Exploring family member and nurse experiences of caring for an older person with advanced dementia in the Emergency Department (ED): an appreciative inquiry

Background: Admission to the Emergency Department (ED) can be stressful for older people with advanced dementia and their family members. Previous research has tended to emphasise the negatives and deficits in care. Little research seeks out what works well or what matters in dementia care experiences in this context. Knowledge embedded in the experiences of family members accompanying an older person with dementia in ED and the experiences of emergency nurses caring for them may be part of the solution in developing strategies for improvement. Aim: This study was conducted in a large ED in the southwest of Ireland. It sought to explore the experiences of family members accompanying an older person with dementia in ED and the experiences of ED nurses caring for the older person with dementia and their family member in an episode of care. The intention was to generate new knowledge to co-create future possibilities for development. Four academic papers are weaved into the thesis. Methodology: Appreciative Inquiry (AI) was the participatory methodology used in this study. AI is an approach which focuses on generating new insights to open the gateway for possibilities and alternative ways of doing. This study pertains to the Discovery and Dream Phases of AI. Methods: In the Discovery Phase, data generation methods were participant observation with ED nurses (n=12) caring for older people with dementia in ED and interviews with family members (n=15) who accompanied an older person with dementia in ED. Interviews were framed through a storytelling approach. In the Dream Phase, ED nurses (n=10) participated in a Learning Conversations Session for further data generation and to co-analyse findings from the Discovery Phase. Data generation methods in the Dream Phase were appreciative framing and dialogue, storytelling and collective sensemaking. These methods were creatively used to maximise the potential for generating new knowledge about worked well in enhancing the experiences of dementia care in ED. The six step approach developed by Braun and Clarke (2006) provided a structure to guide thematic analysis. Findings: This resulted in a number of fresh insights; seeing things from a different perspective, balancing relationship centred and technical care, working in the moment as a sympathetic presence and collaborating in caring for an older person with dementia in ED. The common thread was that the quality of relationships shape the quality of care experiences for family members and ED nurses. In a technical and task orientated environment such as ED, the value of relationship centred care is sometimes underestimated. Despite contextual challenges, it was possible for ED nurses in this study to blend relationship centred and technical approaches to care. Alliances between ED nurses and family members may be pivotal in enhancing experiences of dementia care in ED. This study showed that informal collaborations between ED nurses and family members were happening every day. These collaborations could be strengthened if ED nurses had the courage to ask family members how they would like things to be. To do this, ED nurses would need to overcome their fear of not being able to meet family member wishes or expectations. AI methodology encouraged a deliberate stance away from deficits and negatives which enabled ED nurses to explore situational complexity, vulnerability and fears as well as moments of excellence. Unearthing moments of excellence which sometimes go unnoticed or unrecognised was an important step in stimulating new thinking around what works well and how this could happen more of the time. Conclusion: The outcomes of this research have the potential to contribute to the existing knowledge base in that they provide new insights into what matters and is valued in experiences of dementia care in ED and also generate knowledge about how to operationalise relationship centred care as a pivotal part of emergency nursing practice