A Case Study Exploring How Care is Provided for those with Dementia and Related Behaviours in Residential Care

on Vancouver Island The following proposal will identify the objectives, rationale, gaps in the research, my hypothesis and aims and approach to look into the topic of the person centred care for those with moderate staged dementia who exhibit challenging behaviours in residential care on Vancouver Island. Background Dementia is a condition that results in reduced cognitive ability that affects memory and eventually reduces a persons ability to plan and carry out basic activities of daily living (Gavan, 2011). Many individuals with dementia also experience behaviours and psychological symptoms associated with dementia (BPSD) which include pacing, wandering, agitation, aggression disturbed sleep patterns, and disinhibition (Gavan, 2011). As a result of these symptoms and the need for supervision for memory related tasks, many people with dementia eventually require 24/7 nursing care and for many this means a complex care or nursing home admission. Person centred care is model that is increasingly being espoused as the standard of care in health care today (Brooker, 2004; Chenoweth et al., 2009; Gaspard & Garm, 2009; Nazarko, 2009; Price, 2006; Robinson, 2007; Thornton, 2011). Person centred care aims to ensure that every patient, client or resident is valued as unique; their choices are honoured and they are included, heard, and understood (Gavan, 2011; Thornton, 2011). This care delivery framework is increasingly being adopted in many areas including dementia care facilities (Edvardsson, Fethersonhaugh & Nay, 2010; Kirkley et al., 2011; Rsvik, Kirkevold, Engedal, Brooker, & Kirkevold, 2011; Thornton, 2011). A recent document published by the Alzheimer Society of Canada states that a priority policy option for Canada is to create national person-centered standards for care facilities (Alzheimer Society of Canada, 2010, p. 51). The earliest author of the concept of person-centered care in dementia was Thomas Kitwood. Kitwood defined person centred care as care that values the individual, attempts to view the world from the individuals perspective and creates a positive social environment for every person to reside in. (Brooker, 2004). Thomas Kitwood was a pioneer in dementia care and his ideas were pivotal in changing the thinking and knowing around dementia care (Hill, 2008). A central component to Kitwoods theory was the concept of personhood which is defined as the status that is given to one human being from another that implies value, respect, and trust and recognition (Kitwood, 1993). Embedded in person-centred care is the notion of upholding ones personhood and it has implications in care situations in that it encourages us all to ensure that dignity and respect of the resident is maintained. I have seen person centered care implemented and feel strongly that this is an ideology that is beneficial to those in care and can be implemented with success. While person centred care is recognized as ideal care model for dementia, many complex care facilities are organized around a model that is very similar to hospitals with rigidity in routines and staff roles. In order for a complex care facility to be able to provide care where the resident is the centre of the care

there are many changes that must take place so that the goals relate to the person with dementia rather than the institution. Nurses generally are the professionals that lead the care in residential care settings they are pivotal in shifting a care facility from an institution to a home that is person-centered. The focus on personcentered care has had an enormous impact on the knowledge development and translation in nursing. In January 2011 the Alzheimer Society of Canada published a document entitled Guidelines for Care: Person Centred Care of People with Dementia Living in Care Homes. This document clearly outlines the expectations and philosophy of care beginning with the statement, The Alzheimer Society believes that people with dementia have the right to enjoy the highest possible quality of life and quality of care by being engaged in meaningful relationships which are based on equality, understanding, sharing, participation, collaboration, dignity, trust and respect (Alzheimer Society of Canada, 2011, p. 9). This statement identifies the importance of a need for ethical care as well as meeting other more physical needs in a respectful and dignified manner. This stance is very important and holds up the expectations for nurses and very importantly, it guides practice and further knowledge development in the care of those with dementia. Behaviours and Psychological Symptoms Associated with Dementia If you ask any staff member who provides care for those with dementia, I would anticipate that they would tell you the hardest part of their job is providing care for those who are experiencing Behaviours and Psychological Symptoms associated with Dementia (BPSD). These symptoms vary but they range from vocalizations, agitation, wandering, hurting self or others (Burack, Weiner & Reinhardt, 2012). BPSD may occur for a variety of reasons including frustration, sense of loss, pain, illness or other causes but we know that they are often caused by an unmet need. It is increasingly believed that if a person centered model is in place and truly carried out then the staff are better able to understand the people they provide care on an individualistic level and can anticipate and better meet their needs thereby reducing BPSD as much as possible. In the absence of a person centred approach, medications and restraints may, and are often used to calm or restrict a person. There is a great deal of literature that identifies the harmful effects of these medications and restraints and it is generally considered a last resort in long term care settings to use these measures. Evidence in support of a Person Centered Care Model for those with Moderate Staged Dementia who are exhibiting challenging dementia behaviours Can a person centred care model improve care for those with BPSD? In an integrated literature review completed regarding strategies to implement person centred care in residential care settings in 2010, there were numerous examples of methods to reduce BPSD. One area where staff struggle in residential care and often use medications to calm individuals is in bathing. The publication by the Alzheimer Society of Canada notes that bathing should be completed in a way that is person centred

(Alzheimer Society of Canada, 2011). While this may appear to be common sense, to anyone working with the care of those with dementia, this is a large step forward. For certain individuals with moderate to advanced staged dementia a tub bath is often viewed as extremely frightening (Rader et al., 2006). I have heard residents talk about the fear of being put into a vat of boiling oil when being placed into a tub with the "therapeutic jets" working. Despite these fears, forced bathing has been an accepted practice for years which is likely an unfortunate residual practice dating back to the days when physical care outweighed the psychological or spiritual aspects of the person. However, now with the lens of person-centred care this is viewed in a different light. Forced tub bathing has been challenged by nurse researcher, Joanne Rader, who lead led a research team that investigated the need for tub bathing that was able to show with good evidence that microbes are removed from other forms of bathing equally or at times better than tub bathing. This research concluded with the message that forced bathing could and should end in residential care (Rader et al., 2006). Nurses, now have the evidence to challenge and finally put an end to forced bathing in the care homes where they work. I speak of forced bathing as I have seen residents receive anti-anxiety medications prior to bathing to allow for this process to take place. The use of psychotropic medications needs to be carefully reviewed across all residential care settings as these medications are not meant for long term use and yet once prescribed, are very difficult to remove from a persons regimen of medications. The use of physical restraints is another area where the principles of person-centred care can shift knowledge in dementia care. In April 2009 nursing homes across British Columbia began tracking their restraint use in the Resident Assessment Instrument that was mandated by the BC Ministry of Health. When those statistics are available, it is likely that there may be concerns about the use of restraints in residential care. Physical restraints have been used extensively in care in the past although there are many who recognize the need to decrease their use in residential care and have had success with education (Pellfook, Gustafson, Bucht & Karlsson, 2010). Physical restraints raise ethical issues relating to the autonomy of the individual patient as well as nonmaleficence issues as the use of restraints has caused harm (reduced mobility, skin breakdown, as well as psychological damage) including deaths in persons in care (Mohr, 2010). Similar to chemical restraints more work is needed to create physical restraint free environments in residential care. It is important to note that the philosophy of person centred care will provide a theoretical framework guiding practice for nurses in residential care to find ways that meet the individual needs of each resident. While there are some instances where restraints are unavoidable as in the case when others are being harmed by a resident who is acting in a responsive or a protective manner, in most instances there are alternatives to the use of restraints when the underlying needs are recognized and then met.

Research questions to be answered in this study: Based on the rationale that person centered care is the ethical model of care for those with dementia, this research is centered around the question of how care is actually being provided. In addition, it is important to understand deviation from this ideal through the analysis of barriers and facilitators. And

finally, it may be worthwhile to examine the clinical outcomes for various facilities to determine if there are differences related to the model of care in place.
1. How are people with moderate staged dementia with behaviours cared for in residential care on Vancouver Island?

2. How can barriers be reduced and the facilitators increased so that there is a standardized adoption
of a person centred model of care for this population?

3. Does a facility that is aligned with person centred care values have differing resident outcomes or
quality indicators from other sites that are less aligned with this care model?

Overall objectives The overriding mission of this research is to improve the quality of life for those with dementia, their families and those who provide this important care in residential care settings. I am hopeful that this research will inform policies and guide practice for those in care now and for those who will require care in the future.

In this research I will examine three different complex care homes on Vancouver Island. Using literature that describes the elements conducive to person centered care, a case study design will be used to examine three complex care homes to learn how they each provide care for those with moderate staged dementia who often have behaviours that are viewed as challenging. I will look at a variety of areas that were identified in an integrative literature review completed in 2010 and updated since that time that found that there were recurrent themes to the implementation of person centred care in residential care settings: These themes were: Organizational structure the research repeatedly emphasized the importance of the leadership team being supportive of person centred care and being comfortable with decentralized decision making which is an essential ingredient for person centred care to be possible. Hand in hand with this notion is that staff need to feel valued, respected and safe in order to feel that they can make decisions or have input into the care that the residents will receive. There needs to be ways of knowing the residents in order to provide person centred care, there needs to be mechanisms in place to obtain this personalized information and staff need to have access to it in a timely manner. This includes involving and welcoming the family into the care environment, ensuring that life stories are created and are in places where staff have access to them and staff understand the value in this information, and continuity of staff so that staff develop relationships with the residents and their families.

Education is essential - the largest group of caregivers in residential care require a six month program in order to provide care and many have not received education on how to provide care for those with dementia. All staff require education on dementia, the various forms, BPSD, the importance of person centred care, medications etc. Care that is provided is reflected in person centered care principles the literature provides cues as to how to tailor care so that each persons individual needs are addressed. There are specific interventions such as the use of multisensory environments or the development of person centred bathing care plans but overall, the care needs to, in some way, reflect the individual needs, preferences, values of each resident.

Gaps in the Research While there are studies that provide evidence for person centred care to reduce agitation and aggression as noted above, there no one has looked at dementia care with a case study approach and elements that have been gleaned from the literature. Burack, Weiner and Reinhardt (2012) recently conducted a longitudinal study looking at the impact on organizational change towards a person centred approach to care but did not look at medication usage. They note that it would be beneficialfor future studies to explore the relationship between psychoactive medication usage and agitation overtime within a culture change setting to investigate the individual and combined impact of medication and/or culture change on behavioral symptoms (Burack, Weiner & Reinhardt, 2012, p. 528 Assumptions that need to be addressed It should be noted that there are inherent assumptions in this research which may be challenged when the research is being conducted and they include but are not limited to: Person centred care is not currently in place consistently in all care homes. This may be disproven or supported depending on what is learned through the course of the study. Person centered care is possible everywhere. There may be places where the organizational structures are not conducive for the enactment of person centred care. Most individuals in care, and their families want person centred care. While this research will not be dealing directly with the residents themselves, the families will be a part of this so this can be asked during the interview phase of the study. Facilities will be open to having a PhD student research the care being provided for residents with dementia.

Approach(es) and methods used: Case Study Research Case study research is a qualitative research methodology that has been used in the social sciences and in health care (Anthony & Jack, 2009). While case study research is often perceived to be a method to look at individual situations such as a sentinel event in health care, case study as a methodology for research allows the researcher to explore individuals or organizations, simple through complex

interventions, relationships, communities, or programs (Yin, 2003 as cited in Baxter & Jack, 2008, p. 544). It fits well as a methodology for health care research in that it allows for an examination of the whole rather than a dissection of parts (Anderson et al., 2005) and is an appropriate methodology to look at person centred care in residential care as there are many contextual factors that come into play with the successful implementation of this model of care. Case study research has the philosophical underpinnings of an interpretive, constructivist paradigm meaning that this methodology seeks to understand what is happening through exploration and understanding of meaning to the individuals involved (Stake, 1995; Yin, 2003b as cited in Anthony & Jack, 2009; Baxter & Jack, 2008). Case study research also draws upon multiple data sources including interviews, observation, referring to the documentation sources such as charting, medication administration records and policy manuals (Stake, 1995; Yin, 2003b as cited in Anthony & Jack, 2009; Baxter & Jack, 2008). The case study approach provides a mechanism for theory seeking and testing and may be useful for evaluating a situation as well (McGloin, 2008, p. 47). According to Yin (2003), a case study design should be considered when: The focus of the study is to answer how and why questions The researcher cannot manipulate the behaviour of those involved in the study The researcher wants to learn about contextual conditions because you believe they are relevant to the phenomenon under study; And boundaries are not clear between the phenomenon and context (Baxter & Jack, 2008, p. 545).

Given that the primary question being reviewed in this study is: How are people with moderate staged
dementia with behaviours cared for in residential care on Vancouver Island? Case study research is an appropriate methodology to use.

There are different forms of case study research including Explanatory to explain why something is occurring and look at causal links. Exploratory to look at an intervention which has no single set outcomes Descriptive to describe an intervention or phenomenon and the real life context in which it occurs. Multi-case studies to explore differences within and between cases the goal is to replicate findings across cases. Must choose the comparisons carefully to be able to make some links and later project to other cases or predict contrasting results based on theory. Multiple case studies allow comparisons, particularly in diverse settings (Houghton, Casey, Shaw & Murphy, 2013). Intrinsic when the intent is to undertand what is happening generally not done to create theory but could result in theory. Stake notes that this type of case study is appropriate when you want to look at a particular unique situation Instrumental not directly related to the case being looked at but the intent is more to refine an existing theory. Collective similar to multiple case studies

This study fits best with the topic to be reviewed in answering the question of how dementia care is being provided is a multi-case, explanatory form of case study research. Methods in Case Study Research: Identifying the Unit of Analysis Researchers will need to identify their unit of analysis. Miles and Huberman (1994) note a unit of analysis is a phenomenon of some sort occurring in a bounded context. The case is, in effect, your unit of analysis (as cited in Baxter & Jack, 2008, p. 545). In this research, a unit of analysis will be a unit where those with moderate dementia live in residential care and the question being asked is how is moderate staged dementia care provided in residential care? The units will be first compared internally and then externally to each other to find similarities and differences. Inclusion criteria The inclusion criteria for this study will be three complex care facilities that provide care for: Older adults (over 65 years of age) who are experiencing moderate staged dementia and exhibit behaviours such as wandering, verbally or physically abusive behavioural symptoms, resistive to care and socially inappropriate or disruptive behaviour. The care facilities will not be health authority owned and operated (due to researchers bias). The care facilities will be geographically spread out with a home in south, central, and north Vancouver Island.

Who will be included in the study? The study will be focussing on the staff (ideally managers, nurses, care staff and related staff such as housekeepers and dietary staff) in each setting. In addition, ideally family members will be included in this study as well. The population of older adults with dementia are a vulnerable group and therefore my research will not be targeted at them directly however they are the core of all of this to optimize their quality of life to its fullest extent. Ways to develop authenticity/reliability/validity in case study research: according to Anthony and Jack (2009); Baxter and Jack, 2009; Houghton, et al., (2013): Need to put boundaries around the cases to be studied (i.e. inclusion criteria and rationale). Next step is to explicate the propositions or that which may be present or not (Baxter & Jack, p. 550). Use of multiple data sources such as interviews, documents, participant observations and records. Acknowledgement of theoretical support for methodology (person centred care model)

Explicit attention to rigor with this detailed in the report including the use of an audit trail, triangulation of data, and reflexivity.

Developing the Focus Areas and Questions for this Case Study Research The following table outlines the data collection structure for carrying out the case studies in the three facilities. This is in effect, what Yin describes as the potential propositions or Stake refers to as the issues that are contextually relevant to the implementation of person centred care for those with dementia in residential care. This was developed through multiple means including the themes that emerged from an integrated literature review by the author, Registered Nurses Association of Ontarios report card for client centred care as well as other resources that have been published around the notion of assessing how person centred various facilities are. Potential propositions (Yin) or Issues (Stake) which are wired to political, social, historical, and especially personal contexts Evidence of strong, caring leadership that is comfortable with decentralized decision making. Sources Semi-structured questions to ask that will illicit this. Documentation/records to be reviewed

Organizational supports for person centred care Tellis-Nayak, 2007 Does the facilitys mission and van Weert et al., 2006 value statement clearly state that Boettcher et al., 2004 person centered care is Crandall et al., 2007 important? Chenoweth et al., 2009 Sloan, 2004 Who makes the decisions about Rosvik, 2011 individual clients care? Kirkley et al. (2004) Thornton, 2012 Do staff have input into decision De Souza (RNAO), 2008 making about the areas that affect clients? Do staff feel that they are trusted to make decisions? To staff: do you feel that you are trusted to make decisions? To managers, leaders: do you trust the staff to make decisions? Are staff allowed to be creative and try new methods of care providing? Do they feel safe when doing this? What methods are used to incorporate direct caregivers

Policy and procedure manuals in the areas of client care planning to look at the sources of information. Minutes from staff meetings. Look at sick time, overtime, injuries.

input? Do staff feel valued? Staff have the tools they need to do their job Cohen-Mansfield & Purpura, 2007 Do staff have the equipment that they need to provide the care that is required? Do staff feel that there is adequate staffing to provide person centred care? Are person centred values integrated into the performance reviews Person centred care model needs to be adopted by all areas of an organization Boettcher et al., 2004 Do you receive feedback when you provide specific care for each resident? Do you feel that all the departments (housekeeping, dietary, maintenance, administration) are supported and are able to meet the individual needs of the residents? Can your organization adapt to the needs of the individual residents? Where do you look when you want to learn about a residents life history, preferences, family etc.? Look at template for performance reviews. Information is shared between departments so that everyone knows the residents. Review policies see how they are written. Review documentation in charting and communication to staff. Review documentation. Review medications administered.

Crandall et al., 2007 Chenoweth et al., 2009 Dowling, 2009

The organization is flexible

Sloane et al., 2004 Dowling, 2007 Crandall et al., 2007

Person centered care is embedded in the documentation and communication tools

Staff are encouraged to look into the meaning of each residents behaviour

Methods of Learning about the Person Kontos & Naglie, When a resident has an episode of 2007 behaviour, what type of inquiry occurs? Are there efforts to understand the behaviour? Rasin & Kautz, 2007 Do staff provide care to the same residents on a regular basis? To staff: do you feel as though you know the residents well? To families: do you know who the staff is who provide care to your family member in care?

Continuity of care is achieved

Family is included in the care

Coker, 1998 Egan, 2997 Crandall et al., 2007 Thornton, 2011 Edvardsson et al. 2010 Reid, et al., 2007

Are families included in the admission process and asked about the care of their family members past, preferences, values? Are family members introduced to members of the care team at the time of admission? Are family members welcomed and made to feel that they are important in the care of their family member? Are family members informed of changes in care or when resident has an adverse event? Families are included in the activities such as meals and entertainment? Are family meetings held where family input is sought? Is there support provided for families as the person in care moves through the dementia trajectory including education on dementia, linking with support services, and access to team who is making clinical decisions. Are staff comfortable to call and ask about their loved one in care? Would be good to ask this of managers, staff and families and look at the congruence of answers.

Minutes of family council meetings. Welcome package Any communication sent to families.

Life stories are collected and referred to in a person centred care organization

Clarke, Hanson & Ross, 2003 Hanesbo & Kihlgren, 2000 Coker, 1998 Egan, 2007 Thompson, 2011 McKeown et al. 2010

Are life stories gathered? Where are these documents stored do staff have easy access t them? Do staff refer to the life stories as they plan and provide care? (again would be good to ask this of all areas and see if the answers are similar)

Evidence of life stories in easily accessible areas.

Education is provided for staff on dementia and person centred methods Staff are provided with Kitwood, 1993 Have staff received education on education about person Van Weert, 2006 dementia or how to provide centred care and dementia Dowling, 2007 person centred care? the research notes that Saltmarche, Kolodny & education is key in shifting Sloane et al., 2004 Some areas for education attitudes in staff so that Board et al. 2012 include: they understand that the Gavan, 2011 behaviours are dementia Rosvik, 2011 - Dementia and BPSD related and not intentional - Impact of staff attitudes towards the staff. that affect residents behaviour - Personhood - Development of individual interventions - Methods of how to approach residents with dementia - Techniques to establish person centred bathing - Active listening, communication skills. - Reminiscent techniques - The importance of involving family - The acknowledgement that residents may have dementia but still have feelings If education was provided, were there any methods to evaluate outcomes? i.e. that the education is being incorporated into practice?

Review any references where person centered care for dementia are present and accessible.

Care reflects persons preferences, choices, values and is always respectful of each person Practice reflects that Are residents encouraged to bring in familiar items to furnish their rooms? person centred care is Are residents provided with choice in their clothing? integrated into the facility. Do staff know their personal preferences for routines such as usual times to bed and wake times and are these embedded into their routines or is the resident on the staffs From the Registered schedule? Nurses Association of Do staff know what each resident likes or dislikes to eat and are options available at Ontario Report Card mealtimes? Client Centred Care: How Do staff know who the special people in each persons lives are? are we doing, developed by Are residents called by a name of their choice and are there signs of infantalization Gina De Souza, Best where residents are called sweetie or other terms and are there other uses of

Practice Co-ordianator, Central South Ontario, 2008 Note: I contacted RNAO and this has not been updated. Creativity in care options is encouraged such as the use of a multi-sensory environment.

language that indicates this? Are residents labelled as feeders or totals or are they spoke about in a way that indicates that they are people with these needs? Do staff ensure that glasses and hearing aids are in good repair and clean and ensure that these are used? Are their memory aids in the facility to help residents find their way? Van Weert et al., 2006 Is there any space available to use as a multisensory environment? And if so, is this space used? Is there a portable cart available if no specific space is available. Are residents given the opportunity to use their senses of smell, touch, vision, hearing on a regular basis? Do residents have an individualized plan of care for bathing? What happens if a resident refuses a bath? Does forced bathing occur? What is available for staff to ensure that the bathing experience is pleasant for residents (warm towels, residents soap that is familiar?) There is evidence of different environments for people with moderate dementia.

Person centred care bathing care plans are in place

Cohen-Mansfield & Parpura-Gill, 2007 Crandall et al., 2007 Chenoweth et al., 2009

Bathing care plans are in place and are accessible for staff to use.

Review medication records to identify patterns of use of anxiolytics prior to bathing.

Summary of Case Study Research Case study research is an appropriate fit for this study in that case study research has the ability to explore phenomenon in real-life contexts is aligned with the ethos of nursing as a profession grounded in caring at the human-to-human interface where peoples real-life context is situated (Anthony & Jack, 2009, p. 1178). Anticipated Results/Hypothesis I anticipate learning that there are large disparities between staff, resident and families understanding of what person centred care is as I believe there are multiple meanings of this concept being used. In

addition, I anticipate learning about the barriers that facilities are facing in enacting person centred care and I hope to play a role in my work to remove these barriers in order for this model for the care of those with dementia.

Summary Person centred care needs to be adopted into practice in all long term care facilities where those with dementia reside. It is worthwhile and timely to evaluate if care models are person centered or not and examine what needs to be in place to move facilities closer to this idea. There are many reasons why this model may not be currently being implemented and largely this will be related to decisions at the managerial and higher level that affect the caregiver at the bedside. Those who provide the hands on care need to be free, supported, and applauded when they provide care that is person centred. In the words of Tom Kitwood, good care ... is highly respectful of personhood (Kitwood, 1992, p. 271) and as a result it is our duty to do what we can to make this model a reality in nursing homes across Canada. Person centred care is achievable and with more focus, knowledge, and change, it can become the standard in all long term care settings in the future.

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Kitwood, T. (1997). Dementia reconsidered: The person comes first. Buckingham, UK: Open University Press. Knopman, D.S., Berg, J.D., Thomas, R., Grundman, M., Thai, L.J. & Sano, M. (1999). Nursing home placement is related to dementia progression: Experience from a clinical trial. Neurology, 52 (4), 714-718. Kontos, P. C., & Naglie, G. (2007). Bridging theory and practice: imagination, the body, and personcentred dementia care. Dementia (14713012), 6(4), 549-569. McDonnell, A., Jones, M. L., & Read, S. (2000). Practical considerations in case study research: the relationship between methodology and process. Journal of Advanced Nursing, 32(2), 383-390. doi: 10.1046/j.1365-2648.2000.01487.x McGloin, S. (2008). The trustworthiness of case study methodology. Nurse Researcher, 16(1), 45-55. McKeown, J., Clarke, A., Ingleton, C., Ryan, T., & Repper, J. (2010). The use of life story work with people with dementia to enhance person-centred care. International Journal of Older People Nursing, 5(2), 148-158. doi: 10.1111/j.1748-3743.2010.00219.x Mohr, W. K. (2010). Restraints and the code of ethics: An uneasy fit. Archives of Psychiatric Nursing, 24(1), 3-14. Moore, K., & Haralambous, B. (2007). Barriers to reducing the use of restraints in residential elder care facilities. Journal of Advanced Nursing, 58(6), 532-540. Nazarko, L. (2009). Providing high quality dementia care in nursing homes. Nursing & Residential Care, 11(6), 296-300. O'Connor, D., Phinney, A., Smith, A., Small, J., Purves, B., Perry, J., . . . Beattie, L. (2007). Personhood in dementia care: developing a research agenda for broadening the vision. Dementia, 6(1), 121142. Pellfolk, T. J., Gustafson, Y., Bucht, G., & Karlsson, S. (2010). Effects of a restraint minimization program on staff knowledge, attitudes, and practice: a cluster randomized trial. Journal of the American Geriatrics Society, 58(1), 62-69 Price, B. (2006). Exploring person-centred care. Nursing Standard, 20(50), 49. Provincial Dementia Service Framework Working Group. (2007). BC Dementia Service Framework. Retrieved October 18, 2008 from http://www.alzheimerbc.org/pdf/DementiaServiceFramework_PDF.pdf Rader, J., Barrick, A. L., Hoeffer, B., Sloane, P. D., McKenzie,D., Talerico, K. A., & Glover, J. U. (2006). The bathing of older adults with dementia: Easing the unnecessarily unpleasant aspects of assisted bathing. American Journal of Nursing, 106(4), 40-49.

Rasin, J., & Kautz, D. D. (2007). Knowing the resident with dementia. Journal of Gerontological Nursing, 33(9), 30-36. Reid, R. C., Chappell, N. L., & Gish, J. A. (2007). Measuring family perceived involvement in individualized long-term care. Dementia (14713012), 6(1), 89-104. Robinson, J.G. (2007). Utilizing best practice in dementia care. Canadian Nursing Home, 18 (1), 21-27. Rsvik, J., Kirkevold, M., Engedal, K., Brooker, D., & Kirkevold, . (2011). A model for using the VIPS framework for person-centred care for persons with dementia in nursing homes: a qualitative evaluative study. International Journal of Older People Nursing, 6(3), 227-236. doi: 10.1111/j.1748-3743.2011.00290.x Saltmarche, A., Kolodny, V., & Mitchell, G. J. (1998). An educational approach for patient-focused care: shifting attitudes and practice. Journal of Nursing Staff Development, 14(2), 81-86. Sloane, P. D., Hoeffer, B., Mitchell, C. M., McKenzie, D. A., Barrick, A. L., Rader, J., . . . Koch, G. C. (2004). Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia: a randomized, controlled trial. Journal of the American Geriatrics Society, 52(11), 1795-1804. doi: 10.1111/j.15325415.2004.52501.x Stein-Parbury, J., Chenoweth, L., Jeon, Y. H., Brodaty, H., Haas, M., & Norman, R. (2012). Implementing Person-Centered Care in Residential Dementia Care. Clinical Gerontologist, 35(5), 404-424. doi: 10.1080/07317115.2012.702654. Tellis-Nayak, V. (2007). A person-centered workplace: the foundation for person-centered caregiving in long-term care. Journal of the American Medical Directors Association, 8(1), 46-54. Tellis-Nayak, V. (2007). A person-centered workplace: the foundation for person-centered caregiving in long-term care. Journal of the American Medical Directors Association, 8(1), 46-54. Thompson, R. (2011). Using life story work to enhance care. Nursing Older People, 23(8), 16-21. Thornton, L. (2011). Person-centred dementia care: An essential component of ethical nursing care. Canadian Nursing Home, 22(3), 10-14.

Methodology: Case Study Research Resources Anderson, R. A., Crabtree, B. F., Steele, D. J., & McDaniel, R. R., Jr. (2005). Case study research: The view from complexity science. Qualitative Health Research, 15(5), 669-685. Anthony, S., & Jack, S. (2009). Qualitative case study methodology in nursing research: an integrative review. Journal of Advanced Nursing, 65(6), 1171-1181. doi: 10.1111/j.1365-2648.2009.04998.x Baxter, P., & Jack, S. (2008). Qualitative case study methodology: Study design and implementation for novice researchers. Qualitative Report, 13(4), 544-559. Houghton, C., Casey, D., Shaw, D., & Murphy, K. (2013). Rigour in qualitative case-study research. [Article]. Nurse Researcher, 20(4), 12-17. McDonnell, A., Jones, M. L., & Read, S. (2000). Practical considerations in case study research: the relationship between methodology and process. Journal of Advanced Nursing, 32(2), 383-390. doi: 10.1046/j.1365-2648.2000.01487.x McGloin, S. (2008). The trustworthiness of case study methodology. Nurse Researcher, 16(1), 45-55. Munhall, P. L. (Ed.). (2012). Nursing research: A qualitative perspective. Sudbury, MA: Jones and Bartlett Learning. Sangster-Gormley, E., Martin-Misener, R., & Burge, F. (2013). A case study of nurse practitioner role implementation in primary care: What happens when new roles are introduced? [Article]. BMC Nursing, 12(1), 1-12. doi: 10.1186/1472-6955-12-1 Sangster-Gormley, E. (2013). How case-study research can help to explain implementation of the nurse practitioner role. Nurse Researcher, 20(4), 6-11. Stake, R. E. (1995). The art of case study research. Thousand Oaks, CA: Sage. Yin, R. K. (2014). Case study research: Design and methods (5th ed.). Los Angelos: Sage.