialist nurse needs to possess knowledge regarding

information and communication from the technology perspective to be able to lead the

nursing work forward (Brown, Agronin, and Stein 2019).

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A.7.2.4 Collaboration in Teams

Collaboration in teams is the main factor for care to be given in person-centered

clinics and with the individual at the center (Jacobsen, et al. 2017). There are several

different team combinations, for example, teams within the same professional category,

multi-professional teams, teams across different professional categories, teams based on a

certain type of event or problem, such as trauma teams, support teams, etc. (Brown, Agronin

and Stein 2019). The team is characterized by knowledge exchange as well as collaboration

on an equal level where the focus is to achieve the best possible results for the patient (Goh,

et al. (2017). Specialist nurses with in-depth knowledge can then in their role and

professional responsibility contribute to the team with their competence in nursing, for

example through patient safety work based on current research and continuity in meeting

with the care recipient. The holistic view that specialist nurses contribute to the team is

based on person-centered care and is based on evidence (Brown, Agronin, and Stein 2019).

A.7.2.5 Evidence-Based Care

Evidence-based care is based on development and improvement in health care that

is achieved by measuring, collecting facts, compiling, and presenting results, including

follow-up regarding care and nursing of patients. Specialist nurses need to have the right

tools to be able to make decisions based on evidence. These tools are based on knowledge,

practice, and treatment; all components are needed for the nurse to be able to make a

decision regarding care based on evidence (Goh, et al. 2017).

A.7.2.6 Improvement Knowledge

Quality work with a focus on development and improvement is something that must

continuously take place in every activity within the health care system. It is the management

of the business that must ensure that the entire organization follows the quality standards of

reporting and utilizing information. Quality work can only be carried out by a specialist nurse

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with the competence and appropriate experience required for the assignment. Specialist

assignments require a quality register to be maintained in every hospital. In the register,

current data for the selected patient group is measured, which is compiled and followed up

and can then be compared with national data. The statistical results from quality registers

can be used to drive nursing development and research further.

Closer collaboration between universities and activities has increased the

understanding of nurses for evidence-based care in clinical activities. Nurses realize that

academic education is a meaningful part of the specialist nurse's profession and contributed

clinically to safer care for the patient (Jacobsen, et al. 2017).

A.8 Nurse Who Cares for People with Dementia

Caring for people with dementia is a challenge, mainly because many elderly people

often also have multiple diseases and also have a need to be cared for by a specialist nurse

(Goh, et al. 2017). Due to their cognitive impairment caused by age, this group is an

extensive patient category and this, in turn, places high demands on nursing (Jacobsen, et

al. 2017). The nursing of people with dementia thus takes place, to a large extent, at the

advanced level (Jacobsen, et al. 2017). Related to the common multi-morbidity in people

with dementia, it is not enough for nurses to just have basic knowledge in nursing but in-

depth knowledge is also crucial (Douglas, Brush, and Bourgeois 2018). The nurses in

dementia care have an important role in supervising staff and supporting them in person-

centered care. To be able to perform this as a nurse, in-depth knowledge of nursing is

required (Jacobsen, et al. 2017).

Based on recent studies in dementia related to the lack of education, however, there

are no studies based on competence description for specialist nurses in dementia care. This

means that there is a lack of a written basis regarding the expected knowledge of a nurse

professional in dementia care and as a result, there are few nurses who are further trained

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as specialist nurses in dementia care (Douglas, Brush, and Bourgeois 2018). Many elderly

people, who are the most common patient category with dementia, have multiple diseases

and need specialist competence in several of their disease types. Nurses who work in

elderly care and dementia care hence need in-depth knowledge in geriatrics, gerontology,

and cognitive diseases (Douglas, Brush, and Bourgeois 2018).

A.9 Conclusion
Dementia accompanies several uncertainties regarding lack of knowledge about

different types of dementia (Dixon and Thompson 2018; Maio, et al. 2019) that symptoms

may have another underlying cause of the disease (Paulo, Scruth and Jacoby 2017) and

uncertainty about essential issues (Poole, et al. 2019). The results of the literature review

indicate that the nurses' frustration over their workload related to time and the experience of

uncertainty is something that should be noted concerning the possibility of providing good

and safe care, as otherwise there may be a risk for the patient. According to the author of

the literature review, academia shows that nurses have insight into the areas in which they

need to gain more knowledge to improve the quality of life for people with dementia in

hospitals. Conversely, not all nurses have the same insight into how said knowledge and

training can be acquired. It emerged that the nurses who have completed an education in

the present had a different attitude and understanding of the importance of a formal

assessment that was based on evidence and not personal opinion.

A.10 Recommendations
Smythe, et al. (2017) discovered that further trained nurses found work rewarding if

time and space were given to further train colleagues and implement systems and working

methods that increase the quality of life for people with dementia. Newly graduated nurses

have a greater focus on challenges associated with nursing in hospitals and solutions for

this, as well as an interest in learning more about dementia care as a basis (Smythe, et al.

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2017; Evripidou, et al. 2019). The practical knowledge, current diagnosis, and nursing of

professionals in the real world differ from the treatment and strategies recommended in the

literature. Previously, nursing education did not include nursing science as a theory to any

great extent.

Poole, et al. (2019) and Bhattarai, et al. (2020) drew attention to the behaviors of

nurses, such as that the care of people with dementia is largely based on the experiences of

the nurses. This, nurses, consider good nursing from their point of view, which is based on

their philosophy rather than evidence. Rahman and Dening (2016) saw that top and

specialist functions are a very good tool for nursing to be based to a greater extent on

evidence. It can also be a risk to invest only in individuals and there is a benefit in increasing

the evidence work in nursing and then also focus on raising the minimum level and not only

top functions, for example by organizing for consulting conversations between specialist

nurses and other staff (Handley, Bunn and Goodman 2017; Paulo, Scruth and Jacoby 2017;

Maio, et al. 2019). There is an advantage in having specialist nurses available, as Handley,

Bunn, and Goodman (2017) and Maio, et al. (2019) show in their models, where the benefit

is that they work close to the business and are part of the team around the person with

dementia and drive nursing forward (Paulo, Scruth and Jacoby 2017; Bhattarai, et al. 2020).

The author of the literature review believes that to raise the basic level of knowledge

nurses the help of specialist trained nurses or educational programs is needed. In the

literature, it was found that specialist nurses do not always feel appreciated (Rahman and

Dening 2016; Dixon and Thompson 2018). This could increase if a consulting role was

explicitly present as part of the tasks assigned to nurses as specialist nurses themselves

point out that they desire to have time and opportunity to share their knowledge (Rahman

and Dening 2016; Paulo, Scruth and Jacoby 2017).

Poole, et al. (2019) and Handley, Bunn, and Goodman (2017) address the

importance of collaboration between academic institutions and clinical practice. The author

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of the literature review agrees with this, that evidence-based work in clinical practice is

probably facilitated with a good connection. Through closer collaboration, it would be

possible to reduce the gap between these, as Maio, et al. (2019) describes. The gap may

also become smaller over time, as nursing science is today included to a different extent in

nursing education (Bhattarai, et al. 2020). What Bhattarai, et al. (2020) describe proves this,

as they saw that nurses who studied during their practice had a different attitude to

evidence. The author of the literature review does not believe that this can be taken for

granted as in the long-term, solutions as well as closing such a gap will be the focal point of

future nursing and healthcare. Nonetheless, this itself will be an active process that must be

conducted to get a well-functioning collaboration between academic universities and clinical

activities. With better basic knowledge regarding dementia and people with dementia, nurses

could relate to different conditions in patients without confusion, regardless of whether it is

acute or concerning dementia (Paulo, Scruth, and Jacoby 2017).

One possibility would be to share more knowledge in the nurse's undergraduate

education. If it were to be seen as an alternative, it is important that it is not only about

theoretical knowledge but that the nurse also receives clinical training in the type of meetings

and situations that may arise with people with dementia (Handley, Bunn, and Goodman

2017). The author of the literature review believes that this is something to consider, as

dementia is one of our biggest public diseases globally (WHO 2020) and which unfortunately

continues to increase as our population grows older (WHO 2020). The patient group of

people with dementia will most likely meet with nurses, regardless of which activity they

choose to work in. The author of the literature review believes that there may be again an

increased basic knowledge already in basic nursing education as time passes and improved

education becomes more and more of a priority.

Organizational support and nurses' prerequisites include factors such as the level

and standard of care, working relationships, experienced colleagues, a clear work schedule,

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cooperation between the nurses, and working in teams. These components need to work for

a workplace and/or business to achieve good quality (Rahman and Dening 2016; Poole, et

al. 2019). The majority of nurses experience a lack of organizational support or management

support (Handley, Bunn, and Goodman 2017). Research shows that strained work situations

affect nurses and that they experience heavy workloads in their everyday lives. Nurses

experience stress and pressure both in their professional role and in their personal life

(Rahman and Dening 2016; Dixon and Thompson 2018; Bhattarai, et al. 2020). There is also

a feeling that one does not have time or otherwise is not able to perform the nursing that

they wanted (Dixon and Thompson 2018; Maio, et al. 2019).

Primarily, literature does show that nursing professionals desire a senior consultative

nurse and a forum to share knowledge between colleagues the most. Moreover, they seem

to also want to do away with old care cultures regarding nursing for people with dementia

and continue to strengthen and work for person-centered care. Thus, it is recommended that

nurses be offered such a forum for effectively communicating with one another alongside

being able to access a senior individual who can offer them insight and assistance when

need be. By providing nurses with such means, healthcare settings such as hospitals would

be able to effectively care for patients with dementia in a person-centered manner that

further educates nurses as well as patients and their families whilst improving care.

A.10.1 Need for Knowledge Development

Having Enough Staff on Acute Medical Units

Nurses suggested that units be sufficiently staffed with dementia-trained nurses and

PSWs to improve dementia care: Nurses thought that caring for dementia patients took a

long time; therefore some suggested hiring extra people to assist with their care.

According to nurses, will indeed help to protect the safety of clients with responding

behaviors by assisting the nurses in supervising them. Certain nurses believed that some

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PSWs allocated to them required dementia care education and a compassionate approach

with clients who had responsive behaviors (Bartimaeus, 2018). As a result, several nurses

advocated for one-on-one employees, including such Bartimaeus employees, who are

competent caregivers with experience service users with complicated behavioral issues, to

be allocated to these patients instead (Dillane and Doody 2019).

Provide more education reinforcement

Nurses themselves point out a knowledge gap between practical and theoretical

knowledge regarding person-centered care. Nurses know of the concept of person-centered

care and work in practice based on the concept but do not have the theoretical knowledge

and do not fully understand the care philosophy (Dillane and Doody 2019). There also

seems to be a gap between theoretical and practical knowledge regarding current laws and

assessments based on ethical aspects. Education is needed, for example, regarding human

rights and what regulations they need to abide by when providing care to individuals with

dementia. The nurses who have good knowledge of dementia and what can be appropriate

nursing and measures for various diseases, still lack of knowledge in terms of leadership

and being able to reach out to colleagues for knowledge acquiring purposes (Dillane and

Doody 2019).

Evripidou, et al. (2019) showed in their study that there is a need for education in

several different areas and that service training is something nurses who treat patients with

dementia desperately require. (Evripidou, et al. 2019) also show that it is common for nurses

to confuse delirium with dementia. Nurses who have a good basic knowledge base

regarding dementia, however, experience a challenge in transforming theoretical knowledge

into practical clinical work. What nurses mainly need more knowledge in is treatment, as

they often approach and talk to the person from a reality-oriented perspective. They see this

need for skills development to become safer in their profession and care for people with

dementia (Dillane and Doody 2019).

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The nurses themselves experience that there is good knowledge about dementia, but

that in-depth knowledge is needed when meeting with relatives as well as for support in

mapping and how to use accepted assessment documents (Evripidou, et al. 2019). In

dialogue with relatives, the focal point of the conversation is that of care and how it will be

offered. (Evripidou, et al. 2019) found that theoretical knowledge and also knowledge in the

use of nursing theories as well as assessment documents do not reach the same level as

practical knowledge and experience. Regarding difficult nursing situations with people with

dementia, nurses, on the other hand, are good at exchanging experiences with each other

and other care staff (Dillane and Doody 2019).

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Part B: Implementation of an evidence-based

recommendation with application of
theoretical perspectives on managing change

Managing change is not only difficult but a tiring task for most organizations, with

healthcare facilities such as hospitals often struggling to implement said change. Therefore,

academia needs to offer a set basis for managing change based on evidence. In this regard,

the current section offers implementation recommendations based on evidence for

managing change in healthcare settings.

B.1 Rationale 

After conducting a detailed review of academic literature on nursing patients who

suffer from dementia and the various problems that nurses encounter as well as how said

problems can be overcome, the current section was structured to offer a discussion the

recommendations made previously. In this regard, the current takes the impact of

organizational structure, change, work improvement, team collaboration, and how a nurse's

professional responsibilities and roles impact their acceptance of change into account.

B.2 Organizational Structure

In terms of organizational structure and support, most nurses feel that there is not

enough (Kormelinck, et al. 2019; Lees Haggerty, et al. 2020). They also often complain that

any support work is not done without some form of dissatisfaction or frustration (Reuben, et

al. 2020; Lees Haggerty, et al. 2020). There is an increased need for resources within

organizational support, and here two type of needs emerge. Partly that the organization itself

entails limited opportunities through a lack of support and time set aside, but also the

presence of a lack of competence among individual nurses. Regardless of the country from

which the nurses emanate, they agree that strained work situations affect their work

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(Douglas, Brush and Bourgeois 2018; Kormelinck, et al. 2019). These situations are

perceived as strained from the nurses' perspective as they want to do more than there is

room for in the environment, with time and resource availability being prominent limiters of

the nurse's capabilities (Lees Haggerty, et al. 2020). According to Kormelinck, et al. (2019),

nurses describe their area of responsibility mainly as directing and instructing other care

staff, working with documentation and supporting relatives. They emphasize the importance

of an approach in which person-centered care is adopted in work with people with dementia

(Kormelinck, et al. 2019).

Nurses themselves feel that they are far from the clinical activities and they can

therefore not participate in or drive person-centered care forward to the extent they want

(Reuben, et al. 2020). Additionally, Handley, Bunn and Goodman (2017) state that nurses

feel that their workload is heavy, which affects the quality of treatment of people with

dementia. A possible reason for this may be that nurses themselves do not properly know

how to respond to and deal with difficult nursing situations. Even those who have dementia

knowledge and know how to resolve such situations do not consider the actual time

available to them (Handley, Bunn and Goodman 2017).

B.3 Change and Improvement Work

Nurses, regardless of workplace, all feel frustrated about the introduction of various

system changes that are not implemented correctly (Mkhonto and Hanssen 2018). That is,

nurses want to have proper consultations with organization and department heads regarding

the type of system changes to be implemented. This is because most changes are often

introduced with short notice, no or very little preparation and lack of training (Mkhonto and

Hanssen 2018). These organizational changes create frustration and resistance among

nurses. Nurses, similar to employees in any setting, generally feel that organizational

changes can counteract the service they offer, care, and thus harm not only the organization

but also employees.

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The majority of changes also mean that nurses feel that they come further and

further away from patients and clinical activities (Digby, Williams and Lee 2016). In the care

of the elderly sector, Allen and Close (2010) attempted to try a working model where a

clinically working nurse was used as a consultant in the care of people with Alzheimer's. This

nurse in question had in-depth knowledge and was given further education in a chosen

subject area, in this case Alzheimer's care. During this, a need emerged from an

organizational perspective, where benefits were seen with a competence-supporting nurse

being available to other staff for improving quality in the short and long term (Allen and Close

2010).

Allen and Close (2010) saw in their study that with the NICHE geriatric resource

model and its structure created an increased quality of life in people with Alzheimer's. The

nurses who cared could then acquire more specific knowledge, when they knew what the

situation required and demanded, which led to the nurses becoming more confident in their

professional skills (Allen and Close 2010). Nurses seemed to appreciate being given help

and support from a nurse with in-depth knowledge in Alzheimer's care as well as in

evaluating, responding to and structuring the care around the person with Alzheimer's. With

only a single well-trained nurse, nurses complained about the shortage of trained specialist

nurses (Allen and Close 2010). Organizationally, it has been found that specialist nurses

tend to become responsible for ever larger units or areas, which reduce their opportunities to

be in the business (Digby, Williams and Lee 2016). Nurses, regardless of whether they

worked with elderly care or dementia care, generally want the opportunity for more

knowledge and preferably formal further education in their specialist area. In this regard, the

employer's financial contribution acts as a hindrance as employers do not offer sufficient

financial contributions for further education thereby leading to few nurses choosing to study

further (Handley, Bunn and Goodman 2017).

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B.4 Team Collaboration

Luckett, et al. (2017) showed in their study that while multi-professional team

meetings were appreciated, they occurred on a too sporadic basis. What made it more

difficult was time access based on schedule, as differing professionals have differing time

availability thereby making it challenging for said professionals to have meetings on time.

Nurses saw a need to find new ways in the work to reach out with care in a better way to the

individual. Something they spoke positively about was finding increased opportunities for the

multi-professional team (Luckett, et al. 2017). Thus, it is important to also see relatives as

part of the team to increase the quality of care for people with dementia (Luckett, et al.

2017).

B.5 Problems Nurses Face

Brooker and Latham (2015) state that nurses agree that working with people with

dementia is a positive experience and that it gives a lot in return. The starting point in the

care for the nurses who have in-depth knowledge of dementia care is a desire to alleviate

the person's suffering and increase the person's quality of life (Livingston, et al. 2017). When

working as a nurse for people with dementia, communication skills, and clinical skills are of

great importance, as they often convey to other care staff what needs to be done clinically.

Therefore, nurses can feel that they work the most with these two areas and very rarely have

time to participate in the clinical work themselves (Cations, et al. 2020). For nurses to

maintain their interest in work but also remain in their workplace, nurses want greater

recognition for the work they do, for example, to feel valued for their abilities, knowledge,

and experience and that they were committed to their work (Douglas, Brush and Bourgeois

2018).

It is not only a complex situation to work with people with dementia but also a

challenge to make nurses feel satisfied with their capabilities and work and remain within the

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healthcare system and/or industry (Livingston, et al. 2017). Livingston, et al. (2017) shed

light on how it is possible to set up work and increase understanding of nursing for people

with dementia. They state that treatment should be the main focus of any good nursing

strategy to make the care of people with dementia work in practice. It is necessary to build

up a functioning relationship and work structure with external units, for example, get help

from a specialist in dementia care for support and advice as well as increased cooperation

with relatives. The VIPS structure, in this regard, is highly appropriate for nursing and

becomes support in how nursing should be performed instead of how nurses should act

based on what they consider appropriate.

As the VIPS structure begins to be practiced, the understanding of the nurses and

care staff for the underlying reasons for the person with dementia reacting or acting in a

certain way also increases (Cations, et al. 2018). This increased understanding leads to the

choice of other nursing strategies, which are now based not only on somatic symptoms but

also on symptoms at the psychosocial level (Cations, et al. 2018). Despite the stressful

everyday life that occurs, nurses and nursing staff, through VIPS, see a benefit in taking the

extra time to get to know the person behind the disease, as it facilitates nursing and reduces

the incidence of BPSD (Luckett, et al. 2017). This means that the person with dementia is

perceived as calmer and that it becomes easier to care for them (Luckett, et al. 2017).

B.5.1 Experience of Uncertainty

Most often there are experiences of uncertainty in several different forms in the care

of people with dementia. This uncertainty is characterized by nurses confusing alternatives

and lacking the knowledge to be able to support, help, and advise patients in their current

situation (Harrison Dening, et al. 2017; Livingston, et al. 2017; Cations, et al. 2018). Those

who work inwards meet people with dementia who were cared for acutely, often with other

existing somatic illnesses being the cause of said dementia. Harrison Dening, et al. (2017)

state that nurses want to achieve good and safe care, but are influenced by their philosophy

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on how nursing should be conducted. Nursing can then sometimes be based on the nurses'

own beliefs rather than based on evidence. Most nurses base their nursing philosophy on

providing the care they would like (Luckett, et al. 2017). Which is also framed by stress, for

example, that patients need to be ready for certain times and not based on the person with

dementia (Brooker and Latham 2015).

When implementing a new work structure, nurses feel that they need better

implementation using clearer information of the document for guidelines regarding people

with dementia. This needs to take place in real-time to help nurses get acquainted with the

guidelines before they are to be used (Harrison Dening, et al. 2017). Moreover, practical

help and support in how to work with guidelines in practice can help reduce uncertainty and

stressful decisions for nurses thereby allowing them to remain high functioning in stressful

environments (Livingston, et al. 2017). Nevertheless, nurses consider that guidelines could

be good support and also lead to an increased consensus (Cations, et al. 2018). One topic

that nurses often avoid is that of talking about death with people with dementia. They often

interpret when the person expresses a longing for death as depression and nursing

measures or pharmacological treatment can then in some cases be used as treatment.

Medication for depression is then given instead of talking about death - this

medication is inevitability going up against a disease condition that cannot be cured. The

nurses experience an accepted silence regarding people living in nursing homes and what

these individuals have for faith and religion. This silence becomes even clearer when it

comes to people with dementia. Most nurses do not feel comfortable in these situations and

also do not feel that they know what is applicable based on management and organization

guidelines alone (Cations, et al. 2018).

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B.5.2 Communication

It is a challenge to communicate with people with cognitive impairment, both in trying

to interpret what the person wants to say and for the nurses to convey information to the

person (Luckett, et al. 2017). Information can apply to what will happen next - for example,

treatment/surgery, but also simpler requests such as being able to take medication (Luckett,

et al. 2017). Based on this, Luckett, et al. (2017) state that nurses feel a low level of

satisfaction in their work when they care for people with dementia, primarily due to

frustration, stress, and compassion. The authors saw in their study that education and

support were areas of need in the workplace. Lastly, nurses seem to also desire increased

access to specialist nurses in dementia care both in terms of support and availability,

consultative for other staff, and set aside time for work with the patients who have dementia

(Brooker and Latham 2015).

B.5.3 Knowledge

When comparing nurses who have not had any introduction or training on how

people with dementia can be cared for with those who do, tend to be worse off in terms of

caring for patients, offer reduced results, and are generally more dissatisfied (Smythe et al.

2017). Journal systems and the information collected related to how the care is to be

provided to be solely often based on physical needs or problems, with the focus being on

these tasks being performed correctly rather than meeting the person with dementia's

individual needs (Evripidou et al. 2019). This shows that most care settings tend to lack a

person-oriented approach. Nurses who are not offered sufficient knowledge development

lack self-confidence in their knowledge and ability to provide care for dementia, focusing on

a more psychological level (Dillane and Doody 2019). These individuals can also equate

spiritual and religious experiences and lack knowledge of what separates them (Smythe et

al. 2017).

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By having underdeveloped capabilities and skills, these nurses face various

difficulties, lack knowledge, and are unable to take a stand on more existential issues and

thus avoid speaking of subjects such as death, religion, etc. with patients, thereby

discouraging the patient and possibly harming them mentally (Smythe et al. 2017). It should

be noted that these nurses do not do this out of intent but rather due to them feeling

distressed and fearing the reactions that their patients would have regarding their opinions.

Nonetheless, nurses themselves realize that they require knowledge in these areas and that

this part of the care can be an important and large part of their lives for some people with

dementia (Evripidou et al. 2019).

B.6 Conclusion

In conclusion, a well-rounded educational program for nurses needs to be in place to

educate them on the various ways in which patients suffering from dementia need to be

dealt with and how they can manage stressors and communicate with one another.

Conversely, implementing a person-centered care program for nurses that offers them a

forum for communication with coworkers and a senior individual who can alleviate their

worries and concerns may be challenging. The primary challenges that any hospital doing so

would face would include limited time and resources from the organization's end, resistance

to change due to lack of familiarity or knowledge of the program and its purpose, and a lack

of coordination between nurses due to miscommunication or lack of communication.

Nonetheless, by utilizing set methods for change implementation and management such as

Kotter's change management theory and Lewin's Change Management Model, such change

plans can be successfully executed.

In this regard, Galli (2018) states that utilizing Lewin's Change Management Model is

the easiest and simplest way for organizations to manage change. By identifying three

unique change stages, organizations can plan how they can manage the change, thereby

reducing the possibilities of resistance to the change. This three-step model (Unfreeze,

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Change, and Refreeze) involves developing change motivation, moving the process of

change by encouraging efficient communication and empowering employees to embrace the

change, and returning a sense of stability to the organization following the implementation of

the change. It should be noted that this final step of the Change Management Model

ensures that employees are prepared for future changes while accepting the impact of the

current one.

Conversely, the second strategy recommended to overcome such obstacles, Kotter's

Change Management, is much more complicated than the Change Management Model, as

mentioned above, as it involves eight steps rather than three. However, Kotter's model is

built on Lewin's Change Management Model as it segments the three steps as mentioned

above into eight steps, which involve creating urgency, forming a coalition, developing a

change vision, communicating the vision, encouraging employees to act on the change plan,

ensuring that short-term achievements are attained, that the change is built on, and that it is

integrated into the organization as a prominent part of it.

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Part C: Critical reflection on peer teaching and

evaluation of learning from the module

C.1 Introduction
In the choice of articles, the author has not considered the type of activity area. The

literature review could have been further deepened by choosing an area of activity (Xiao and

Watson 2019), such as improving nursing leadership only, improving nursing education only,

or so on. A delimitation and in-depth study provide a good picture to illuminate a

phenomenon (Kraus, Breier, and Dasí-Rodríguez 2020), and thus, it is recommended that

future works utilize such an approach to this subject matter. Essentially, by conducting a

broad search of academia, the author provided a good picture of care as a whole and

similarities and differences between forms of activity (Xiao and Watson 2019). This literature

review could advantageously be supplemented with in-depth studies of different areas of

activity. The nationality of the selected articles is widespread and was not narrowed down to

a single nation; rather, the literature review's goal was to offer an overall picture. At the

beginning of the work with the literature review, the idea was that the study would stick to the

United States where the structure for the development of the healthcare sector is similar to

other Western nations, and it would then create high credibility and transferability to use the

results in future clinical applications.

In the first database search, on JStor, there were too few useful search results, and

the search thus expanded to other academic databases such as Google Scholar and NCBI,

with it being further expanded to others. Thus, the geographical limitation had to be opted

out in favor of a larger basis that enabled an analyzable dementia care picture. Despite the

different nationalities of articles, there were clear similarities in the challenges nurses face in

caring for dementia people. It can be seen as a strength and breadth in most represented

countries, according to Kraus, Breier, and Dasí-Rodríguez (2020).

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C.2 Conducting a Literature Review

When searching for articles in databases, the author had received a predominant

number of hits, after which the author began by reading the title and summary, it emerged

that most of the hits found via databases were literature studies and not original articles. It

was not feasible to use a manual search in this step for the original articles used in most

literature studies were older than the inclusion criteria, alternatively already included, or did

not meet the literature review's purpose. Based on the fact that the original articles' range

was lower than what the author of the literature review in the first step had perceived, it was

therefore chosen to both changes and expand the keywords (See Part A for inclusion criteria

and keywords). Conditions were kept regarding dementia care, nursing care, and a timeline

of five years. Both care and nursing were included in different keyword combinations with the

Boolean term AND. As additional searches for academic works were conducted through

other medical-related databases, including PsycINFO, MEDLINE, and CHINA, the author

was able to amass a great deal of literature for their review.

Thus, it was important to selectively procure literary works from these databases as

several irrelevant articles began to show. Most of the abstracts were read to determine

whether the searched article corresponds to the literature review's purpose. The abstract of

a searched article is a crucial starting point for assessing its relevance and deciding if it is to

be included in the literature review (Barn, Barat, and Clark 2017). Although a few articles

that fell outside of the criteria were also included, the author ensured that these exceptions

did not apply to the majority. Searching of databases and collecting data took place by

electronic means entirely, and the collection performed was based on the inclusion criteria

mentioned previously. It should also be considered that only free-to-view works were used

as purchasing individual articles was not within the financial budget of the current author.

Keywords used in database searches are based on the purpose of the literature review:

nursing, healthcare, dementia, care, patient-centered, collaboration, or hospital.

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The selected keywords were used in varying combinations. In combination, a

Boolean search term was used, and the selected search term was AND, which is an

accepted search term for database search (Busalim 2016). A peer-reviewed approach was

used to ensure quality and credibility from a scientific perspective in the database before the

search began (Barn, Barat, and Clark 2017). The data collection ended with a manual

search via the reference lists of the selected articles to find articles that were not in selected

databases or articles that did not come up based on selected keywords (Busalim 2016). The

manual search did not generate more articles. In the literature review, no distinction has

been made between articles with a qualitative or quantitative approach, as the use of

different approaches can provide a broader basis to see the subject from different angles.

The weakness with several different approaches, which was an observation to

consider in the current work, was how the selection of articles went and how decisions about

limitations were made related to relevant research, according to Barn, Barat, and Clark

(2017). The author has used accepted assessment material and believes that the selected

articles create reliable material. Searches in databases generated several duplicates, the

duplicates were excluded, and the articles were selected based on first-hand hits. In total,

Google Scholar, JStor, PsycINFO, NCBI, MEDLINE, and CHINA had been chosen to be

used as academic databases for the current review. The literature review did not have

difficulty achieving saturation based on the planned inclusion criteria; however, certain

exceptions were made to account for works that added historical accuracy and furthered the

literature review's overall quality.

The literature review highlights the need for nurses for high conditions and

knowledge in meeting people with dementia. There were also areas and activities where

nurses feel that they had good knowledge regarding dementia. However, areas emerged

that can be strengthened to increase these conditions regarding knowledge among nurses.

For example, competence description (for specialist nurses in dementia care), further

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education in dementia care, increased nursing program knowledge, work based on

evidence, strengthening the multi-professional teamwork, and continuing working for good

working conditions. Thus, based on the areas of improvement presented, in-depth formal

competence is recommended to increase the conditions for nurses to provide good nursing

care for dementia. The results also show that person-centered care should be at the center

of care for people with dementia. To be able to meet this, there is also a need for in-depth

knowledge among nurses.

Through the literature review, the current author learned several interesting facts

regarding nursing and how individuals suffering from dementia react to and perceive others.

Before conducting this review of academic literature, the current author lacked sufficient

knowledge regarding how dementia patients should be regarded, the difference between

dementia and diseases such as Alzheimer's and delirium, and so on. Moreover, the author

learned how nursing, as a practice, should not be centered only on the treatment of a given

disease, illness, etc. but rather that the treatment of a person should focus first and foremost

on them. A fact that may seem obvious in hindsight, the current author, learned that nursing

should, especially in dealing with individuals going through and experiencing the

tremendously stressful disease that is dementia, focus on care; this is not to say healthcare

or care as in treatments but rather the type of humane care only an individual with a

sufficient understanding of the other as well as empathy can give. Not only does academic

literature verify this fact that care should be person-centered, but rather literature goes on to

emphasize it as being critical to the treatment and quality of life of patients, regardless of

whether they have dementia or not.

Although nurses have been shown to resign or become cynical to their profession in

their later years (Handley, Bunn and Goodman 2017), after experiencing enough trauma to

leave them emotionless (Handley, Bunn and Goodman 2017), it is the emotions as well as

the forethought that nurses have that can greatly improve a patient's quality of life.

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Therefore, it was critical for such a review focusing on the conditions and knowledge needs

of nurses who care for individuals with dementia to focus on person-oriented care and how

nursing knowledge plays a part in the type and quality of care a nurse can provide. By not

limiting the literature review to only evaluating a certain methodology or assessing a single

subject of focus, the current work was able to offer insight into a subject matter seldom

discussed outside of the nursing profession and dementia patient care. Additionally, through

the course of evaluating several articles and literary works, the current author was able to

amass a considerable amount of insight and knowledge as to how nursing professionals

perceive dementia patients and how the skill sets of these professionals can influence their

behaviorr.

C.3 Conclusion
Although dementia is a widespread issue that affects millions of people around the

world, very rarely is it brought up in mentions of healthcare or education. Other more

prominent issues such as cancer, HIV, and the like often take the spotlight away from a

subject matter equally as important. In learning about dementia and the various types, the

author was able to evaluate how healthcare for these individuals can be improved based on

recommendations from prior academics as well as the author’s subjectivity. The

recommendations thus made during the literature review emphasize this subjectivity

combined with academic objectivity. Whether or not such approaches will be successful is

not a questionable matter as the current literature on this subject continually enforces the

notion that the best practices for dementia patient treatment are patient-centered.

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