An NIHR Alert summarised the findings of a study that observed interactions between health professionals and people with dementia to determine how best to phrase requests in order to get a positive response
Citation: Nursing times (2021) Careful phrasing of requests could help people with dementia accept care. Nursing Times [online]; 117: 3, 38.
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Introduction
Specific phrasing of requests led to more positive responses from patients who were confused or resisting care, according to research summarised in a National Institute for Health Research Alert. A study in an acute hospital setting looked at different ways of asking people with dementia to perform tasks or to agree to requests (O’Brien et al, 2020).
Researchers explored responses to requests by health professionals to carry out tasks such as eating, drinking, personal care, giving medication, and rehabilitation. It was based on 41 video recordings of interactions between people with dementia and nurses, medical staff and allied health professionals. More than 600 requests made by professionals were recorded. Professionals’ phrasing, tone and question construction altered the chance of a positive response.
More than a quarter of hospital patients have dementia and many refuse food, drink, medication or requests to be examined. It may be difficult to tell whether a patient with dementia is deliberately rejecting a request or refusing to respond; is simply unable to respond; or is agitated or frightened because of the unfamiliar and busy hospital setting.
However, such refusals may worsen their condition, increase their stay in hospital and negatively affect clinical outcomes. This presents health professionals with a dilemma. They need to strike a balance between respecting a patient’s wishes, while also delivering effective care.
There has been little previous research into communication with people living with dementia. This study was part of the larger VOICE programme, which is using its findings to produce communication skills training for health professionals caring for people with dementia in hospital.
Box 1. What did the study find?
Researchers analysed the conversations to identify which approaches worked best. In 28 of the 41 recordings, patients showed some level of refusal: outright refusal, unclear response or no response. Patients sometimes indicated that they lacked ability, were unwilling, or did not see the need to perform a task. Sometimes, they just said “no”.
Successful requests were framed in various ways: from encouraging or suggesting a patient perform a task; to statements of why they need to carry it out; or direct instructions.
This study showed that phrasing, tone and question construction could make refusal more or less likely:
- Requests that allowed the option for refusal often led to refusal, for example, requests which started, “Is it OK if I…?” or “I was just wondering if…”
- Where professionals sounded entitled to make a request, and phrased it as an instruction, patients were more likely to agree “I am just going to….
The entitlement was softened with the permission-seeking “is that alright?” - Being clear about the size or effort involved in the task with phrases such as “it’ll only take a minute” could reassure patients. Words like “just” helped to minimise the task
- Inviting the patient to "try" to perform a task worked well
- However, this study stressed that no manner of verbal requesting would ultimately override a patient’s right to refuse to comply with a request
Implications for nursing
Many patients living with dementia do not fully understand why they are in hospital and/or the consequences of refusing care. Declining treatment can affect care, length of stay and clinical outcome. Repeated refusals also affect job satisfaction for those caring for them.
Training in communication techniques can lead to better concordance from dementia patients. Health professionals with more skills and approaches will feel more confident when caring for these patients.
Based on this research, training programmes have been designed to help health professionals communicate more effectively with hospital patients with dementia. Researchers developed an e-learning resource to help explain this work on refusals and requests.
Future research will investigate the best staff responses to specific aspects of patients’ behaviour such as agitation, distress, confusion, and aggression. Researchers also want to study whether changing staff communication patterns could lead to better outcomes.
NIHR Alerts
On 1 April 2020, the National Institute for Health Research launched its new website, NIHR Evidence, to disseminate research evidence to health and social care professionals, patients and the public. NIHR Alerts are accessible summaries of research that informs practice. They are available here
- The National Institute for Health Research (NIHR) Dissemination Centre aims to put good evidence at the heart of decision-making in healthcare. NIHR Signals are summaries of the most relevant research, published on the Discover Portal
- Sign up for Signals tailored to your interest here
O’Brien R et al (2020) When people living with dementia say ‘no’: Negotiating refusal in the acute hospital setting. Social Science & Medicine; 263: 113188.
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