Dementia Gateway: Difficult situations

Case study: Responding to feelings unlocks solutions

Mrs Hall accuses hospital staff of assaulting her – but by focusing on her feelings staff discover the real reason for her distress.

Background

Mrs Hall has dementia and has been admitted to hospital four days ago with a chest infection. This is being treated and physically she is recovering well. However, Mrs Hall is very unsettled on the ward, particularly at night. She seems agitated and frequently gets out of bed, walking up and down the ward. She is disturbing other patients and the nurses are concerned.

One day when Mrs Hall's daughter arrives at the hospital, she finds her mother in a very distressed state. Mrs Hall tells her daughter that in the middle of the night a male nurse forced her to swallow a tablet and she was very frightened. Mrs Hall's daughter immediately approaches the ward manager and angrily complains about the incident.

Focusing on and empathising with the feelings of people with dementia can be quite intense and emotional for the staff involved.

Read the full case study:

Understanding the situation - 1. Research and development findings Open

Much has been written about communication and therapeutic interactions with people with dementia. The ward manager had recently received training in person-centred communication and understood that the feelings and perspectives of people with dementia are very important and need a sensitive and empathic response.
Understanding the situation - 2. Views collected from key people Open

Mrs Hall's daughter was very angry and upset about what her mother had told her. She wanted to complain about the abusive treatment of her mother. The ward manager agreed that the incident sounded very serious. She sat down with Mrs Hall and her daughter and said to Mrs Hall. 'I understand you're very upset?'. Mrs Hall confirmed that she was indeed feeling upset.

The ward manager asked Mrs Hall to explain to her what had happened. Mrs Hall began talking about the incident, but her account was disjointed and kept changing. Initially she said that in the middle of the night two male nurses had forced her to swallow a tablet. Then she said it was just one nurse, who made her swallow lots of tablets, and then she described a man in a three-piece suit who she said had shouted at her in the night.

The ward manager knew that there had been no male nurse on duty during the night, nor had any other men been on the ward. Mrs Hall had been given a tablet at 7am, but this needed to be chewed rather than swallowed whole, and it was administered by a female nurse. She explained this all quietly and clearly to Mrs Hall and her daughter.

Mrs Hall's daughter was embarrassed and began apologising. She said that her mother was clearly confused and nothing had happened. However, the ward manager reassured Mrs Hall's daughter that her mother's feelings were important and needed to be listened to.
Actions Open

The ward manager felt that clearly Mrs Hall's feelings were very real and present, even if she was confused about facts. She decided that it was important to continue the discussion and to try to draw out Mrs Hall's feelings, for example by saying, 'That sounds very upsetting.'

She gave some gentle prompts and asked questions to try to help Mrs Hall clarify what she was saying and pinpoint any particular concerns. One question she asked was, 'What was the worst thing about it?'

Mrs Hall replied, 'I couldn't see. I couldn't see anything.'

'Was the worst thing the dark?' asked the ward manager.

Immediately Mrs Hall replied, 'Yes!'

Mrs Hall went on to emphatically express that she was scared of the dark. She appeared visibly relieved that this had been understood. Mrs Hall's daughter explained that at home Mrs Hall never switched all the lights off – she slept with a bedside lamp on. On the ward, the lights in each bay were routinely switched off at night. No wonder Mrs Hall had been so agitated and upset each night – the poor woman had been terrified.

Mrs Hall had not known that over each bed was an individual light, which could be left on during the night when the lights in the bay were switched off. Straight away, the ward manager switched this light on and made a sign stating that the light should be left on at all times, which she stuck this to the wall next to the switch. Later, she handed this information over verbally to all the staff on the ward, explaining that the darkness seemed to be a key factor in Mrs Hall's ongoing agitation and distress at night, as well as being the trigger to the accusation made by Mrs Hall and her daughter.
Results Open

As Mrs Hall spoke about her feelings her face and body visibly relaxed. She appeared to be very relieved when the ward manager showed that she understood her feelings and, in particular, her fear of the dark. She indicated both non-verbally and through her verbal response that she was very pleased about the sign by her light switch.

Mrs Hall's daughter was very appreciative of the time the manager took to speak to them both, of the respect that she showed to Mrs Hall and of the intervention regarding the bedside light. She also said that she felt sorry that she hadn't thought to mention her mother's fear of the dark, but it hadn't occurred to her that this could be relevant.

The nurses were pleased that the accusation had been dropped. They were also impressed that their manager had uncovered an important – and resolvable – reason behind Mrs Hall's behaviour.

During the first night Mrs Hall spent with her own light on there was a marked change. She stayed in her bed and whenever nurses observed her she was asleep. She was in a good mood when she woke in the morning. It was clear to everyone that Mrs Hall was much happier. When the ward manager saw her next, two days later, she was very animated, much less confused and actually said how much the light was helping.

The ward manager suspected that past traumatic experiences of Mrs Hall may have contributed to her belief about events taking place during the night, but she decided that it would not be helpful or appropriate on this occasion to attempt to delve into these past experiences, particularly since Mrs Hall was only on the ward for a short stay. What seemed important was to focus on resolving Mrs Hall's feelings in the present and finding ways of avoiding triggering any painful memories.
Advice for others Open

In any care setting it is essential that all staff are aware of the importance of focusing on and empathising with the feelings of people with dementia. This can be quite intense and emotional for the staff involved, and in order for staff to sustain this approach, managers need to recognise that front-line staff need emotional support too.

It is important that the organisation develops a shared ethos of care, where all staff are aware of the need to attend to the feelings of people with dementia. Interactive and experiential training in person-centred communication can help staff put themselves in the position of the person with dementia, understand how things might seem from the person's perspective, and recognise the messages about feelings and needs that tend to lie behind a person's 'different reality' or 'challenging behaviour'. It is helpful if staff receive this training as a team, preferably from someone who has an understanding of their roles, resources and the people they are supporting.

The feature 'A different reality' in this section looks at this difficult area in more detail and explains the importance of tuning into feelings.
Financial implications Open

Training in person-centred dementia care is an important investment. Its impact will be maximised when the Key messages of the training are reinforced by senior staff – for example, through team meetings, supervision and role modelling.