Caregivers' perceptions of aggressive behaviour in nursing home residents living with dementia: A meta-ethnography.

AIM: To explore how formal caregivers perceive and interpret aggressive behaviour in nursing home residents living with dementia, by synthesizing knowledge from published qualitative studies. BACKGROUND: Nursing home caregivers are exposed to aggressive behaviour from residents living with dementia. The way caregivers perceive aggressive behaviour may affect their feelings and actions related to situations and thus nursing care. Knowledge about caregivers' perceptions of aggressive behaviour has previously not been synthesized. DESIGN: Noblit and Hare's interpretative meta-ethnography. DATA SOURCES: A systematic literature search in CINAHL, PubMed and Scopus supplemented by manual search strategies, were completed. Nine studies from five countries, published between 2001 - 2015, met the research objective and inclusion criteria and were included. FINDING: Five themes describing formal caregivers' perceptions and interpretation of residents' aggressive behaviour emerged: "A manifestation of the disease"; "a way to express themselves and their needs"; "a reaction to caregivers" attitude and approach"; "a reaction to a stressful and demanding environment"; and "an unavoidable situation that seems impossible to solve". Themes were synthesized into the metaphor: 'tailoring using unpredictable patterns' and visualized in a model. CONCLUSION: Caregivers perceive and interpret aggressive behaviour related to the resident's illness and person, the caregiver's attitude and approach, or a demanding environment. Further research and theoretical development is important, as shown by different perceptions and interpretations, as well as central definitions in research publications. The study informs evidence-based practice and health-policy by showing the importance of developing reflective relational nursing care, knowledge, and competence in nursing homes.

TIME - Targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms: protocol for an effectiveness-implementation cluster randomized hybrid trial.

BACKGROUND: Nearly all persons with dementia will experience neuropsychiatric symptoms (NPS) during the course of their disease. Clinicians and researchers emphasize the need for an evidence-informed standardized approach to managing NPS that integrates pharmacological and nonpharmacological treatments for real-world implementation. The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) represents such an approach and is a multicomponent intervention based on the theoretical framework of cognitive behavioural therapy. METHODS/DESIGN: The trial is a 3-month cluster randomized trial conducted in 30 nursing homes including 168 participants with dementia and a high level of agitation. Each nursing home defined as a cluster will be randomized to receive either the TIME intervention (the intervention group) or a brief education-only intervention regarding dementia and NPS (the control group). TIME is a manual-based, multicomponent programme that includes a rigorous assessment, one or more case conferences and the treatment and evaluation of NPS. Patient-level measurements are taken at baseline (prior to randomization) and 8 and 12 weeks later. The primary outcome measure is the change in agitation, as defined by the Neuropsychiatric Inventory-Nursing Home Version, at 8 weeks from baseline. Secondary outcome measures include change in agitation at 12 weeks from baseline, and change from baseline at 8 and 12 weeks in other NPS, quality of life, and the use of psychotropic and analgesic medications. Mixed methods will be used to follow, measure and explore the implementation process and the effect of the intervention at the individual staff level and the organization level. Combining measurements of clinical effectiveness and implementation outcomes define this trial as an effectiveness-implementation hybrid trial. DISCUSSION: Measuring the implementation and effect of complex interventions aimed at reducing NPS in nursing homes is challenging. In this study protocol, we describe a multicomponent program, TIME, and discuss how an effectiveness-implementation cluster randomized hybrid trial can meet these challenges. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02655003 . Registered 6 January 2016.