Chapter three

This chapter will critically discuss the evaluation of the methodology used in all the
appraised articles. The aim of appraising articles is to ascertain the validity, strengths
and weaknesses of the research articles, look at the evidence, gaps, the outcomes
of the studies and apply it to the an area of study. Aveyard (2010), Polit & Beck
(2012).
3.0 Critical analysis and findings
Cognitive deficit in PLWD impairs their ability to complete motor and perceptual tasks
thus this chapter will critically discuss issues and support needed by PWLD in
feeding themselves and what inhibit them from recognising the need to accept help
with feeding from staff members (Chang & Roberts 2008). According to the
Alzheimer Association (2015) appropriate nutrition is vital for a well-built body and
vitality. However, for PLWD deprived nutrition could intensify behaviour symptoms,
for example, aggression, which consequently triggered unintentional weight loss
(Alzheimer Association 2015). As dementia advances, loss of appetite and weight
loss become a major concerns, because malnutrition has an impact on aggressive
behaviour in PLWD. Therefore, weight loss and malnutrition may compromised their
health, thus physicians recommend supplements between meals as additional
calories (Alzheimer Association 2015). PLWD are found to have a high rate of
feeding difficulties which includes clamping of the mouth shut, spilling food from the
mouth, pooling food in the mouth, difficulty swallowing and refusing food while being
fed (Volicer et al. 1989). These feeding difficulties interfere with adequate
consumption of calories and nutrients and may be associated with malnutrition
(Chang & Roberts 2008, Wasson et al. 2001).
Lopez et al. (2010) conducted a study in a nursing home in Southern America with
the aim of determining and gaining a broader understanding of the nurses
perception or beliefs, knowledge and roles in feeding residents with advanced
dementia. The study was a qualitative descriptive design and the data collection
method adopted was an interview (Parahoo 2010) with a purposeful sampling
method. The sample size used was 11 female experience nurses (Parahoo 2010).
Boswell and Sharon (2014). Written informed consent from all participants was

obtained from the University of Pennsylvania institutional review board and the
administrators in each facility. The Interview was conducted, at every stage in
research process there are ethical implication (Parahoo 2014). Eligibility criteria for
participants selection included nurses being 18 years or over, ability to speak
English, readiness to participate in the study and having six months experience in
caring for PLWD (Parahoo 2014). The population samples size used were 11 nurses
with an average age of 44 years and the years of dementia experience working with
(PLWD) was 21.3 years. The rationale for using 21.3% is that these people are
knowledgeable about the disease condition, know how to manage CB, had
knowledge

of

physiology

in

addition

to

knowing

how

to

manage

both

pharmacological and non-pharmacological intervention CB related to nutrition Lopez

et al (2013). Although these nurses have experience in almost of the requirement
above, they lacked education in managing CB in PLWD nutritional requirement.
Therefore, training was required on how to best manage PLWD nutritional needs.
Data collection for this work was an interview which was digitally recorded, including
written eld notes of observations which lasted between 20-45minues. Which in
qualitative studies are used in gathering data resulting in a face to face between the
studied group and the researcher (Boswell & Sharon 2014). Data analysis, all
recorded interviews were transcribed verbatim besides the authors acknowledging
outcome; the interview did not reflect the whole views of the population, which
indicate selection of bias (Polit & Beck 2012). However, in the findings, the research
discovered three major areas of interest.
Firstly, most of the nurses who responded to the interview seem to be lacking in the
awareness of identifying PLWDs nutritional deficits and the need to give heightened
priority in meeting the nutritional needs of residents with advanced dementia residing
in a care home. Furthermore, none of the nurses were able to give a valid account of
the intervention using assisted feeding or any other intense intervention such as tube
feeding because it lacks evidence and the analyses suggested the nurses could not
indicate the benefit. The second finding however is about the role of nurses in tube
feeding, which the majority of the nurses responded that weight loss should be
reported to the charge person. The last area of interest in the study was the moral
agency attentiveness, which accounts for accountability for ethical decision and
deed. The concerned is unawareness or information about the moral dimension in

nursing procedures in advance dementia. In conclusion, it was noted that nurses

observed their task of tube feeding judgements as trivial amongst their numerous
responsibilities, which was frequently reluctant to be engaged in complicated
decision.
Page and Hope (2013) used qualitative methodology design in Manchester to
investigate the perception of specialist dementia nurses based on their unmet
training and educational desires in addition to assessing their own knowledge and
skills following a gained consent from the researchers (Parahoo 2010). The design
study was an online survey a means of collecting data from a qualified large number
of respondents within a limited time frame (Naoum 2007). With a sample size of 40
registered randomly selected nurses across the UK in attendance at the Manchester
National Dementia conference to form a cohort group which was relatively good for
the study given that the selection was made in a large conference with participant
representing various professional nurses. (Polit & Beck 2012). Benner & Keyefian
(2008), argues that it is useful to introduce a study design with an overall report
about what it encompass (Benner & Keyefian, 2008).
Page & Hope (2013), aim of the criteria for their study participants selections from
dementia conference, was to measure the participant knowledge and skills against
expected enhanced dementia practice level and this signified avoidance of selection
bias (Polit & Beck, 2012). Part of ethical protocol is ensuring a clear inclusion and
exclusion criteria in a research study (Holloway & Wheeler 2010). Data analysis
revealed the emergence of six themes with respondents asked to measure their own
existing level of knowledge and skill in relation to each item with a scoring ranging
from 1 (very poor) to 10 (extremely proficient). Additionally, respondents were
requested to deliberate on the extent to which there was an unmet training need for
each item within the theme by assigning a score from 1 (strongly agree) to 5
(strongly disagree).
Nevertheless, the study findings, shows the need for recognition for a new approach
in dementia care. It acknowledges the presence of an unmet educational nursing
knowledge lacking in training mostly in biomedical aspects of dementia knowledge in
pharmacological and non-pharmacological and as such they needed an in-depth
knowledge before been delegated with clinical duty.

Additionally, it was observed

that the most devastating unmet need is enhanced knowledge of dementia

behavioural and psychological symptoms. Consequently, the research appears to
have been optimistic because the training and education of nurses at a larger scale
might result in a huge number of nurses caring for dementia to be competent in their
field of practice which will ultimately lead to enhanced care quality delivery of the
safety of the individual affected.
Furaker and Nilsson (2009) research is a qualitative design conducted in Sweden. It
focused on the competence of certified nurse assistants (CNAS) caring for people
with dementia in a residential care home. The study obtained a written consent from
the 12 (CNAs) working in the four nursing homes. Cronin, Coughlan and Smith
(2015) support that inform consent is central to the principles of autonomy in
research this added strength to the study. Data collection was done through dairy
notes. Polit and Beck (2012) support that diaries are useful in providing an intimate
and detailed description of a persons everyday life. In addition, a combination of
diary with an in-depth interview, which gives useful information on how they can
carry out their work and identify their lack which Grey & Smith (1999) cited in Furaker
and Nilsson (2009) supports that diaries are assumed to be a supplementary method
such as interviews and observations (Grey & Smith 1999).
Furaker and Nilsson (2009), used diary notes and interviews which were transcribed
and analysed using conventional content analysis. The finding were categorised into
three main categories and a number of subcategories were identified. Tesch (1990),
and Weber (1990), cited in Furaker and Nilsson (2009), that qualitative analysis may
allow fuzzy boundaries between categories. Consequently, the result presented
indicated that behaviour and strategies shows that PLWD frequently suffered mood
swing, which was manifest in diverse ways for example agitation, care refusal and
CB. Motor agitation was demonstrated when a resident walked around or repeated
certain wishes or questions. Knowledge related to dementia and mental health
diseases must be highlighted. CNAs lack competence in crucial theoretical
understanding about dementia diseases. It is remarkable that CNAs, caring for
people with serious dementia, have minimal insight for regarding dementia residents
conflicting behaviour. Therefore, the need for formal education centred on these
diseases is essential.

Di Napoli, Breland and Allen (2013) study was carried out in three specified skilled
nursing homes in Birmingham, Northport and Alabama. The study used a multicentre
approach which gives strength to this study and it allows generalizability giving that
research took place in different centres thus giving opportunity for more participants
to be involved as supported by (Wood & Haber 2006). The sample size was 178
PLWD, using large sample size give credibility to the study (Cronin, Coughlan and
Smith 2015). The data collection methodology used was a questionnaire and focus
group discussion. Cronin, Coughlan and Smith (2015) agreed that questionnaire is
used as a method of testing the existent or absence of an intervention impact in a
study.

Data were collected from 100 focus groups recruited from staff at three

specified locations. A focus group enabled the researchers unpick problems that
remain untouched by other data collection methods such as group discussion which
explore people insights into problems, allow them to share their views and gain
knowledge from each others (Kitzinger 1995),(Doody et al. 2012). Using this
method is paramount in focus group discussion given that, it enables participants to
express themselves freely (Holloway & Wheeler, 2010).
Data were analysed by double-entered and password protected database using
SPSS Version 19.0 for Windows a significance level of p < .05 was used for every
analyses. The study finding highlights the significance of training interventions for
nursing home staff. The interventions were to be focused on increasing staff
knowledge of sexuality and dementia, in addition to improving attitudes and
decreasing stigmatisation around sexuality and dementia, mostly same-sex
residents. Furthermore, PLWD sexuality discloses curious understanding, as the
study concentration centred on staff knowledge and perceptual experience on
sexuality in older individual with dementia. Furthermore, due to consequence of lack
of knowledge in older adult sexuality, specific amongst PLWD, nurses frequently
misinterpret or have problems comprehending dementia sexual disinhibition
behaviour Di Napoli, Breland and Allen (2013). For example, as a result, there
appears to be misinterpretation in an effort made by staff to balance defending
service users from impending danger or injury, deciding service users' consent to
sexual capability, in addition to guaranteeing their space, and standing on their
autonomy.

The strength in this study is that it gives additional knowledge concerning nursing
home staff knowledge in late-life sexual behaviours management in nursing home
by exploratory the associations between staff characteristics, knowledge of late-life
sexuality and dementia, attitudes toward late-life sexuality, and understanding of the
relation between cognitive ability and sexual expression. The limitation is that the
study results were mostly correlations between variables measured at a giving point,
with impeding explanation of relationship between associated variables
Smyth et al. (2013) conducted a cross-sectional survey design in Australia to assess
the knowledge of Alzheimers disease amongst staff nurses. The study has a focus
aim which is to assess knowledge about dementia across a range of healthcare staff
in a regional health service district Moule & Hek (2011), support that focused aim will
guide the researcher on what the researcher is aiming to accomplish. As a means of
appraising the level of their knowledge, the researchers used a survey with validated
30-item Alzheimer Disease Knowledge scale (ADKS). Data collection was done with
the help online Survey Monkey software. Mass e-mails containing a link to the
survey were sent to all staff in the health district, using the internal email system. Out
of the 4,750 district health service staffs emailed, approximately 1,659 accessed
their email and 410 individuals started the survey. Among these 410 individuals that
commenced the survey, only 360 respondents accomplished the task of the main
dependent variable scale Alzheimer Disease Knowledge Scale (ADKS) and these
answers consist of the final data set. The concluding sample was a reply rate of 21.7
percent (360/1659), with the denominator as the people who welcomed the survey
as defined as having opened the electronic mail. Ultimately, the sketch was executed
online with a well-structured questionnaire, sent through to participants personal
email. 360 nurses responded to the survey, was appropriate. The conclusion is easily
being made using a precise and accurate, appropriate sample size (Nayak 2010).
Ethics approval was obtained for the project as a low risk, study from the health
service region and one participating university. Data analysis was carried out using
IBM SPSS Statistics 19. Two tests were undertaken to check for potential biases
in the sample achieved.
The first was comparing the demographic characteristics of the respondents
completing the ADKS with those not completing it. The findings shown that
knowledge level was focused directly towards staff members experience caring for

dementia. Generally, knowledge of dementia. The first result displays no significant

changed and the second has indicated a significant difference with the present of
bias, the second potential bias was if the sample precisely represented the entire
regional health service staff population When the respondents demographic
characteristics were compared with the population data privileged, several
statistically significant differences were found 0 5 level. Conversely, the respondent
sample represents mostly females, few were below 30 years with more over 50 years
old, allied health staff were more with few medical staff than the population. As a
result of these differences, a population weighting procedure was utilised to regulate
resultant biases in the results. The strength of this study is that the finding gives
credibility to earlier analysis which demonstrates that knowledge and specialised
practice support the improvement of care delivery

Cross et al. (2008) conducted a qualitative research design in Glasgow, using a

survey sampling method with a sample size of 65 experience community psychiatric
nurses (Polit & Beck 2012). The study aims to assess the degree of memory
rehabilitation of the (CPN) attending to dementia patients. The study was approved
by the Greater Glasgow Local Research Ethics Committee in Scotland with consent
obtained from all participants. The design used was structured group interview and
questionnaire Moule & Goodman (2011). Data analysis was convened by
anonymised to ensure the protection of confidentiality and meet data protection
requirements, and coded onto SPSS for analysis purposes. Normality of
distribution inspection was maintained and non-parametric inferential methods used
where suitable. Additionally, correlational analyses and means comparisons of two
groups were utilised.
First, general information on clinical experience, numbers of dementia patients on
caseload and classication (mild, moderate, severe dementia) were recorded. Next,
participants completed. Case Vignette Data analysis was convened through the use
of completion of questionnaire covering knowledge in memory strategies. Assumed
their knowledge in memory rehabilitation remained little or zero percent. The
percentage given is alarming and has given a clear indication that education in

dementia and training can be given a due consideration. The range of total years of
nursing experience was 1 to 33 years; mean years 20.2
Educational interventions for family caregivers can have positive effects on
caregivers well-being and quality of life, role satisfaction and knowledge, with
reducing the burden and depression. Furthermore, responses from the correlational
analysis definition of terms data from Memory Strategies questionnaire with
frequency calculates data from identical questionnaire displayed a significant positive
correlation between measures (r = 0.56, N = 65, p < 0.0001). This signifies a huge
size effect, equivalent to d = 1.3, occurrence of giving advice was positively
associated with memory strategy knowledge. Overall, the result shows that the
CPNs with a higher memory strategies, knowledge provide adequate counsel more
often compared to those with inadequate knowledge.
The study of Jones, Moyle & Stockwell-Smith (2013) was conducted in three
Australian dementia care facilities in Australia, the study aim to determine the
knowledge of dementia among carers concerning aetiology and pathology,
symptoms and treatment to investigate staff perceptions of the importance and
adequacy of dementia education and training opportunities. In addition to using the
aim information in developing an educational intervention to improve quality of care
provision for the elderly PLWD. The study design was qualitative research, sample
size was 35 health care participants, 24 females and 11 males between ages 20 to
59 years. The sample size was adequate for the three care homes (LoBiondo
&Haber 2006). The ethical approval protocol was fully observed from human
resources committee and seeks consent from all participants before the study
(Rebar & Gersch 2015). Interestingly, the inclusion criteria for the participant
selection was that the staff must have been working for at least doing two shifts a
week, though their years of experience were not mentioned
Data collection was carried out by the completion of a short questionnaire and a
semi-structured interview, semi structured the interview is more formal than the
unstructured interviewed given that number of specific topics around to be based on
the interview (Naoum 2007). Based on SKDT of a 33-item instrument of true/false in
assessing care staff level of dementia knowledge in three areas: which are,
dementia a normal sample distribution, in assessing participants knowledge on

dementia. (Polit & Beck 2012). Data analysis was adopted through the means of an
Australian terminology version of Staff Knowledge of Dementia Test (SKDT). (Rebar
& Gersch 2015). The study finding shows the necessity for improving the care staff
knowledge on dementia symptoms such as aggression as well as education
implementing training in dementia be given a direct practical competency
requirement for effective care delivery