Behavioral and Psychological Symptoms of Dementia
Subject: Other Medical Specialties
Nursing Philosophies, Grand Theories, and Conceptual Models I would choose the Neuman Systems Model (NSM) for this discussion because its general features and nuances are very useful for my practice (Whetsell, Gonzalez, & Moreno-Fergusson, 2015). The key principles of the model include a holistic view of the patient, attention to the environment, and the importance of the prevention of disruptions in the stability of the patient’s state. It is noteworthy that the concept of prevention in NSM includes the primary, secondary, and tertiary types (Whetsell et al., 2015, p. 476). Certain details are also noteworthy: for example, the model classifies stressors in a way that includes the intrapersonal ones and states that the goals of nursing need to take into account the client’s perceptions (Whetsell et al., 2015, pp. 475-476). In my practice, I apply the holistic patient-centered care (PCC), take into account the environmental factors, and employ the three forms of preventions whenever applicable. I do not typically classify the stressors as suggested by Neuman, but I agree that this process would provide some guidance for the development of goals.
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The model seems to belong to the totality paradigm because it works to determine the components of the systems (in particular, the barriers) and attempts to describe the way patients interact with the environment (Smith & Parker, 2015). In my view, such a paradigm might be preferable for my practice because the analysis of the elements of the system facilitates the development of interventions and nursing goals. Also, the totality paradigm seems to be promoting more structured nursing activities than the simultaneity one (Smith & Parker, 2015, p. 265). With respect to the four metaparadigms, the model appears to have directed me to the following conclusions. Concerning the person paradigm, the model promotes the holistic approach, which corresponds to my ideas. Concerning the health paradigm, the model offers a customized approach determined by individual normal lines of defense (Whetsell et al., 2015, p. 474). Concerning the environment paradigm, the Neuman’s approach acknowledges the interaction between the person and the environment, although it focuses on stressors. This focus can be explained by the fact that Neuman’s model suggests focusing nursing on building the resistance of the patient in the stressor areas (Whetsell et al., 2015, p. 476), which is performed in collaboration with the patient with the aim of ensuring his or her stability. In effect, this redefinition of nursing seems to describe it relatively extensively. The Use of a Nursing Theory to Guide DNP Projects Using PubMed search, I have located few articles that could be applicable to the topic of Behavioral and Psychological Symptoms of Dementia (BPSD) and explicitly used a nursing theory to develop their argument or guide their research, and one of them is written by Moyle, Rickard, Chambers, and Chaboyer (2015). The article is predominantly aimed at testing the “Partnering with Patients Model of Nursing Interventions,” which is based on PCC and the capabilities approach (CA). Moyle et al. (2015) describe PCC “partnering “with” patients, rather than providing services “to” them” and CA as a human flourishing approach that “values the individual choice and their opportunity to participate as a full member of society” (p. 254). The model, which, according to the authors, needs more development to become a practice-level theory, is based on the active participation of healthcare workers and patients (and their families or other caregivers) in the development of interventions. The authors carry out a study of a case of a patient with dementia to test the model. The particular intervention that was developed for the treatment of patient’s anxiety is the use of an animal-like companion robot. The authors demonstrate how the model was applied as a framework for intervention development. In particular, they show that the intervention was tailored to the patients’ needs (who was reported to like animals and had lost her dog) through a collaboration of the nurses, the patient, and her family. In general, the patient provided input information (her preferences, her reaction to the robot), and the nurses analyzed it and perfected the intervention. The intervention managed to reduce the patient’s anxiety and provided nurses with a deeper understanding of triggers, which helped them to manage this patient’s BPSD. Thus, the authors tested a model based on PCC and CA by studying one case and made conclusions about the need for additional research. As for the contribution to my project, the article acknowledges the importance of BPSD management and demonstrates that additional nurse training can help them to be more effective at this activity. Therefore, the article supports my problem statement. Moreover, the article contains an application of a broad model to a more specific BPSD intervention aimed at reducing anxiety in patients. While I doubt the feasibility of advocating for the use of robots in correctional institutions, the logic and the model of intervention can be applied to other cases and lead the practice of working with BPSD. Thus, the article bridges nursing theory and BPSD management practice, which makes it useful for my project and my personal practice. Nursing Theories and Nursing Middle-Range Theories My research does not target patients: it is aimed at educating nurses on the topic of Behavioral and Psychological Symptoms of Dementia (BPSD). As a result, I suppose that the Neuman Systems Model (NSM) can be related to the nursing actions in the context of BPSD management, but not specifically to the problem, intervention, and outcomes of my proposed research. Still, NSM, which is extensively described by Whetsell, Gonzalez, and Moreno-Fergusson (2015), is very useful from the point of view of my aesthetic knowing, and it can be applied to the issue of BPSD from multiple perspectives.
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First, the model’s attention to the stressors (including external and internal ones) can be employed during the assessment of BPSD and the planning of interventions. BPSD involve a variety of behavioral and psychological symptoms like anxiety, depression, agitation, and so on (Cerejeira, Lagarto, & Mukaetova-Ladinska, 2012; Spector, Orrell, & Goyder, 2013). Revealing stressors and responding to their presence seems to be important for the management of these symptoms. Second, the model pays particular attention to the prevention of issues, which includes three levels: the prevention that occurs before stress, during it, and after a relevant treatment (Whetsell et al., 2015, p. 476). All these levels of prevention can be applied to different elements of BPSD management. For example, when we arrange a safe environment for the patient, we ensure the first level of prevention. However, this process is typically intercepted by newly discovered stressors (for example, growing anxiety as an internal stressor or a reaction to an external one), which results in us finding a way to treat the patient and ensure a long-term recovery. Thus, all the three levels of prevention seem to be of use for BPSD management, especially in case they are applied to the previously discussed stressor identification. Finally, the idea of nursing that is embedded in NSM presupposes taking into account the client’s perceptions, which is important for BPSD management because of the tendency of these symptoms to have unique combinations in every particular case. Thus, NSM can be applied to the nursing activities that are related to my problem statement, and it may also provide some suggestions for the specifics of intervention. It may also contribute the idea that a situational (stressor-focused), customized (patient-oriented), and prevention-based approach to nursing actions can ensure a relatively successful management of complex symptoms like BPSD, which highlights the importance of developing an appropriate practice. This practice is the expected outcome of my proposed study, and it is apparent that its appropriateness can be improved through training, which explains my problem statement. Therefore, NSM can also be related to the elements of my PICOT question. Empiric and Aesthetic Critical Appraisal Critical appraisal tools are meant to assist nurses in evaluating knowledge and evidence (Milner, 2015). Typically, they are employed with rather specific categories of evidence, including particular types of research studies (Claywell, 2014). Most often, critical appraisal tools are related to empirical knowing; possibly, such a choice is explained by the fact that empirical knowing is exceptionally helpful for evidence-based practice (Claywell, 2014, p. 194). However, it is not the single way of knowing; in fact, Carper has determined four of them, including ethical, personal, and aesthetic knowing in addition to the mentioned one. The latter aspect refers to the knowing that can be described as situational (Johns, 2013); it can be suggested that case studies view this knowing from the research perspective. Thus, both perspectives are essential for evidence-based practice, even though the latter can be regarded as a more limited one. Nowadays, there are many critical appraisal tools, which tend to differ in the specifics of their design as well as their effectiveness and the area of use (Claywell, 2014). Despite the differences, Milner (2015) and Claywell (2014) point out that they are united by their aim, which defines their key elements. The latter include the criteria that are supposed to determine the credibility, validity, and usefulness of evidence. The specific criteria can vary depending on the tool as well as the evidence that it evaluates. The application of critical appraisal tools to the Neuman Systems Model (NSM) can yield the following results. From the empiric perspective, NSM comes from a credible source because it was developed by Betty Neuman, a skilled and experienced nursing professional. Also, NSM appears to have been checked for validity because it has received the acclaim of the nursing community (Whetsell et al., 2015). From the aesthetic perspective, NSM is very useful: I have demonstrated that its general principles and specific nursing advice can be applied, among other things, to BPSD management. Thus, the use of two perspectives highlights different positive features of NSM. My new research with respect to the tools suggests an additional understanding of the importance of different points of view. In general, I suppose that the appraisal of theory from multiple perspectives is bound to be beneficial, even though it might not be required for every particular instance. In general, though, the necessary perspectives of appraisal depend on the needs of a nurse who intends to carry it out. According to Milner (2015), the key principle of evidence-based practice is that “nursing is both a science and an applied profession” (p. 465), which implies that both empiric and aesthetic (as well as general and limited) perspectives can be of use depending on the situation.
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Borrowed Theories Maslow’s hierarchy of needs has been criticized for the lack of detail, questionable hierarchy, and excessive generalization (Kalat, 2016, p. 347), but I think that it can offer certain insights into human psychology while also being easy to use. Moreover, Kalat (2016) points out that the hierarchy can be revised to fit a particular purpose of its user. As a result, I suggest viewing this model, which it can be regarded as a theory borrowed from the field of psychology, from the perspective of nursing knowledge and practice. The Maslow’s theory is aimed at explaining human motivation, especially the conflicts in it, which is supposed to be achieved through the organization of needs “from the most insistent needs to the ones that receive attention only when all others are under control” (Kalat, 2016, p. 347). The classic hierarchy is often presented in the form of a pyramid, which includes physiological needs as the most basic ones; they are followed by the need for safety and the need for belonging (social interaction). After that, self-esteem needs follow; they include, for example, the need for accomplishments and their recognition. Finally, the self-actualization is viewed as the highest level of needs (the tip of the pyramid), which refers to unlocking one’s potential to the greatest extent. Kalat (2016) points out that initially, the model implied that higher-level needs could not be attended before lower-level ones, but human experience shows that it is not true. Also, the author highlights the fact that there are cultural and individual variations, which may modify the presented layout of the pyramid. As a result, it may be more logical to pay attention to the presence of these layers, which highlights the fact that human motivation can be viewed as a rather complex phenomenon. As a general and simplistic model, Maslow’s theory can have a wide variety of applications in different areas of advanced nursing practice, some of which seem to be relevant for nursing leadership. From the perspective of clinical application, the model appears particularly useful for the development of holistic solutions. Also, it is apparent that its use implies the promotion of a patient-centered approach to healthcare, especially in case the pyramid is viewed as a flexible model that can be customized. The fact that Maslow’s model can be used to motivate patients (for example, encourage self-care) seems to be particularly important in my view because I have been working with patients with mental issues who often lack motivation. Moreover, nursing management and leadership can also be facilitated with the help of the model: as shown by Redknap, Twigg, Rock, and Towell (2015), Maslow’s theory it applicable to nurse motivation and job satisfaction management. Thus, Maslow’s model seems to be particularly relevant to nursing leadership: it can help advanced practice nurses to promote appropriate methods (like the patient-centered approach) and to lead both patients and other healthcare professionals towards better outcomes and quality of care. EBP Scholarship There are several types of scholarship that can be found in the activities of the nurses in our practice environment. Given the specifics of my workplace, we often need to engage in the scholarship of teaching with respect to correctional officers. Unfortunately, our encounters are only semi-formal, which is why we have few materials to provide to them, but we gradually accumulate both the experience and research that are required for the process. The lack of the knowledge about psychiatric disorders in correctional officers sometimes results in inappropriate decisions. I was reported, for example, that an officer at our facility misinterpreted a BPSD symptom for aggressive behavior, and the patient ended up being charged with battery. Nowadays, correctional officers are not equipped for managing this kind of work, so we try to improve the situation. In fact, my project is going to be another effort in this direction. Apart from that, I would like to report our advancements in the scholarship of application in the field of nursing information technologies. It is an ongoing process, and much remains to be done, but we are integrating information technology into our nursing processes with relative success through the effort which is directly led by one of my colleagues. My proposed project appears to refer to the teaching type of scholarship because it is predominantly related to communicating knowledge (Fisher, 2015). Basically, the aim of the project consists of raising the awareness of nurses and, preferably, correctional officers with respect to BPSD, which can be regarded as a teaching process. On the other hand, it can also be suggested that certain programs and advice can be implemented in the course of the project because it is likely to involve an already developed BPSD awareness training program. These programs typically lack testing and are likely to require adjustments to the specific learning needs of the participants (Spector, Orrell, & Goyder, 2013). As a result, the process of the use of the programs in practice might be used to describe the project as partially referring to the scholarship of integration and application (Fisher, 2015). As for the rest of the categories, the proposed project is aimed at improving the quality of care, which is impossible without proper training and exceptional awareness of BPSD (Spector et al., 2013). Frame a Practice Question Using the PICOT Format There is sufficient evidence to behavioral and psychological symptoms of dementia (BPSD) being difficult to manage. For example, Kales, Gitlin, and Lyketsos (2015) offer a state of the art review which shows that BPSD are challenging, costly, and cause stress to patients and caregivers, reducing their quality of life. The authors indicate that the issue is the result of the complexity of BPSD, which can involve a combination of a variety of symptoms with different etiology (from the specifics of dementia to interpersonal interactions). As a result, there is no single solution to the issue. Also, the authors highlight the fact that BPSD management requires holistic treatment, which makes it more time- and resource-consuming. Thus, the difficulty of BPSD management is established. Also, there is some evidence to the fact that the settings of correctional institutions make the management of BPSD more difficult. Feczko (2014) provides an overview of the evidence related to the BPSD management in correctional institutions. In particular, the author points out that the category of older adults (which is the key risk factor in the case of dementia) in prisons differs from that in the general population due to the lower quality of life that leads to premature aging. However, the author also reports that there is no valid statistical information of the prevalence of dementia in correctional institutions. Thus, it can be inferred that the issue does not receive sufficient attention while obviously remaining a hard-to-manage medical condition. The author also points out that the medical staff needs to work together with the officers to ensure the appropriate management of dementia in correctional institutions. Thus, it is established that correctional institutions have their specifics from the perspective of BPSD management.
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Finally, there is some evidence to medical and other workers being insufficiently equipped for working with BPSD. Spector, Orrell, and Goyder (2013) point out that the difficulty of BPSD management is the key reason for the issue, which may be complemented by the lack of appropriate training. The authors demonstrate that the obvious solution to the problem is additional training, but they highlight the fact that there is relatively little research on BPSD management training. Still, their systematic review indicates that there is evidence to training improving the quality of BPSD management. Thus, the issue of BPSD management in correctional institutions is proved by the complexity of the process as well as the specifics of the settings, and the solution to the issue consists of improving the nurses’ and officers’ preparedness through additional training. Evidence-Based Practice Change Models Of the multiple evidence-based practice change models, the proposed research is interested in those that focus on the environment because of the specifics of correctional institution patients, who are exceptionally vulnerable, and staff, which includes people without medical education (Feczko, 2014). A model that corresponds to this requirement is the Advancing Research and Clinical Practice Through Close Collaboration (ARCC) model as described by Schaffer, Sandau, and Diedrick (2012). This model has an explicit focus on the organizational processes: the first two stages presuppose assessing the culture and the readiness of the institution, and the second one is devoted to determining the barriers and strengths pertinent to the change. The third stage highlights the importance of collaboration during change by establishing the need for the mentors that guide it. The fourth stage is the change itself; the final stage also presupposes evaluating the outcomes. The change model is applicable to the proposed research. For example, the analysis of the organizational culture, facilitators, and barriers is especially important since the research targets both nurses and officers, who are likely to have different perceptions and motivation. Also, the establishment of the mentor system is expected to help due to the difference in medical knowledge between the groups. As for the implementation and evaluation of change, the study offers a course that resembles a test of a change, but this fact makes the evaluation of the outcomes particularly important. A well-established and widely used quality improvement model is the PDSA cycle, which stands for “Plan-Do-Study-Act” (Taylor et al., 2013). The “Plan” stage involves studying the process to be improved and considering future actions. The following stage presupposes carrying out and testing the plan. The outcomes are studied to check if they correspond to the requirements; eventually, they can be acted upon or adopted. The proposed research is aimed at quality improvement, which is why the application of the model is possible. For example, the proposed research may be viewed as the first three stages of the cycle. The planning stage is going to involve the analysis of the BPSD management at the workplace and the determination of the chosen solution; the “Do” stage will include testing the solution, which is the aim of the research. Moreover, the study is also going to involve the examination of the results, which is necessary to respond to the PICOT question. However, the acting upon the improved process will only be carried out if the results are appropriate, and there is a chance that another cycle will be required before the desired outcomes are achieved. Interprofessional Collaboration for Improving Practice If defined broadly, interprofessional collaboration refers to the joint work of the people of various professions towards the same goal. In the case of healthcare, the goal is the quality of care and the safety and well-being of patients, which is a goal that a leader or change agent with the Doctor of Nursing Practice (DNP) education can manage (Ash & Miller, 2015). Other DNP ways to contribute can include, for example, the promotion continued education. It is the role that I am going to play for my DNP project, which is an educational effort aimed at improving the understanding of Behavioral and Psychological Symptoms of Dementia (BPSD) in my coworkers. Indeed, I have some experience in working in interprofessional teams, and I typically collaborate with other nurses, psychologists, and physicians. Also, I think that a significant part of the interprofessional communication that I engage in is that between nurses and correctional officers. This kind of work is rather specific due to my settings (a correctional institution), but I believe that this factor makes it even more important to consider. There are many issues that are related to the lack of appropriate education in officers; apart from that, their perspective differs from that of nurses, which makes collaboration difficult at times. For example, Melnikov, Elyan-Antar, Schor, Kigli-Shemesh, and Kagan (2016) discuss the problem of the stigmatization of patients with mental illnesses by the officers, which can be alleviated by nurses who should provide training and lead meaningful change in the organizational culture. Returning to my project, I would like to point out that the improvement of the officer’s awareness of BPSD is very important for the well-being of patients. For example, BPSD can be mistaken for violent or aggressive behavior, which may result in the patient receiving punishment rather than treatment. Thus, my project is directly aimed at improving our collaboration and, eventually, the safety of patients. Ash and Miller (2015) also point out the fact that nurses can learn from the performance of the people of other professions through the mentioned “strategic alliances” (p. 237). I think that the communication between nurses and officers is currently lacking, and I have to admit that I have a rather limited understanding of the officers’ perspective. In future, I hope to develop my understanding of their position because I suppose that it can assist me in building well-functioning teams with the officers and leading some of the quality improvement changes (including my DNP-project) as a DNP-prepared nurse. DNP Roles The key role that I want to play in the future is that of an advocate for the rights of my patients; also, I think that it is impossible without raising the awareness of mental health, which is why I intend to consider the role of an educator in my community. My DNP project already requires me to play the second role. Both these functions can be regarded as rather typical for a DNP-prepared nurse and probably should not be viewed as emerging, especially when compared to roles like DNP entrepreneurs or nursing informatics specialists (Riley, 2015; Zaccagnini & Edinger, 2015). However, I suppose that the mentioned agendas can result in me being involved in project management, which can be viewed as a relatively novel role. I am likely to require well-developed communication skills for my chosen roles; also, I might need to lead the change in my organization, which calls for a noticeable understanding of the activities of leaders and change agents. DNP-prepared nurses receive the required training: as stated by Riley (2015) and Zaccagnini and Edinger (2015), DNP programs aim to enhance their graduates’ understanding of organizational change, leadership, and healthcare delivery improvements. Also, as an educator, I require the expert knowledge in the area of my practice and research skills, both of which are provided by DNP programs. Riley (2015) insists that DNPs are expected to be better at educating nurses than nurses with a Master’s degree (p. 404), even though the author also states that DNP programs are not aimed at educators. Thus, as a DNP-prepared nurse, I should be equipped to perform my chosen roles. References Ash, L., & Miller, C. (2015). Interprofessional collaboration for improving patient and population health. In M. Zaccagnini & K. White (Eds.), Doctor of Nursing Practice essentials (pp. 235-272). Sudbury, MA: Jones & Bartlett Learning. Cerejeira, J., Lagarto, L., & Mukaetova-Ladinska, E. (2012). 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