All nurses have a duty of care to their patients (Brooker and Waugh, 2013). Nurses are expected to play a safeguarding role, recognising vulnerable patients and protecting them from harm, abuse and neglect. Elderly patients are at especial risk due to their poor health, disabilities and increased frailty (de Chesnay and Anderson, 2008). Of concern here, is the higher than average incidence of abuse in elderly people with dementia (Cooper et al., 2008). Nurses play an important role in recognising signs of abuse and acting as advocates for their dementia patients. Here, the principles of safeguarding and how they are applied in dementia nursing are presented.
Dementia: Cause of Vulnerability
Dementia is a group of symptoms that are associated with declining functionality and physical health of the brain (NHS Choices, 2015). This decline in mental function makes a person increasingly vulnerable (de Chesnay and Anderson, 2008). Dementia is typically seen in elderly people with one in every three people over 65 having dementia, and two-thirds of these will be women (Alzheimer's Society, 2014). The signs and symptoms of dementia demonstrate how this condition makes someone vulnerable to harm, abuse or neglect (Hudson, 2003) as they include: memory loss, reduced thinking speed, reduced mental agility, language difficulties, lower levels of understanding and reduced judgement. Furthermore, as dementia develops people become more apathetic and isolated as they lose interest in socialising, putting them at increased risk. Dementia can alter a person's personality (Hudson, 2003). They may find it difficult to control their emotions and hard to empathise. They may appear more self-centred, suffer from hallucinations and even make false claims or statements. All of these factors make it difficult for relatives and carers to interact with the dementia patient especially when offering very personal care (Adams and Manthorpe, 2003). Dementia reduces a person's ability to live independently and, as the condition progresses, they will increasingly need support and assistance. Their lack of mental capacity makes dementia patients vulnerable to the actions of others (Hudson, 2003). They will require assistance with decisions and gradually lose their autonomy as the dementia progresses, eventually relying on others for even the most simplistic decisions. Depending upon the stage and severity of their dementia, they may be living at home with support from relatives, or they may be in residential care.
Safeguarding: Duties and Expectations
Safeguarding adult patients means to protect those at risk of harm from suffering any abuse or neglect (Tidy, 2013). The CQC (2015) defines safeguarding people as "protecting people's health, wellbeing and human rights, and enabling them to live free from harm, abuse and neglect". Safeguarding is seen as an essential component of high quality health and social care. The healthcare provider is expected to minimise the risk of any abuse or neglect befalling a patient, identifying any potential causes and taking steps to mitigate them. A patient's right to live safely and free from abuse or neglect must be protected, and their wellbeing promoted with ample consideration for their own views and beliefs. The overall responsibility for safeguarding vulnerable adults lies with Adult Social Care (Dementia Partnerships, 2015). They receive and process and safeguarding issues from their partner agencies. However, each partner agency is expected to have its own procedures and practices to recognise and respond to any safeguarding alerts. This means that all staff employed by a health or social care provider has a duty to identify and report any safeguarding issues. Nurses caring for patients with dementia therefore have a duty to identify and report any signs of abuse or neglect (Hudson, 2003). Furthermore, they must have the knowledge and skills necessary to provide quality care to these patients with reduced mental capacity. Abuse of a vulnerable adult can occur anywhere: at their home, in a hospital or a residential care setting (Tidy, 2013). Abuse can include physical actions, sexual abuse, mental or emotional abuse, neglect and also financial abuse. Often, the abuser is well known to the victim (de Chesnay and Anderson, 2008). They could be a neighbour, relative or friend, carer, nurse or social worker, a fellow resident or service user. The adults most at risk of abuse are the frail elderly people who either live alone, or live in residential care, but without any family support (Mandelstam, 2008). In terms of suffering physical harm, the most at risk are those adults with mental or physical disabilities.
Dementia Specific Issues
Dementia patients are vulnerable adults, their degree of vulnerability dependant on the stage and severity of their condition (Tidy, 2013). The Department of Health describes vulnerable adults as those who are unable to take care of themselves, or who are unable to protect themselves from harm (DH, 2000). People with care and support needs require help and assistance from both the nursing and social care disciplines. Part of the nurse's duty is to safeguard their vulnerable patient from abuse and neglect (SCIE, 2015). The Care Act (HM Government, 2014) requires local authorities to perform safeguarding duties. This stipulates a multiagency approach where any safeguarding concerns are recognised, acknowledged and addressed. Dementia patients are especially vulnerable as they increasingly lack the mental capacity to participate in the decision-making process that will ultimately protect and promote their own interests (BMA, 2011). This means that any decisions made regarding their care or treatment are made on their behalf. This loss of autonomy disempowers them and makes them subject to others' will. Coupled with the ageing process, declining physical health and increased frailty, this puts dementia patients in a highly vulnerable position.
Steps a Nurse Can Take: Identification
Safeguarding adults with dementia is a difficult task. It is widely acknowledged that it is difficult for the nurse to spot signs of abuse in dementia patients due to similarities between signs of abuse and symptoms of their underlying condition. General signs of abuse can include frequent arguments between the caregiver and the patient, and changes in the dementia patient's personality or behaviour (Tidy, 2013). Yet, as noted above, these are also signs and symptoms of the progressive disease. Furthermore, spotting such trends requires the nurse to have good knowledge of both patient and carer. Recognised signs of emotional abuse such as rocking, sucking and/or mumbling to themselves are also dementia-like (Tidy, 2013). Often professionals can only detect the signs of physical abuse and neglect by way of a detailed physical examination. The nurse should look for signs of physical and sexual abuse such as physical injury, bruising and bleeding. These may seem more easily detectable, but can be concealed or explained away as accidents. Signs of neglect, including weight loss, dirty living conditions, poor personal hygiene and untreated physical problems, should be identified by the nurse. Again, factors associated with dementia such as increasing apathy, reduced taste / appetite may be the underlying cause and will need to be explored. Effective safeguarding requires the nurse needs to get to know their patient, discussing all aspects of their well being with them and/or their carer. People with dementia are especially vulnerable to abuse being less able to remember or describe what has occurred (Alzheimer's Society, 2014). Victims, whether they have dementia or not, find it difficult to tell anyone what has happened. Added to this general reluctance, are issues specific to dementia: patients may feel that they will not be believed, have difficulties recalling and communicating events. The distress caused by the abuse may exacerbate these difficulties. Dementia patient are often not believed, being discredited and thought of as confused and unreliable. Therefore, to protect their patients and best represent their interests it is essential that the nurse understands them and establishes a good trusting relationship. Dementia patients are also at increased risk of financial abuse. This can include sales-people taking advantage of them, relatives or carers accessing their bank details or causing them to alter their will and/or gain power of attorney (Adams and Manthorpe, 2003). Yet, the nurse should remember that some of these actions may be necessary steps so as to provide care to elderly dementia sufferers. For example, a carer may need to pay for some goods or services for the patient, and, in cases of significant reductions in mental capacity, power of attorney has to be awarded to ensure that all aspects of the dementia patient's life are managed. Nurses should be aware of the Mental Capacity Act (HM Government, 2005). This was introduced to help protect the rights and wellbeing of those who lack capacity. It governs the responsibilities and jurisdiction of those making decisions on another's behalf. It aims to ensure that people's autonomy is protected, but where they cannot make a decision, they are not ignored and any actions are in their best interest (Adams and Manthorpe, 2003). The demanding care needs of dementia patients can result in high levels of 'carer stress' to be experienced by relatives and friends. This may cause that individual to do abusive things and behave out-of-character. Nurses should recognise that carers of dementia patients experience greater strain and distress compared to carers of other elderly people (Alzheimer's Society, 2014). The enforced change of lifestyle resulting from caring full time can manifest as resentment and dislike. External pressures and stress can make people abuse others, as can a history of being abused themselves, previous violent or antisocial behaviour. Nurses should endeavour to develop a good relationship with both patient and carer(s). They should seek to establish trust and empathy and learn about the people behind the condition. This will enable the nurse to offer high quality care as described in the next section.
Steps a Nurse Can Take: Prevention
Nurses should recognise that abuse can take place in all settings and be performed by all people (Tidy, 2013). Abuse of dementia patients in formal residential or hospital care settings is usually a sign of an overall poor quality of care. It signifies that staff are not appropriately trained and skilled in dementia care. They do not understand the complex needs of these patients and therefore cannot adequately address them. Thus, where a nurse identifies abuse at an organisational level, the situation should be reported so the necessary systems and training can be put in place. Remedial action on this scale is outside the scope of this essay, but where a colleague or individual carer acts inappropriately, the nurse can intervene to educate and train them. The communication difficulties posed by dementia patients does mean that it is more difficult to offer person-centred care. This results in an individual's needs not being met. This is further exacerbated where the dementia patient exhibits behavioural and psychological symptoms such as restlessness, shouting and aggression. These can result in the patient being restrained or medicated inappropriately. Therefore, nurses should ensure that they have the knowledge and skill to work with dementia patients so as to act in their best interests. On occasion, the requirements of the Mental Capacity Act are not followed appropriately: Staff assume that all dementia patients lack capacity and therefore don't involve them in decisions. Nurses should be aware of, and understand, the Act. They should know how to implement it and where to gain advice if necessary. Ideally, there should be continuity of care. The same nurse should work with the patient and their carer(s) throughout the progression of the condition. By knowing the patient well, they will be better able to facilitate person-centred care, upholding the patient's interests and best representing their views. The nurse also has safeguarding duties with regards to home-based care. Improving the emotional and practical support given to family carers of dementia patients is recognised as key to safeguarding patients. These carers have little or no training and often do not feel adequately prepared (Alzheimer's Society, 2014). They often find the situation stressful and demanding: circumstances that could lead to abuse or neglect. The nurse should therefore ensure that they are approachable and inspire confidence in the patient and carer. They should provide education and advice to carers and ensure that back-up support and resources are available to those who need it at all times. Developing a good relationship between all parties is essential in preventing abuse from occurring, ensuring the patient's needs are met and their interests respected.
Nurses play a key role in protecting dementia patients from abuse. In order to effectively safeguard their patients, it is essential for nurses to understand the types of abuse, how and why it may occur. Dementia patients are at especial risk due to their declining mental capacity and reliance on others. Nurses are well placed to identify and prevent abuse through establishing close, open and trusting relationships with both patient and carer. Nurses can act as advocates for their patients, representing their best interests and facilitating person-centred care. Through providing education and support for carers, nurses can ensure that all the dementia patient's needs are met.
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