An investigation of psychological variables influencing the provision of person-centred dementia care by clinicians

Abstract

Person-centred care (PCC) is currently considered best practice for the delivery of dementia care. Patients with a diagnosis of dementia often require a multidisciplinary treatment team approach across health and medical disciplines. Despite broad recognition of PCC as optimal dementia care, there are challenges translating PCC frameworks into routine clinical care. This thesis aims to investigate how clinicians’ individual psychological variables influence the provision of dementia care. Existing frameworks of PCC focus on implementing changes using a top-down approach within an organisation. This thesis provides a unique contribution to the literature by investigating how individual clinician factors influence the provision of care. Further, the identification of modifiable psychological variables provides direction for the development of required clinical intervention to enhance clinicians’ capacity to provide PCC. This body of research consists of three distinct research phases that produced five papers for publication. Each phase of research was guided by the previous stage, involving a review, two quantitative studies and one qualitative study. The first research phase consisted of a narrative review of the literature to identify the potential psychological variables of clinicians that may influence the provision of dementia care. This review showed that establishing a meaningful connection with patients who have a diagnosis of dementia is an important aspect in the delivery of PCC. The review also synthesised evidence-based research about death anxiety, ageism and coping strategies in the context of Terror Management Theory. Based on these findings, an argument was put forward that people with dementia elicit higher levels of death anxiety in clinicians based on patients being (a) older in age, and (b) having a degenerative condition, which may influence the provision of PCC. A model describing the possible influence of psychological variables on the provision of PCC was proposed for further examination. The second phase of research consisted of two quantitative studies that investigated aspects of the proposed model from the narrative literature review. This phase consisted of an experimental study and a survey that produced two subsequent papers for publication. The first study was an examination of the relationship between death anxiety and fear towards patients based on the age and illness of the patient. Participants were 94 undergraduate nursing students who were presented with a fictional patient varied by age (29 years or 71 years) and illness(arthritis, cancer or dementia). The results showed that higher levels of death anxiety were associated with the older dementia condition compared to the other conditions, supporting the model proposed in the first phase of research. Greater fear was also associated with the dementia target patients. The second quantitative study examined the relationship between psychological variables such as death anxiety, coping strategies, and depersonalisation of a patient by clinicians who provide care to patients with a diagnosis of dementia. A study sample consisted of 119 participants (83% female, Mage = 40.27, SD = 12.78) across disciplines including nursing, psychology, occupational therapy, social work, physiotherapy, medicine, dietetics and other allied health professionals. Mediation analysis showed that death anxiety had a significant positive effect on depersonalisation via coping strategies; however, there was no direct effect of death anxiety on depersonalisation. A direct relationship was found between death anxiety and a measure of patient engagement. These findings were interpreted in the context of the proposed model of PCC. The final phase of research was an exploration of the aspects of the provision of care from the perspective of clinicians who routinely provide dementia care. Specifically, the aim was to identify factors that influence the provision of care and what skills are used to establish effective, meaningful connections with patients who have a diagnosis of dementia. A qualitative inquiry was conducted using semi-structured interviews for 12 nurses and allied health professionals employed at specialist older persons mental health services (inpatient and community). Thematic analysis was conducted across participant interviews. All participants discussed the importance of establishing an effective therapeutic relationship with patients who have a diagnosis of dementia. The results showed that factors which influence the delivery of dementia care include limited control for patient outcomes, societal views, own biases, and emotional challenges. Strategies used to manage these barriers include acceptance, use of reflective practice and workplace supports, and self-care practices. The final paper produced as part of this research details the qualitative inquiry regarding the skills needed to establish a meaningful connection with patients who have dementia, relevant to PCC. A thematic analysis identified five themes: empathy, unconditional positive regard, congruence, psychological flexibility and communication. Taken together, the findings from these studies make a unique contribution to the literature about the influence of psychological variables on the provision of dementia care. Several theoretical, clinical and policy implications from this research are discussed, including recommendations about the use of clinical interventions and training to enhance the quality of dementia care. The use of the clinical psychology intervention, Acceptance and Commitment Therapy (ACT), may be relevant to enhance the psychological flexibility of clinicians providing dementia care. Finally, skills training using known person-centred counselling principles may also be useful in promoting the translation of PCC principles into routine clinical care. Keywords: dementia; person-centred care; death anxiety; therapeutic alliance; psychological flexibility

Date of Award	2021
Original language	English
Supervisor	Tricia BROWN (Supervisor), Anita MAK (Supervisor) & Kristen Murray (Supervisor)