Academic and Practice Enquiry

NUR6027

What is the impact of doll therapy on

older adults with dementia?

S11735925

Word count 6000

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Contents

Abstract………………………………………………………………………….p.3

Introduction……………………………………………………………………p.4

Methodology………………………………………………………………….p.6

Results……………………………………………………………………………p.8

Recommended Focus for Proposed Change………………….p.14

Practice Change Results………………………………………………..p.15

Recommendations and Conclusions……………………………..p.20

References……………………………………………………………………p.22

Data extraction tables 1-10…………………………………………..p.30

Results table…………………………………………………………………p.31

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What is the impact of doll therapy in older adults with dementia?

Abstract

Every four seconds someone is diagnosed with Dementia (World Health Organisation, 2012). A

decline in communication skills, impaired memory and reduced ability with daily activities are most

characteristic of this condition; many individuals also experience behavioural and emotional

disturbances. (Gataric et al, 2010) Pharmacological interventions do not always meet the emotional

needs of the person with dementia (Hachinski et al, 2006), furthermore the use of anti-psychotics in

older adults with existing cerebrovascular damage increases the risk of stroke (Sacchetti et al, 2010).

In light of this, non-pharmacological therapies such as music therapy, aromatherapy and the use of

tactile activities are becoming more widely used to enhance the well-being of people with dementia

(Holt et al 2009; Woods et al 2012; Vink et al 2013). Doll therapy involves engagement with a doll

through various forms, such as: cuddling, dressing, feeding and talking to the doll (Mitchell and

Templeton, 2014). The aim of this integrative literature review is to examine the impact of doll

therapy in older adults with dementia. The following databases were reviewed: Cumulative Index of

Nursing and Allied Health (CINAHL) Psychological Abstracts (PsycINFO) MEDLINE and SwetsWise. The

inclusion criteria were: sample have a confirmed diagnosis of dementia; intervention in the form of a

doll. Exclusion criteria were: intervention in the form of pet therapy. 10 studies were selected on this

basis and three themes emerged: (i) Doll therapy may not be suitable for all persons with dementia.

(ii) Health professional lack sufficient knowledge on the topic of doll therapy for persons with

dementia. The final theme on which constitutes the proposal is; (iii) Withdrawal of doll therapy may

result in anxiety. The recommended change results are that hospital wards become ‘doll friendly’.

The Promoting Action on Research Implementation in Health Services (PARIHS) framework has been

used to consider application of this proposal. This paper concludes that ‘doll friendly’ wards are; a

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viable addition to the existing dementia friendly scheme within National Health Service (NHS)

Hospitals.

Introduction

Rationale

Recent figures suggest that around 841 million people worldwide have dementia, with this predicted

to rise to 2 billion by 2050. Currently, in the U.K there are over 1.4 million people over the age of 85,

living with some form of dementia (United Nations, 2013). The Alzheimer’s Society (2014a) reported

that research into dementia equates to only £90 per person, yet a person with this condition costs

the NHS £30,000 per year. In light of the significant increase in dementia statistics and evident

financial disparity, the demand for research in this area is palpable.

The review question relates to older adults (aged 65+) with a dementia diagnosis; dementia being an

umbrella term for a progressive neurodegenerative disease. The various forms of which include, but

are not exclusive to: Alzheimer’s disease, vascular dementia, mixed type dementia and lewy bodies

(Alzheimers Society, 2014b). Patterns of progression are dependent on the type of diagnosis,

however behavioural and emotional disturbances are collectively common characteristics of most

types of dementia (Stacpole and Thompsell, 2011). Signs of distress, such as agitation, aggression

and wandering occur in 60-90% of people with dementia (James et al, 2008). Professional and non-

professional caregivers (within this context caregivers being any individual providing regular care to

a person with dementia) identify these behaviours as the most challenging and frustrating element

of the condition (Livingston et al, 1996). Behaviour motives require exploration with a focus on

therapies to reduce negative behaviours (Groulx,1998).

Design

The review question and population group studied was influenced by the authors’ deep-rooted

interest in dementia care. Research gathered was intended to contribute to my chosen area of work

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and to assist in my personal career goals (Hendry and Farley, 1998). The first step was to determine

the direction of the work (Todd, Bannister and Clegg, 2004). Preliminary research was concerned

with dementia and ‘pain management’ but when sourcing information, non-pharmacological

therapies emerged. However, this subject was too broad and in order for data to be more

manageable, a more narrow aspect of the topic was required (Cronin et al, 2007). ‘Doll Therapy’

materialised as an aspect of non-pharmacological therapies. (Having worked with dementia patients,

I had witnessed several interactions with dolls, but not recognised this as a legitimate form of

therapy). Although doll therapy is not widely practised in the UK, it is an established concept, early

studies (Moore, 2001, Tamura et al, 2001) reported a reduction in negative behaviours and an

increase in positive behaviours. When considering a question, the PICO model was applied to ensure

that it was focused and answerable (Straus et al, 2005). The original question posed was ‘What are

the benefits of doll therapy for older adults (65+) with dementia?’ However, this appeared to

provide the answer within the question, and the hypothesis that doll therapy is beneficial is

supported by overwhelming anecdotal evidence (Moore 2001; Gibson 2005; Lash 2005; Verity 2006).

What the research lacked was other factors which may influence the impact of doll therapy. An

integrative literature review was required to identify this gap in the literature (Caulley, 1992). All the

available evidence on this subject was analysed, in order to identify and synthesise the information

grouping similar conclusions, to present evidence based recommendations for practice (Taylor et al,

2007).

Considering that one third of older adults with dementia live in residential care, whilst two thirds

remain in the community (Alzheimers Society, 2014a) the research should be of value to both

professional and non-professional caregivers. However, the clinical context of the question is

geriatric nursing with the focus on medical wards within a hospital setting. Adult nurses frequently

encounter dementia patients who account for 25% of hospital bed occupancy (Global Burden of

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Disease Study, 2010); although actual figures are deemed to be much higher as dementia is grossly

underdiagnosed (Connelly et al, 2011).

Public interest has peaked in dementia care following the publicity of the Francis report (2013),

where vulnerable and older adults were mistreated in a hospital trust. Media involvement has

highlighted poor standards of care for persons with dementia (Ash Court Home) a panorama

documentary aired on BBC in 2012 revealed maltreatment and physical abuse of a patient with

dementia, subsequently dementia is more topical as a healthcare issue than in previous years.

In the past it was considered that older adults with dementia were in receipt of good care if their

personal hygiene needs and nutritional requirements were met (Kovach, 2000). Despite standards of

quality being derived from risk-reduction, this custodial approach failed to recognise the ‘person’

behind the dementia and a new culture of person centred care emerged (Kitwood and Bredin 1992).

Today the focus is on non-pharmacological interventions, such as reality orientation, reminiscence

therapy, music therapy and aromatherapy (Mitchell and O’Donnell, 2013).

Review Aims

The aim of this review was to identify the impact of doll therapy in older adults with dementia. The

research was intended to isolate an area of dementia care which had been previously overlooked,

and propose a change in practice. The person with the diagnosis was paramount in this research,

and the fundamental aims are based on optimising the well-being of people with dementia.

Methodology

Search strategy

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Databases specific to healthcare interventions were searched, Cumulative Index of Nursing and

Allied Health (CINAHL) Psychological Abstracts (PsycINFO) and MEDLINE (Aveyard, 2014). When an

article was not available in full it was sought in SwetsWise. An independent search was performed

using keywords, boolean operators were used to combine keywords and expand the search

(Coughlan et al, 2013). The following combinations were included: dementia OR alzheimers AND

dolls AND therapy/therapies AND non-pharmacological interventions AND toys AND activities AND

stimuli/stimulation. The snowball technique as described by Ridley (2008) was adopted, whereby

references within relevant papers were followed up, this was done using SUMMON to source the

original work and ‘google scholar’ which, despite being a citation index, has also been noted as a

useful resource for this purpose (Jasco, 2008). Manual searches of supplementary literature were

conducted in the library and 3 articles were ordered from the inter-loan service. The Cochrane

library was searched, this is regarded as the ‘gold standard’ evidence in healthcare research (Glasper

and Rees, 2013). However, systematic reviews on this topic are yet to be published on this database.

Limited information was available specific to doll therapy and/or toys, and it was anticipated that

very few RCTs existed, therefore the inclusion and exclusion criteria needed to be more flexible. The

following inclusion criteria were adopted: (i) sample have a confirmed diagnosis of dementia; (ii)

intervention was in the form of a doll. The only exclusion criteria was: (i) intervention in the form of

pet/animal therapy. It was decided that due to lack of research on the topic, all other relevant

literature addressing the question would be considered. International papers were sourced in the

English language with no set timeframe, dates were purposely not set as to find earliest works in this

field. Primary and secondary evidence were selected to include both quantitative and qualitative

data. Quantitative research presents a measurable outcome (Polit and Beck, 2008), whilst qualitative

information provides a holistic perspective (Holloway and Wheeler, 2010). Both of which are

appropriate in healthcare studies in order to apply evidence based research into practice (Nepal,

2010). As a result 10 of the most relevant articles were analysed using appropriate Critical Appraisal

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Skills programme (CASP) tools to their design. CASP was originally developed for purchasers of

healthcare, by the Oxford Institute of Health Sciences, as a tool for applying the principles of

evidence based practice to medicine (Milne et al, 1995). It is essential that healthcare professionals

make an informed judgment based on the quality of the research, therefore a recognised process

enables a systematic approach in order to determine the strengths, weaknesses and limitations of

the paper (Burns and Grove, 2009). Data was extracted and arranged into tables (Data extraction

tables 1-10). Themes were identified from recurring main findings. These collated perspectives were

grouped into three main themes to provide a unique answer to the review question.

Results

The combined themes unique to this research and in relation to the impact of doll therapy in older

adults are: (i) Doll therapy may not be suitable for all persons with dementia. (ii) Health professional

lack sufficient knowledge on the topic of doll therapy for persons with dementia. (iii) Withdrawal of

doll therapy may result in anxiety. Each supporting article has been analysed.

Doll therapy may not be suitable for all persons with dementia

A study by Ellingford et al (2007), supports the theory that doll therapy may not be suitable for all

persons. The aim of this pilot study was to determine changes in behaviour following the

introduction of doll therapy. A retrospective analysis of case notes was conducted (n=34 doll users,

n=32 non-doll users). The author is credible and well-known in this field. The design has many other

strengths: objective measures were applied, confounding factors were acknowledged and data

collection was blinded. Furthermore, the study is ethically sound, it received consent from the local

health trust; being based on indirect introduction of the variable, it enabled participant’s freedom of

choice. Data analysis was measurable and clearly presented, statistically significant findings were

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expressed with P values; therefore the calculated probability of rejecting the null hypothesis

strengthens this evidence (Brennan and Croft, 1994). The outcome demonstrated that doll therapy

has a positive effect on behaviours, with a noticeable difference compared to non-doll users. The

findings state that 92% of subjects choosing the dolls were female, which strongly suggests that

successful implementation of doll therapy may be dependent upon gender. This implies that males

may be less inclined to choose this therapy and is in line with the theme that dolls may not be

suitable for all persons with dementia.

An earlier study supporting this theme was carried out by Murray et al (2003). A randomised

controlled trial (n=18) was conducted on patients with dementia, to examine the effect doll therapy

has on language, cognition and emotional states. Randomisation is applied to ensure that as far as

possible, the two groups are similar, except, that one group is given the intervention. This

strengthens the results, as any differences in the end are more likely to be due to the intervention

(Craig and Smith, 2012). Standardized tests found that, despite all subjects falling into the ‘middle

stage’ category of dementia, each participant responded differently; therefore the impact of doll

therapy was found to be variable. This paper is logically consistent in the sense that it presents a

clearly defined process (Coughlan et al, 2007), which detailed specific inclusion and exclusion

criteria. It may be argued that this study is more robust than Ellingford et al (2007), as consideration

was given to independent variables and sampling was conducted with the aid of formal assessment

instruments. In addition the subjects had a medical history review to eliminate external influencing

factors. Tasks and data collection were sufficiently randomised, with results displayed in tables,

illustrating mean and standard deviation. Information based on participants mood was compiled by

the subjects. An emic perspective may be insightful, however, acknowledging the subjects have a

clinically recognised cognitive impairment; it is debatable if a self-rating questionnaire was a suitable

design. Exposure to the variable was limited, which may have affected the results. Furthermore,

there was no consenting committee, therefore ethical considerations were less accountable than

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Ellingford et al (2007). The trial recommends that doll therapy should be assessed on a ‘case by case

basis’. This supports the original theory that doll therapy may not be suitable for all persons with

dementia, and further expands on the notion that successful implementation cannot be determined

by gender or stage of the disease.

More recently, Heathcote and Clare (2014) conducted a review of 5 case studies to ascertain

whether doll therapy is experienced as therapeutic and calming, or patronising and inappropriate.

Findings were consistent with the theory that doll therapy may not be appropriate to every person

with dementia; recommendations are that doll therapy should be introduced sensitively, and patient

choice should be respected either way. This literature is the most up-to-date within this theme and

results are clearly displayed in the form of a review, with supporting evidence. Nonetheless, this

evidence is weaker than Ellingford et al (2007) and Murray et al (2003), due to the significant

differences in sample size and lack of pre-determined strategy. Furthermore, results may be biased

as the author (and manager of the home) had a vested interest. However, this study should be

regarded equally important as studies of this type are valid in healthcare, due to their holistic insight

(Polit and Beck, 2010).

In summary, there is strong evidence to suggest that doll therapy may be more successful within the

female population. Successful implementation may not be dependent on the progression of stage of

dementia. Doll therapy may not be suitable for all persons with dementia and each person should be

assessed on a ‘case by case basis’, however, patient choice should be respected either way.

Health professionals lack sufficient knowledge on the topic of doll therapy for persons with

dementia.

Recent evidence suggests that there is a distinct lack of awareness for healthcare professionals on

the topic of doll therapy. Mitchell and Templeton (2014) conducted a literature review to examine

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ethical considerations of doll therapy. The combined literature is descriptive and qualitative, with all

important outcomes considered; consequently, results can be applied to the local population (Ryan

et al, 2007). This paper is a reliable account of doll therapy and provides a lengthy discussion on the

ethical dilemmas faced by healthcare professionals. The recommendations call for doll therapy

guidelines and further knowledge for health professionals.

Mitchell and O’Donnell also called for guidelines in 2013. (Mitchell and O’Donnell, 2013). The peer-

reviewed paper was also aimed at health professionals, to provide an overview of the theory of doll

therapy. The background information was less detailed than Mitchell and Templeton (2014) and

therefore less thought-provoking, however, both authors; credible in this field, agree that there have

been limited studies on the topic. Moreover Mitchell and O’Donnell (2013) expressed concern that

doll therapy is becoming more apparent in clinical practice without practitioners applying the

evidence base. This view is also supported by Cullum et al (2008), maintaining that, patients are not

only entitled to but have prospects of receiving high quality care, and evidence based nursing

delivers this expectation.

Higgins (2010) further adds to the debate, stating that doll therapy faces potential difficulties due to

a “lack of a standardised approach” (p.20). This literature review supported by 2 case studies,

combines primary and secondary evidence including both quantitative and qualitative data. Both of

which are appropriate in healthcare studies in order to apply evidence based research into practice

(Nepal, 2010).

To summarise, the evidence, mainly literature reviews agree that Health Professionals lack sufficient

knowledge on the topic of doll therapy for persons with dementia. There is a consensus on the

pressing need for guidelines in this area to promote education and good practice.

Withdrawal of doll therapy may result in anxiety

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A recent quasi-experimental study (n=10) investigated the effect doll therapy has on behaviours of

exploration, caregiving and abandonment in persons with dementia. The study was conducted in

Italy, subsequently, cultural differences should be acknowledged; nevertheless common aspects of

human experience may be deemed as universal. Pezzati et al, (2014) compared an experimental

group who had used doll therapy for more than 2years with a control group who had never been

exposed to the variable. The researchers offered a balanced overview of the issue and the design

followed strategic steps to reduce any bias. This was a controlled experiment, it used recognised

indicators for baseline assessments, and was assessed independently. Analysis was blinded and

statistics were scientifically convincing; being displayed using chi-square, t-test and p-values.

P=0.001, therefore the researcher is sure that chance is not an explanation of the result, and that

caregiving behaviour is due to the intervention. However, an over concentration on quantitative

data may be seen as an inappropriate way to measure the effectiveness in health and social care

(Oliver and Peersman, 2001). Nonetheless, strong evidence (p=0.001) suggests that long term doll-

users were more likely to display behaviours of exploration and caregiving, compared to non-doll

users (Pezzati et al, 2014). The researchers maintain that these behaviours arise from a state of

safety, therefore withdrawal of the dolls may result in anxiety.

These findings are also supported by Mackenzie et al (2006), who conducted a pilot study to

establish the goals of doll therapy and how it is best implemented. The main findings of this study

include nurturing the doll, possessive behaviour towards the variable with a reported escalation of

arguments over doll ownership. Two of the authors have had several previous papers published on

doll therapy and are considered pioneers in this field. The study had a sufficient number of

participants (n=14), in addition the control group was self-selecting, which reduced selective bias.

Data was retrieved by convenience sampling questionnaires, which contained mixed methodology

and were completed by staff. However, Pezzati et al (2014) conducted their research over a much

longer period. Participants in the Pezzati (2014) study were exposed to doll therapy for more than 2

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years, compared to the 3-6 weeks of Mackenzie et al (2006). Staff were not blinded to participants,

this may affect the results as measurements may be consciously or subconsciously altered. However,

in these studies blinding is not always possible as the sample are actively engaged (Craig and Smith,

2012). The study had certain limitations; namely, rated behaviours were worded positively and

measures used were non-validated. However, the study acknowledged its weaknesses as a pilot and

recommended further work of a more rigorous design.

James et al (2006) carried out an observational, descriptive study (n=13), conducted over 12 weeks,

to examine the impact of doll therapy on activity and affective states. Findings were almost identical

to those of Mackenzie et al (2006) both papers noted that participants became over-invested in their

dolls, which at times led to them putting the dolls needs before their own. In addition, subjects

displayed ‘possessive behaviour’ and more specifically, were ‘anxious about leaving the doll’; this

clearly supports the original theme and echoes the work of Mckenzie et al (2006). This evidence is

valid in the sense that formal assessment instruments were used, and an external credited assessor

was employed. Potential biases were acknowledged: staff were not blinded to the participants, also

staff were involved in predicting outcomes, which may have had an influence on the results.

Bisiani and Angus (2012) conducted a single case study, recording behaviours pre and post doll

therapy intervention. Non-probability sampling was adopted and a recognised behavioural tool was

used. Qualitative evidence is not intended to generalise findings to the population, as it is recognised

that findings are unique to that individual; therefore, despite the sample being significantly lower

than the previous papers, the evidence is considered just as trustworthy (Polit and Beck, 2012).

Ethical guidelines were adhered to with a strong theoretical underpinning of the topic.

Geographically, the research facility was not UK based, nonetheless, as with Pezzati et al (2014) the

same ‘universal’ rationale should be applied. Strong evidence was put forward by Bisiani and Angus

(2012) to support the theme that the person was reluctant to leave the doll, and that this at times

led to anxiety.

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To summarise, clinical research suggests that dolls may provide an element of security to a person

with dementia. Trials observed that doll users show behaviours of nurturing and caring towards the

doll, this at times may lead to them putting the dolls needs before their own. Significant findings

show a reluctance to be parted from the doll, indicative that long-term doll users become attached

(to their doll). Therefore, the evidence suggests that withdrawal of doll therapy for existing users

may indeed result in anxiety.

Recommended Focus for Proposed Change

The research identified that doll therapy may not be suitable for every person with dementia, and

that there is a lack of awareness on the topic, amongst healthcare professionals. The evidence

suggests that when doll therapy is practised in the community or a nursing home setting, attachment

and ‘bonding’ takes place. When that person is admitted into hospital, they may become separated

from their doll; this was identified as the problem requiring change. Furthermore, hospitalization

increases a persons level of dependency, vulnerable adults are likely to feel anxious and insecure

(Henderson et al., 2007). Therefore in answer to the original question, the impact of doll therapy (for

existing users), is that withdrawal may result in anxiety, and the recommended focus for proposed

change is that hospital wards become ‘doll friendly’. These proposals are based on the principles of

paediatric nursing. When children are admitted into hospital, they are encouraged to bring their

favourite toy (NHS Choices, 2014). In this setting, dolls are acceptable and recognised as comforting,

the same concept should apply to older adults with dementia.

In the main this would involve an awareness campaign headed by a facilitator, with the aim of

creating a welcoming environment for doll users. Practical changes would include an updated ‘This is

me’ document (Alzheimers Society, 2014c). This tool is currently used to assess individual needs of

patients with dementia. The proposed addition would ascertain if a patient is an existing doll user,

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thereafter, it is recommended that procedures are put in place to encourage the continuation of

practice.

Practice Change Results

The Promoting Action on Research Implementation in Health Services (PARIHS) is a framework used

when implementing changes in healthcare. PARIHS identifies a relationship between three main

components of change: evidence, context and facilitation. (Rycroft-Malone et al, 2002). Likewise,

Kitson et al (1998) maintain that these are the key elements of successful implementation of change

to practice. Although the Promoting Action on Research Implementation in Health Services

framework itself has been open to question and may be considered more theoretical than practical,

its strengths lie in collaboration and the recognition that change comes about, when external factors

are accounted for.

Other models exist such as: Advancing Research and Clinical Practice through Close Collaboration

(ARCC) which primarily addresses implementation. The John Hopkins EBP model, has less emphasis

on organisational changes, but involves an action plan. In addition, for the experienced EBP

practitioner- the Stetler model can be used in potential guideline development. Each of these

provide an organised approach to implementing evidence based practice, with patient experience

being the key component in all models (Schaffer, 2012).

Evidence

The first element of the PARIHS framework is a focus on the evidence used to implement change.

Healthcare decisions should be based on reliable, sound evidence (Ham et al, 1995). There is strong

evidence to suggest that if doll therapy is being successfully applied to patients with dementia, then

‘withdrawal may result in anxiety’ (Pezzati et al, 2014; Bisiani and Angus, 2012; James et al, 2006;

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Mackenzie et al, 2006). The individual research articles in support of this claim are robust, because

they have been critically analysed using the appropriate CASP tools. Although the theme has been

derived from a structured process of synthesis, limitations are acknowledged. It would be

inappropriate to conduct trials based on this hypothesis alone; as, if removal of the variable causes

anxiety (as predicted), this type of trial would breach the moral rules of non-maleficence, as

described by Beauchamp and Childress (2009). However, the presented evidence collectively

demonstrates behaviours of: caregiving, exploration, nurturing, possessiveness, selflessness and

over-investment. It can be asserted that such behaviour is generally associated with human

relationships; therefore that some people with dementia are still able to form strong bonds, which

consequently lead to separation anxiety when parted. This is also supported by Kitwoods theory of

attachment (Kitwood, 1997) and coincides with the accepted notion that doll therapy reduces

behaviours of anxiety, in persons with dementia.

However, Carper (1978) describes four aspects of nursing knowledge, with empirical research being

only one part of the decision-making process. In order to provide high quality care, the views of

patients must be considered (Darzi, 2008).

Patient experience

There is overwhelming evidence that doll therapy is beneficial to people with dementia. Many

authors agree that doll therapy improves, reduces aggressive behaviour, and promotes well-being

for some individuals with dementia (Knocker 2002; James et al, 2006; Verity 2006; Higgins 2010).

Furthermore, older adults with dementia may lack meaning to their lives, putting them at risk of

depression (Phinney et al, 2007). Activities are a way of restoring a sense of responsibility to a

persons’ life (Nygard and Ohmen, 2002; Pool,2008), therefore having a doll may add an element of

purpose, increasing self-esteem and consequently reducing the risk of depression.

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However, the notion of giving dolls to older adults may be contentious; several authours maintain

that doll therapy is demeaning and infantilising (Milton, 1985; Hughes et al, 2006; Forster, 2010).

This viewpoint is shared by Mulrow et al (1997), who found other interventions, such as music

therapy, to be more ‘acceptable’. Doll therapy may be considered less appropriate for older adults

than other therapies, although, Angus and Bowen, (2006) argue that people with dementia should

not be stereotyped with our expectations. A different point of view is that doll therapy actually

restores dignity by providing an opportunity to be the care-giver, as opposed to the constant

receiver (Andrew, 2006). Furthermore, there is no evidence to suggest that doll therapy is

disrespectful, harmful, or degrading (Bisiani and Angus, 2013).

Ultimately, patient experience should evolve around person-centred care. Gill (2013) maintains that

patient-centred care involves nurses getting to know their patients better, in order to understand

their individual needs. Many authors (Blackhall et al., 2011; Brooker, 2003; Kitwood, 1997) endorse

validation as a person-centred approach to dementia care. Validation warrants the person’s sense of

reality. Gibson (2005) argues that quality dementia care is concerned with accepting the persons

perception of place and time. Therefore if the adult engaging with the doll is happy to do so,

healthcare professionals should validate and respect those feelings. In addition, Morton and

Bleatham (1988) discuss the detrimental impact of the opposite approach- reality orientation.

Maintaining that healthcare professionals, placing their sense of perspective onto a situation, can

leave the person with dementia feeling confused and humiliated. Therefore when considering

patient experience in dementia care, it is imperative that the evidence is based on person-centred

care through validation.

Context

In the PARIHS framework, context is related to the environment where the proposed change will

take place (Rycroft-Malone, 2004). The proposed changes apply to older adults who are admitted

onto a medical ward in a hospital trust. Consideration is given to how receptive the environment will

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be to the introduction of doll friendly wards. Nonetheless, any proposed change requires a

willingness, therefore staff attitudes are to be considered along with the actualization and practical

elements of making those changes (Edwards et al, 2007; Hannes et al, 2007; Larrabee et al, 2007).

Firstly, the issue of dementia is topical and Thomas (1985) states that changes are more likely to be

made if they are compatible with current government thinking. Government policy endorses person-

centred care for all older adults in society: High Quality Care for All, (2008) No Decision about Me,

Without Me, (2012). This is further demonstrated by the introduction of the ‘dementia friendly’

scheme within NHS Hospitals. The proposal of ‘doll friendly’ wards is in line with this programme,

and therefore may appear attractive for the department.

Furthermore, ward managers are more likely to adopt change if resources, finance and staffing are

not affected (Greenhalgh, 2006). The proposals are not concerned with introducing dolls, merely a

continuation of existing use, therefore funding should not be an issue for implementation. A

different aspect which may appeal to managers is a reduction in incidents. Regular audits are carried

out on wards, and the manager is responsible for meeting certain targets (CQC, 2013). Bisiani and

Angus (20102) found that doll therapy reduced the risk of falls in dementia patients. Therefore, the

adoption of a falls prevention programme, improves the wards prospects.

Despite this, successful implementation may be dependent upon the culture of the ward. Negative

cultures, as recorded in the Francis Report (2013) have a major impact on care provision. If person-

centred care is not a shared vision amongst frontline staff (as discussed in patient experience), then

change is unlikely to be supported, regardless of government policy and management approval.

In response to this, the Department of Health (2012) are promoting a culture of compassion

amongst healthcare professionals. The 6Cs: care, compassion, competence, courage, communication

and commitment are recognised as the fundamental values of nursing. However Dewing (2004)

suggests that the ability to provide person-centred care is psychologically and socially profound.

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Therefore, compassion in nursing is not merely an act of kindness; it also demands education and a

level of expertise.

The application of evidence to practice is also influenced by leaders within the organisation. Many

authors (Bach and Ellis, 2011; McKenzie and Manley, 2011) agree that effective leadership is patient-

centred. Despite this, leadership styles vary; a transactional approach is likely to be obstructive to

change, whilst transformational leaders are more likely to be supportive (Wong et al, 2013).

Therefore, the success or demise of any change may be attributable to the ‘type of’, as opposed to

the ‘role of leaders.

Facilitation

Facilitation involves making something easier for others (Kitson et al, 1998) however, facilitation is

open to debate depending on the scale of the change (Rycroft et al, 2007). Practical elements of any

change require a facilitator, although external facilitators have a financial impact on the organisation

(Lambert and Glacken, 2005), therefore, it is more favourable, if possible to utilise the existing

workforce. The role of ‘Dementia champions’ is to advocate the rights of people with dementia in

NHS Hospitals. (Waugh et al., 2011). Based on this account, it feasible to suggest that this existing

position lends itself to the role of facilitator of the proposed change.

Hostilities may arise from other staff, patients or visitors, who are uncomfortable with the use of doll

therapy (Salari, 2002). However, existing awareness of key principles, such as validation, equip

Dementia Champions with the skills to overcome these objections. Nonetheless, Aita et al (2007)

argues that awareness alone, is not sufficient, as knowing about the change is different to applying it

in practice.

In order for successful implementation, proposed changes to practice need to be clear and specific.

Facilitators tend to favour guidelines and policies as opposed to formulating fresh ideas (Hewitt-

Taylor et al, 2012). The National Institute for Health and Care Excellence (NICE). NICE are considered

S11735925 19

to be the pinnacle in developing guidelines for health and social care practitioners. However, there

are currently no formal guidelines on the use of doll therapy in dementia management, (Mitchell

and O’Donnell, 2013). Conversely, it may be argued that dementia champions are nurses and

evidence based practice is a principal of the Nursing and Midwifery Council (NMC, 2008), therefore,

facilitators should develop their own guidelines for practice. However, Heaslip et al (2012) claim that

many nurses lack confidence in their own research skills. This supports the claim that without formal

guidelines, facilitators lack clear and specific instruction.

According to Burrows (1997) facilitation involves critical reflection. Reflection can provide a deeper

understanding of a topic and ultimately improves care (Oelofsen, 2012). Dementia champions may

be more inclined to facilitate doll therapy, after analysing their role in relation to patient centred

care. Patient centred care is the driving force of ‘Dementia friendly’ wards in NHS Hospitals. The

fundamental aims of such wards is to promote holistic care, through enabling activities of daily living

(The Kings Fund, 2014). Therefore, Adoption of doll friendly wards is more likely to come about if

facilitators reflect on these shared values

Recommendations and Conclusions

The first stage of this integrative review was to determine the focus and direction of the work. The

sourcing of evidence and systematic approach helped develop personal research skills, whilst the

analysing component; encouraged a deep learning of the topic. Prolonged engagement with the

literature highlighted the significance of person centred, and evidence based practice in delivering

appropriate healthcare. However, methodological limitations of the studies has as impact on the

strength of this review, it is acknowledged that adoption of and further research on these

interventions are recommended.

S11735925 20

The key points of this review, based on the presented evidence are that; Doll therapy may not be

suitable for all persons with dementia. Also, Health professionals lack sufficient knowledge on the

topic of doll therapy for persons with dementia. The proposals of change are based on the key

findings that, withdrawal of doll therapy may result in anxiety. The recommended change in practice

consists of hospital wards developing a ‘doll friendly’ approach. The likely outcome is happier

patients and a reduction in incidents. This can be achieved through promoting awareness of the

topic, and adaption of the ‘This is me’ tool. The Promoting Action on Research Implementation in

Health Services (PARIHS) framework identified that there is strong evidence to support this proposal,

furthermore, the concept is in line with Kitwoods (1997) established theory of attachment. Patient

experience is a vital component of implementing change, and there is overwhelming evidence that

doll therapy is beneficial to people with dementia. This review has considered if doll therapy is

demeaning to a person with dementia. Based on the evidence, patient experience should not be

founded on the perspective of others, therefore, if the adult engaging with the doll is happy to do so

healthcare professionals should respect their choice. Aspects of implementation were examined, it is

perceived that dementia is currently a topical issue for the NHS, therefore the environment is likely

to be more receptive regarding initiative in this area. However, it is acknowledged that the culture of

the ward may have a significant impact on implementation. Furthermore, success may depend on

leadership styles within the organisation. In addition, it is perceived that facilitation is possible with

input from ‘Dementia Champions’. It is anticipated that their existing role and knowledge may give

support to the process. Furthermore reflective practice may enhance the facilitators desire to

promote person centred care. However, lack of guidelines may cause uncertainty about best

practice and it is further recommended that NICE formulate guidelines specific to doll therapy in

dementia care. In the meantime, this paper concludes that ‘doll friendly’ wards are; a viable addition

to the existing dementia friendly scheme within NHS hospitals.

S11735925 21

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