From the clinic to the fireside: a community- centred approach to specialised expertise in dementia

Aggression, agitation, psychosis, hallucinations, and abnormal motor symptoms have a major impact on people living with dementia. Older-adults’ psychiatrists play a key part in supporting them. However, a shortage of consultant psychiatrists exists, while the number of people with dementia is increasing. Some remote and rural areas have no access to these professionals. So, such support for people affected by these experiences may be variable or non-existent, depending on where they live. This study examined a novel service in the Shetland Islands. Advanced practice dementia nurses provide specialist support to people living with dementia (and other professionals), with the remote input of a psychiatrist based in Aberdeen.
Objectives
This study aimed to gain insights into how effective this approach is in supporting people living with dementia, and also how well it supports carers and other professionals.
Methods/methodology
Semi-structured interviews were used in collecting data from health/social care managers and professionals, and family carers of people living with dementia. Realist evaluation methodology and critical realist philosophy underpinned the work and provided the means of analysis and interpretation.
Key learnings
Service model success here is underpinned by four main factors;
• Exclusively community-located processes (no ‘come to clinic’ approach).
• Longitudinal nursing assessment buttressed by maintaining relationships with people participating in service processes.
• The use of nurses possessing unusually advanced specialised skills and expertise.
• The emergence of a new service delivery approach shaped around the activities of these nurses (as opposed to making the new nursing role and activities fit an existing ‘traditional’ service structure).

Conclusion
This role and associated service approach resulted in notably improved outcomes for participants. However, educational programmes for preparing advanced practice nurses may not yet fully reflect the specialised needs of this particular role. Also, it should be acknowledged that service delivery structures, and the roles of other involved professionals, should be re-conceptualised to gain optimal benefit from this new approach.
Potential impact
It is suggested that this approach, if adopted, could be utilised more widely as an important means of addressing contemporary workforce and demographic challenges in this field.