The prevalence of dementia is increasing globally (World Health Organization, 2015). According to a World Alzheimer Report (Prince, Albanese, Guerchet, & Prina, 2014), 47.7 million individuals worldwide have dementia, with 7.7 million new cases diagnosed every year. Dementia is defined as a persistent and progressive decline of cognitive functions leading to a loss of functional abilities; causes include degenerative neurological diseases, such as Alzheimer's disease, and vascular and frontotemporal dementia, among others (Nogueras, Postma, & van Son, 2016). Dementia dramatically affects everyday life, with problems ranging from a broad spectrum of cognitive deficits to specific behavioral changes and functional deficits (Giebel, Challis, & Montaldi, 2015). Older adults with dementia are at high risk for chronic stress and experience difficulties in communication, problems in social relationships, and cognitive changes (Williams et al., 2016), eventually experiencing feelings of loss of control and dignity (Digby, Lee, & Williams, 2017).
The burden of providing care to individuals with dementia is widely recognized. Behaviors of older adults with dementia include aggression, agitation, wandering, withdrawal, and vocal outbursts, which can lead to distress among nurses (Williams et al., 2016). Despite these challenges, nurses can have positive interactions with individuals with dementia. Specifically, forming close relationships with individuals with dementia can be rewarding, and nurses may feel a sense of reward from having contributed to their well-being (van Knippenberg, de Vugt, Ponds, Myin-Germeys, & Verhey, 2017). Unfortunately, few studies have identified nurses' positive experiences in caring for older adults with dementia, whereas research on nurses' burnout has increased worldwide (Elliot, Williams, & Meyer, 2014).
Korea has traditionally been influenced by Confucianism, which values respecting one's parents and older adults. Thus, when parents age and begin showing symptoms of dementia, Korean individuals generally provide care in the home as opposed to using nursing facilities or geriatric hospitals (Maeng & Lee, 2017). Hence, the professional treatment delivery system for older adults with dementia is in its infancy. Models for providing care to individuals with dementia, such as person-centered care and need-driven care, have been introduced from developed countries to manage the increase in individuals with dementia in Korea (Son, Park, & Oh, 2018). However, sufficient education on these models has not been provided to nurses, owing to lack of literacy on caring for older adults with dementia and/or lack of financial resources. As such, there is a lack of systematic education and training for Korean nurses caring for older adults with dementia in geriatric hospitals or nursing homes (Son et al., 2018). Taken together, research suggests that professional care options for individuals with dementia living in Korea are limited (Kang & Son, 2017).
Qualitative research methods are often used to explore an individual's experience (Choi, Choi, & O'Donnell, 2018), and grounded theory seeks to generate a theory from actions, interaction, and processes by interrelating categories of information (Denzin & Lincoln, 1994). Thus, grounded theory is a suitable method to explore nurses' experiences in caring for older adults with dementia. The current study sought to explore factors that might improve care provided to individuals with dementia by exploring nurses' positive experiences to develop a practical approach that would complement the current body of nursing knowledge.
A qualitative study using grounded theory was conducted to explore positive care experiences of nurses who provide care for individuals with dementia. Participants were recruited from nursing homes and geriatric hospitals in Seoul and Gyeonggi-do, South Korea. Inclusion criteria were nurses who cared for older adults with dementia for more than 1 year and voluntarily agreed to sign the consent form. Data were collected using theoretical saturation of data, which is a process of continuously collecting data until the same contents are repeatedly stated and no new information is found. Thirteen nurses participated in interviews, and no participant refused to sign the consent form. In addition, the collected information was compared across cases and with the current literature. For example, because nursing environments for individuals with dementia vary greatly depending on the institution, and because approximately 70% of nurses have been working within the same institutions for approximately 3 years (Kang & Son, 2017; Son et al., 2018), data were collected by comparing the differences in nursing experience according to length of experience (i.e., 1 to 9 years) in providing care for individuals with dementia. The study question was: “What are nurses' positive experiences in caring for older adults living with dementia?” Semi-structured interviews were used to gather data.
Interviews were conducted in Korean and took place in counseling rooms where participants could express their experiences without interruption. Each interview lasted between 60 and 90 minutes and took place in November 2017. Interviews were digitally recorded and transcribed. The quotations in this article were translated into English by the researchers and were subsequently proofread by a professional English editing company. Further, participants' non-verbal expressions were recorded through field notes.
Data collected were analyzed using grounded theory (Corbin & Strauss, 2014), which comprises three steps: (a) open coding, (b) axial coding, and (c) selective coding. Open coding was used to explore the phenomena, axial coding was used to relate codes to one another, and selective coding was used to propose the theoretical framework (Corbin & Strauss, 2014).
The Institutional Review Board of the researchers' organization approved the study protocol. Participants were informed about the study purposes and process and told that they could withdraw any time without adverse consequences. Participants also understood that the recordings would be kept for 3 years following the study. Participants signed the consent form with all the above points in mind.
Thirteen nurses participated in the study. All were women ages 37 to 61 years, and most were married. More than one half of participants were college educated, and their experience in providing care to individuals with dementia ranged from 1 to 9 years (Table 1).
Findings from Open and Axial Coding
A total of 33 codes, 12 categories, and 21 sub-categories were derived through open coding (Table 2). Categories were analyzed using axial coding, which was illustrated using the paradigm model (Figure 1). The paradigm model is a holistic framework that explains phenomena using related factors of causal conditions, phenomenon, contextual conditions, intervening conditions, action/interaction strategies, and consequences (Kalateh Sadati et al., 2016).
Results of Open Coding of Nurses' Positive Experiences In Dementia Care
Paradigm model of nurses' positive experiences in caring for older adults with dementia.
Causal Conditions of Nurses' Positive Experiences
The category Caring Feelings from the Heart was derived as a cause for nurses' positive experiences. Participants thought of their parents when taking care of older adults with dementia and believed the good nature of older adults made them (i.e., nurses) care from the heart.
I think of my mom when seeing older adults living with dementia, especially when talking to them. What they say is similar to what my mom used to tell me. They are like my mom.
The clients look just like my grandmother. I usually check their conditions when starting work. There are grannies who take candy out of their pockets and put it firmly in my hands. I feel like they are my real grandmothers.
Older adults are very pure, like a child. They have no bad intention or thoughts in what they do. They do not act badly anymore when understanding the situation.
Phenomenon of the Nurses' Positive Experiences
The category Unconditional Caring was the core phenomenon of the paradigm model. Phenomenon in grounded theory refers to what is happening in the participant's experience (Corbin & Strauss, 2014). Nurses in the current study spontaneously formed intimate and caring relationships with older adults with dementia, which led to the phenomenon of unconditional caring.
I feel as if I have met my grandmother when being with older adults living with dementia. I usually do not talk about anything personal to others, but I do it with them. I feel close enough to them to [talk about my] personal life.
There are times when I get busy suddenly. I work fast then, so I used to drop a bag of medicine onto the floor. Older adults living with dementia do not get angry. They instead thank me for my efforts. They are generous and have a lot of consideration.
An older adult always smiles at me. I feel warm then. I feel like she is my family, not a client.
Contextual Conditions of Nurses' Positive Experiences
The categories Maturity as a Nurse and Understanding Care of Older Adults were derived as contextual conditions that affect positive experiences in the care of older adults. In the current study, nurses with more experience in the care of older adults recognized older adults with dementia as autonomous individuals and understood the difficulties of their families; these nurses seemed to have more positive attitudes in caring for older adults compared to nurses with less experience in the care of older adults.
I have been taking care of older adults living with dementia for about 9 years. I know almost everything about them. I usually accept the client's feelings as they are when they act aggressively. Then they understand that I am trying to help them. They come to trust me.
Family really influences dementia symptoms. It improves when the family visits. The client who refused to eat begins to eat when the family comes.
The family sometimes gets angry talking to older adults living with dementia. I explain that it is not necessary to take it emotionally because it is just one of the symptoms. It is most important to stabilize them when the symptoms appear.
Intervening Conditions of Nurses' Positive Experiences
The categories Familial Support and Confidence in Nursing were also derived. Nurses understood that family support of older adults is important, which led to collaboration with the family. Nurses who were confident in caring for older adults in the current study seemed to have more positive attitudes toward their care of these patients.
I am confident. I have a lot of experience in caring for older adults living with dementia. I understand the symptoms well, so the clients are not difficult for me to care for; of course, they sometimes show aggressive symptoms, but I am used to them. I can handle it well.
I cannot take good care of older adults living with dementia without the family's help. I do not know anywhere else, but the family is cooperative with me in this nursing home. My clients sometimes fight with each other, but their families understand the situation well and thank me for my efforts.
Action/Interaction Strategies of Nurses' Positive Experiences
The categories Building Trust With Clients, Implementing Emotional Care, Caring for Dementia Symptoms, and Collaborating With Human Resources were derived and reflect the strategies nurses used when caring for older adults with dementia. Nurses in the current study built trust with older adults with dementia by providing consistent care and checking their conditions frequently. They also provided emotional care using verbal and nonverbal communication. They used strategies to address dementia symptoms without letting emotion get in the way, and they sought additional help when needed.
It is important to build trust with older adults living with dementia. I cannot start providing care if they do not trust me. I go often and check their conditions. They did not even make eye contact with me at first, but later they came to trust me enough to talk about their family.
I like holding the hands of my clients. There is a feeling of warmth beyond words. It is, of course, good to have a friendly conversation with them, but I prefer to have physical contact.
Dementia clients sometimes suddenly turn aggressive. I feel hurt in my mind when they behave like that since I am a human. It is good to accept it only as a symptom of this situation. They return to normal when the symptom disappears, so I do not have to take it emotionally.
Cooperation is most important. We [nurses] have to know the clients' conditions best, and it is better to share their information with other medical staff and, of course, with the family. I learned a lot of things that I did not think about clients while working with them.
Consequences of Nurses' Positive Experiences
The categories Gratification in Nursing Practice and Appreciation Toward Life were derived, which were consequences of nurses' positive experiences in caring for older adults with dementia. Most nurses in the current study were satisfied and pleased with their work in caring for older adults, and they reflected on their experiences positively.
I feel rewarded when the [clients'] family says, “Thank you,” but more than that, I am more satisfied with clients, especially when their condition improves. There was an older adult always yelling at me. I consistently took good care of her. Her condition eventually improved, and she started talking to me.
Many people say it would be difficult to take care of older adults living with dementia. It is really hard, but not all of them. I feel great about helping them and also feel that I have done much for society, so I am happy.
I look back on myself. I wonder if I am taking good care of my clients, without any shortcomings, and I think about my life. I also think that my parents could get dementia later, which makes me humble.
Findings from Selective Coding
By means of selective coding, a core category was derived to describe the storyline of nurses' experiences, which summarizes and integrates the results from axial coding. This storyline led to the development of a conceptual framework to report nurses' experiences from a theoretical perspective (Figure 2).
Gratified in Caring model.
Core Category. The core category, comprising all categories of nurses' positive experiences in caring for older adults with dementia, was defined as Hearty Caring for Older Adults. Nurses identified caring feelings and provided this care unconditionally. The feeling of care was found to depend on the amount of previous experience in nursing combined with an understanding of the needs of older adults with dementia. To provide unconditional care, nurses use strategies such as building trust with clients, implementing emotional care, recognizing dementia symptoms, and collaborating with others. This process varies according to nurses' confidence in nursing and older adults' level of familial support. As a result of unconditional care for older adults, nurses reported feelings of gratitude toward life.
Conceptual Framework. A conceptual framework, the Gratified in Caring Model, was developed by integrating and abstracting the core category from nurses' positive experiences in caring for older adults with dementia (Figure 2). The model integrated the categories and subcategories derived from the open coding. These categories were then clustered into nursing philosophy, attitudes, knowledge, skills, and family support based on the paradigm model and the core category of nurses' experiences. The model emphasizes nurses' sound philosophy as a significant element in cultivating positive experiences, which needs to be incorporated in the education and grooming of nurses to provide proper attitudes, knowledge, and skills. In addition, clients' family support was found to be important in fostering positive nursing outcomes.
The current qualitative study was conducted to explore nurses' positive experiences in caring for older adults with dementia using grounded theory; as a result, a paradigm model, the core category Hearty Caring for Older Adults, and the Gratified in Caring Model were derived. Nursing experience and categories identified in the current study are discussed to suggest basic resources for developing programs that promote positive nursing care of older adults with dementia.
Nurses in the current study tried to understand the lived experience of older adults with dementia. They practiced under the notion of “recognizing the client as an autonomous adult,” which was part of the category Understanding Care of Older Adults and is consistent with the subtheme “understanding the patient as an autonomous person” reported in a study that explored lived experiences of nurses in dementia care units (Egede-Nissen, Sellevold, Jakobsen, & Sorlie, 2017, p. 752). These results suggest that nursing staff should be trained to respect the autonomy of older adults with dementia. More specifically, it is important for nursing staff to view the older adult as an independent individual, and to view him/her as someone with a debilitating condition (Egede-Nissen et al., 2017). Positive care experiences reported in the current study included “gratification in nursing practice” and “appreciation toward life.” These positive outcomes suggest that caring for older adults can be beneficial to nursing staff as well as clients themselves.
The results of the current study included the category Implementing Emotional Care, which involves providing verbal and non-verbal emotional support to patients. This care is equivalent to the care processes of “meeting the psychological and physical needs of the clients with a human touch” in a study that explored dementia care experiences of health care professionals (Scerri, Innes, & Scerri, 2015, p. 1916), and is also consistent with the subtheme “sensitivity to understanding clients' verbal and nonverbal expressions,” which was identified in a previous study (Egede-Nissen et al., 2017, p. 752). The categories Maturity as a Nurse and Understanding Care of Older Adults derived in the current study can be a foundation for positive attitudes in nursing care for individuals with dementia.
Nurses in the current study showed Unconditional Caring, which may be influenced by the culture in Korea where older adults are respected and revered (Maeng & Lee, 2017). Nurses also recognized the importance of involving families in care, which complies with past research (Digby et al., 2017). There-fore, family support is a high priority for nurses, and their ability to maintain cooperative relationships with family members plays an important role in their positive experiences of caring for older adults.
Limitations of the current study include the small sample size restricted to a specific geographic region. As such, generalizability is limited. Cultural differences should be explored in future studies.
Implications for Research
The results of the current study emphasize nurses' positive attitudes and collaboration with family in caring for individuals with dementia. This research may help develop evidence-based educational resources for nurses and nursing students. Specifically, teaching a person-centered approach may be helpful. In addition, practical training on finding older adults' interests and strengths may be beneficial.
The current study also provides support for the use of a Gratified in Caring Model for nurses working with individuals with dementia. This model may help nurses engage in active care of individuals with dementia and includes developing and testing nursing training programs for effective care.
The current qualitative study explored nurses' positive experiences in caring for older adults with dementia. A Gratified in Caring Model is presented, which may guide future nursing trainings. The categories and sub-categories of this study may help nurses understand the framework of positive care experiences and apply this information to their nursing practice. This research suggests that caring for individuals with dementia can be a positive experience and recommends a paradigm shift in the approach to nursing.
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|Participant/Age (years)||Marital Status||Education||Place of Work||Work Experience in Dementia Care (years)|
|7/58||Single||Graduate school||Geriatric hospital||3|
Results of Open Coding of Nurses' Positive Experiences In Dementia Care
|Caring feelings from the heart|
Thinking about one's own parents
Appreciating older adults' good nature
|Maturity as a nurse|
Experienced in care of older adults
|Understanding care of older adults|
Recognizing client as an autonomous individual
Un derstanding client's family
Forming intimate relationships
Developing caring relationships
Receiving support from family
|Confidence in nursing|
Establishing confidence as a nurse
|Building trust with clients|
Maintaining a consistent attitude
Checking status frequently
|Implementing emotional care|
Using verbal communication
Using non-verbal communication
|Caring for dementia symptoms|
Understanding dementia symptoms
Managing dementia symptoms
|Collaborating with human resources|
Working with other medical staff
Cooperating with client's family
|Gratification in nursing practice|
Feeling satisfied with work
Feeling pleasure in nursing care
|Appreciation toward life|
Showing respect for clients