M.F. is a 37-year-old male presenting to the Emergency Department with dypsnea at rest that has been present for two to three weeks. His condition has worsened over the past two days. He presented with rapid respirations, complaints of periodic confusion, nasal flaring, and irritability. He had an occasional nonproductive cough and was afebrile. The chest x-ray showed bilateral effusion and possible pericardial effusion.

This patient is non-compliant with hemodialysis. On admission to the Emergency Room he had an elevated blood urea nitrogen and creatinine. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Primary Diagnosis and Priority Secondary Diagnosis

M.F. was admitted to the hospital with a primary diagnosis of pneumonia and a secondary diagnosis of chronic renal failure.

Patient History

M.F. has a history of failed renal transplants times two. He also has severe pulmonary hypertension and chronic heart failure. M.F. is non-compliant with his dialysis; he is supposed to have dialysis three times a week. He currently only goes twice per week. The patient is a smoker of one half pack per day and at this time has no plans to quit. He lives with his fiancée, who is present at the patient’s bedside. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

PATHOPHYSIOLOGY OF THE PRIMARY AND PRIORITY SECONDARY DIAGNOSIS

Pneumonia is an excess of fluid in the lungs resulting from the inflammatory process. Inhaling infectious organisms or agents that irritate the lungs can trigger inflammation. The inflammation occurs in the alveoli, bronchioles and interstitial spaces of the lungs. Organisms multiply within the alveolar spaces causing an immune response. White blood cells migrate to the area causing local capillary leak, edema, and exudates. These fluids collect in and around the alveoli, thickening the walls and thus reducing gas exchange. This leads to hypoxia. If the organisms move into the blood stream sepsis results.

The fibrin and edema cause a stiffening of the lungs. This stiffening reduces lung compliance, decreasing the lungs vital capacity. The inflammation of the alveoli causes collapse, further reducing the oxygenation of the blood.

People develop pneumonia when their immune systems are unable to combat the virulence of the invading organisms. Bacteria, viruses or fungi can cause pneumonia. Inhalations of toxic gases or aspiration are among other causes of pneumonia (Ignatavicius & Workman, 2006). NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Patients with pneumonia have flushed cheeks, bright eyes, and an anxious expression. They may have pleuritic pain or discomfort, myalgia, headache, chills, fever, cough, tachypnea, tachycardia, and sputum production. Crackles are heard when there is fluid in the interstitial and alveolar spaces. Wheezing may be heard when there is inflammation and exudates in the airways. These patients may be hypotensive as a result of vasodilatation and dehydration.

Chronic renal failure is an irreversible kidney injury. This disease is progressive and ends with the kidney function being too poor to sustain life. The first sign is diminished reserve. In this stage there is no build up of metabolic wastes in the blood. The unaffected nephrons can compensate for the injured nephrons. As renal damage increases systemic blood pressure increases, causing increased glomerular pressure, which will damage more nephrons. As more nephrons are damaged the patient progresses to renal insufficiency. This stage has a build up of metabolic waste in the blood stream. Levels of blood urea nitrogen and creatinine increase, the kidneys are no longer able to maintain hemostasis. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Three main causes of renal failure include diabetes mellitus, hypertension, and glomerulonephritis. Polycystic kidney disease, a hereditary renal disorder, in adults can lead to chronic renal failure.

Chronic renal failure can cause lethargy, seizures or coma. The patient is at risk for fluid overload, hypertension or heart failure. They may also have breath that smells of urine, shortness of breath or tachypnea. In later stages the patient may experience anemia or abnormal bleeding. As kidneys fail the patient may have oliguria. The skin may become itchy or develop a layer of crystals called uremic frost (Ignatavicius & Workman, 2006).

M.F. suffers from shortness of breath, due to increased fluid build up. The fluid builds in his lungs from his chronic renal failure, giving bacteria a place to multiply and causing the immune inflammatory response. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

ACTUAL OR POTENTIAL IMPACT OF RELEVENT MEDICAL HISTORY ON THE PRIMARY DIAGNOSIS AND PRIORITY SECONDARY DIAGNOSIS

M.F. has a history of chronic renal failure. He also has a history of non-compliance with his dialysis. When M.F. does not get his dialysis he is at risk for fluid overload. This fluid builds up aggravating his hypertension and his chronic heart failure causing an increase in his pulmonary hypertension. By increasing the fluid in his lungs he decreases his gas exchange causing hypoxia. When the body senses hypoxia it starts to shut down the kidneys, causing a further fluid to build up and the decrease in the other functions of the kidney. One of which is production of erythropoietin. Since the kidneys are not producing this hormone, his body is not producing red cells, causing anemia. M.F. now further decreases his oxygenation levels, which could lead to a decrease in his level of consciousness, causing lethargy and confusion. M.F. had a low hemoglobin level that required treatment in the hospital (see medical management section). NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

MEDICAL MANAGEMENT: PNEUMONIA

Medical interventions for pneumonia include obtaining a sputum specimen for culture, a chest x-ray to look for areas of increased density, a complete blood count to identify white blood cells and red blood cells and hemoglobin for anemia, arterial blood gases, pulse oximetry for oxygenation. They could also include a blood urea nitrogen level to monitor for dehydration. Blood culture specimen to rule out sepsis. Monitor for signs and symptoms of infection.

M.F. had a slightly elevated white blood cell count (n=5.0-10.0) that ranged from 10.3 to 11.3 on discharge. His hemoglobin (n=14-18) was low upon admission at 7.9; he was given two units of packed red blood cells. His hemoglobin was still low upon discharge, at 10.9, but the patient was not lethargic, confused or short of breath. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

X-ray on discharge showed a decrease in the size of infiltrates. M.F. remained afebrile throughout his admission. Upon discharge he was able to ambulate 50 yards, without any signs of distress. He had two negative blood cultures this admission.

To decrease the amount of fluid being retained M.F. was encouraged to follow a renal healthy diet. This would include foods low in protein, sodium and phosphorous (Medical College, n.d.). As kidney function declines these products build up in the blood stream. In order to lower the strain on his kidneys, M.F. was given instructions on foods that meet these criteria. M.F. was also encouraged to attend his dialysis three times per week, as directed by his physician. Hemodialysis is the most common type of dialysis. It uses a filter to remove waste products from the blood stream. It then returns the cleaned blood back to you (Castner, 2008). NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

NURSING INTERVENTIONS

Textbook recommendations for nursing interventions include cough and deep breathing, use of incentive spirometer, to improve lung compliance. It recommends monitoring vital signs and breath sounds, to assess for improvement of infection. Also recommended is adequate hydration to thin secretions.

M.F. was encouraged to cough and deep breath every hour. He was very lethargic on day one and did not try more than twice. He did increase his attempts on day two. He was given instruction on the incentive spirometer, and was encouraged to use this every hour. He made no attempts on day one. On day two he was able to raise the level to 750mm for three seconds. He increased his efforts and was able to keep the level up for four seconds and repeat this five times each hour upon discharge. The patient’s lung sounds cleared from crackles to clear by discharge. The patient’s respiratory rate returned to between 18-20 breaths per minute upon discharge. M.F. was kept to an 1800 ml per day fluid restriction, due to his increased fluid volume. He remained afebrile throughout his stay. He had a non-productive cough upon admission; this did not clear during his hospital stay. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

PHARMACOLOGICAL MANAGEMENT

Treatment options include antibiotics to stop the spread of infection. Bronchodilators may also be used to improve gas exchange. The use of oxygen management is encouraged to increase oxygenation of the blood.

M.F. was on two liters of oxygen via nasal cannula and was able to maintain his pulse oximetry at a level between 92-95%. Upon discharge his pulse oximetry showed 95% on room air. He was started on Avelox (antiinfective) intravenously, and then changed to oral upon discharge. He remained afebrile throughout hospital stay. His white blood count rose slightly, but no other signs of bacterial infection was noted. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

PROVIDER AND MANAGER ROLE: NURSING CARE PLAN

“P” Impaired gas exchange

“R” Ventilation-perfusion imbalance

“C” decreased level of consciousness, dypsnea at rest, decreased oxygen saturation <90%

Goal statement

The patient will show improving lung fields and remain free of respiratory distress, as evidenced by clearing chest x-ray and improved oxygen saturation levels by discharge.

Nursing interventions

The nurse will monitor patient’s respiratory rate, depth and effort including use of accessory muscles, nasal flaring and abnormal breathing patterns. The nurse will encourage the patient to cough and deep breath. The nurse will teach and encourage the use of the incentive spirometer hourly. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Evaluation of progress toward patient goal

M.F. had a hard time complying with the nursing interventions.

When using the incentive spirometer his lung sounds went from crackles to clear. His respirations went from 28 breaths per minute to 18. He maintained a pulse oximetry of between 92-95% on 2 liters of oxygen. He was able to ambulate in the hallway without respiratory distress. The chest x-ray taken on the day of discharge showed a decrease in the infiltrates in the patient’s lungs. This patient met his goals upon discharge.

PROVIDER AND MANAGER ROLE

Role of the Multi-Disciplinary Team

M. F.’s care depended on the ward clerks to order the appropriate tests at the appropriate times. It also included the ancillary services to do the tests as ordered. A nutrition consult was ordered to teach proper diet for a patient that has chronic renal failure. A mental health consult was ordered to evaluate the patient for depression. Also a social worker talked to the patient about his need for transportation to dialysis upon discharge. The discharge planner was also helpful in making dialysis appointments for this patient. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Provider of Care Role

As provider of care I monitored the patient’s vital signs, paying particular notice of his temperature to monitor for infection. I also evaluated M.F.’s breath sounds, noting improvement daily. I gave the patient his medications on time. I also encouraged the patient to cough and deep breath and use his incentive spirometer. I assisted M.F. in ambulation when needed.

Manager of Care Role

As manager of care for this patient I needed to instruct him on the use of his incentive spirometer and the importance of using this equipment to increase his breathing ability. I also monitored his laboratory and radiology results to be sure these were done as ordered. I made sure all the doctors orders were noted in a timely manner and carried out as instructed. I gave this patient his discharge instructions and made sure he was knowledgeable about his diet. I answered any question M.F. had on the information given to him during his admission to the hospital. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Growth in the Manager of Care Role

I was able to see the importance of recognizing the affect of all co-morbidities of the patient. For each disease process there is an effect on other systems, and each of these effects must be taken into account when treating the patient.

When teaching this patient I also was learning the things needed to help in achieving a healthier lifestyle for this patient. This helped me develop a knowledge base that I can build upon. Since this patient was not receptive to instruction, I had to find ways to get him to comply with his orders. I learned to depend on others on my team to help get the job done. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Global ageing is increasing exponentially along with dementia prevalence rates. The demographic trends show that dementia along with other comorbidities has a serious effect on prolonged hospitalisation than people without dementia, with a huge impact on health services and the national economy .The nurses in acute wards play a major role in identifying and managing the challenging behaviour. The interventions seems to be inconsistent due to the busy context of the acute wards and lack of guidance on care of dementia patients with challenging behaviour, which again has a detrimental effect on dementia patients. Upon reviewing the literature, a gap is identified about experiences of nurses caring for dementia patients with challenging behaviour . Hence the writer plans to explore the experiences of nurses in dementia with challenging behaviours using a Husserlian phenomenological approach with the hope that it can contribute to the nursing practices. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Chapter 1

1.1 Introduction

Dementia is a progressive degenerative disease of the brain, and the fourth leading cause of death for the age group of 65 and above (O’Callaghan 2008, cited by Jean and Murphy, 2011). Currently there are about 41,470 people with dementia live in Ireland as per EuroCoDe age/gender specific dementia prevalence rates (2006 census of population). Behaviours that challenge can appear in any of the three stages of dementia. Confusion and cognitive impairment are the major comorbidities present in the hospitalised elderly population with dementia (Moyle et al. 2008).

Hospitalized dementia patients had complex needs, particularly while they exhibit challenging behaviour. Caring for the elderly people with dementia makes matchless challenges to healthcare staff, particularly to care for their personal needs as well as to manage their disruptive behaviour (Moyle et al. 2008). While attending the heavy work load along with high emotional involvement can produce stress on nursing staff which could lead to frustration and dissatisfaction (Chou et al. 2012). Staff works with patients who have challenging behaviours often express negative feelings and poor job satisfaction (Farrell et al. 2010). Even though there were many studies conducted in the area of dementia and associated behaviours , few studies done about nurses’ experiences in caring for dementia patients with challenging behaviour. Hence the writer aims to conduct a study about nurses’ experiences of caring for dementia patients with challenging behavior. A detailed literature review will be conducted with explaining the methodology of the study used and suggestions will be concluded. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

1.2 Search strategy

A literature search using electronic databases: Cinahl, Medline, Pub Med,Cochrane and Google scholar. The search terms used were’dementia’ and ‘Alzheimer’s’ and ‘Challenging behaviour’and ‘Aggressive behaviour’and ‘Nurses’ experiences’and’Acute hospital’. Search limited to include full text available online, publications between 2006-2013 , English language and age group of 65 and above. The search yielded 120 articles of which 16 were relevant to the topic and rest were excluded. Out of 16 studies 7 were dealing with dementia patients in acute hospitals and 6 were about challenging behaviour in dementia patients and 3 were dealing with nurses’ stress and job satisfaction. Reference list was also reviewed from the articles used to review. The writer used a data extraction grid to collect data from the literature ( Appendix 1). NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

1.3 Review of Literature

1.3.1 Caring for older people with dementia

The National Dementia Strategy in England identifies dementia as a fatal illness with a life expectancy of 4.5 years from diagnosis to death (Xie et al.2008). Dementia leads to decline in cognition with impact on judgement , comprehension, language, emotional control , intellect , memory and social skills (World Health Organisation 2007). Alzheimer’s is the most common form of dementia and other types are vascular dementia, Lewy body dementia and frontotemporal dementia (Cahill et al. 2012). Dementia has three stages; early, moderate and severe (http://www.dementia.ie).

In a qualitative study by Nolan (2007) using a purposive sample of seven nurses with the thematic approach reported that the physical layout of the acute ward as inappropriate to care for older people with dementia and the highlighted alarm is the safety of the patient. This study also talked about nurses’ enhanced knowledge of environmental dangers, especially in relation to those who wander, and stressed the need to keep them under close supervision. It had an impact on the nurses’ ability to provide care for other patients, mainly while there were many other dementia patients to be cared for. Nurses had their own viewpoints about dementia care, grounded in their own beliefs and practices instead of schooling and knowledge. Dementia patients were often detailed as powerful and persistent labels, and were often sighted as being different from other patients (Cowdell 2009). This study, using an ethnographic approach suggested that instead of meeting the needs of the clients , care mainly focussed on completing the physical needs and provision of care included less amount of good communication. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Due to functional deficits, dementia patients were unable to complete their activities of daily living and due to the time constraints nurses had to take over such activities (Nolan 2006). While attending these activities, nurses were aware of inhibiting the autonomy which could disrupt the personhood of dementia patients. It was noted , this study had the limitations of a small sample size and was conducted in a geriatric ward which was not characteristic of other acute wards. Similar results were found out by a study of Edberg et al. (2008). A qualitative study by Edvardsson et al. (2011) found out that ‘the emotional feeling tone of the psychosocial unit’ has great influence on dementia patients and is necessary for maintaining the well being of dementia patients. Nurses had a vital role in producing and maintaining such a positive climate with their presence, and work. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

1.3.2 Challenging behaviour in dementia

Challenging behaviour has been defined as ‘an active attempt by the person to express an unmet need, which could be physiological and psychological’ (Stokes G 2000, cited by Andrews 2006 ) or ‘can be a sign of pain or suffering , or a reaction to carer’s torment, which consecutively increases the behavioural problems’ (Bird et al. 2007). A quantitative study by Pulsford (2011) using the Management of Aggression in People with Dementia Attitude Questionnaire (MAPDAQ) to assess the behaviour, the result shows that staff finds the aggressive behaviour mainly as circumstantial, could be from an interaction with staff or from the nature of care providing. Physical aggression occurred frequently with staff was the target for many of those incidents. This study was limited by less response from staff. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Moyle et al. (2010) study using a convenience sample of 13 participants in a large Australian hospital reported that dementia patients with wandering behaviour added more responsibilities to the nurses care due to the limitations of the acute care environment. So they had an attitude to devalue such patients which led to nurses managing the safety issues of the patient, and less intervention were used to meet the physical, social and emotional needs of persons with dementia. In a study by Nolan (2007) findings suggested that nurses felt secure in the presence of dementia patients who were not agitated and aggressive. A cross sectional survey by Cubit et al. (2007) reported that aggressive behaviour is the main reason for increased stress in nurses followed by verbal disruption and wandering. Moyle et al. (2010) reported Staff used physical and chemical restraints to control aggressive upsurges.

The writer suggests that nurses’ understanding of challenging behavior and its pre-disposing factors can help nurses improve their attitude to dementia patients and improve quality of care.

1.3.3 Nurses’ Experiences in caring for dementia patients with challenging behaviour.

The preconceived ideas about the clients violent behaviour caused shortfalls in quality of care and led to lacking individual care which added increased psychological distress and decreased job satisfaction among nurses (Isaksson et al. 2009). This study had limitations of a small sample size and conscious biases present, but the trustworthiness is proved by discussing the findings with other research groups and by seminars with other researchers. Nurses described caring for older people with dementia in an acute hospital as reaching to feelings of incompetence and job dissatisfaction , and tended to focus their efforts on physical care due to lack of confidence (Cowdell 2009). Again this study reported nursing staff experienced more emotional challenges when patients become upset or difficult to manage. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Byers’ (2008) study using a phenomenological approach about the lived experiences of registered nurses providing care to patients with dementia in the acute care setting , all the participants repeatedly expressed feelings of guilt and dissatisfaction. Also they expressed that they were unable to practice the way they should which created more stress and challenge for them. Similar results were found out by Edberg et al.’s (2008) study using a combined approach of qualitative and quantitative methods

Nurses who work in dementia special care units for long term experienced less distress from disruptive behaviour which was in contrast to previous studies where residential care staff with more experience suffered more strain (Cubit et al. 2007), but this study had used the convenience sample for cross sectional survey and the survey tool was limited by asking to recall events from the past week, thus reliability can be questioned. Edvardsson et al. (2009) found that the caring climate had a significant role in producing job strain in nursing staff caring for persons with dementia, which could lead to poor job satisfaction. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

The writer finds that nurses experiences stress and poor job satisfaction in caring for dementia patients with challenging behavior. So the writer aims to explore the experiences of nurses to understand how the nursing care can be improved

1.4 Methodological issues in the literature:

Upon reviewing the literature, the studies which gave information about the experiences of nurses about dementia care where qualitative studies and had rich descriptions about the topic but as the samples were small in size in qualitative research and the studies conducted in single sites, the results cannot be generalised. Edberg et al.’s (2008) study used a focus group and participants were recruited through the personal awareness of moderators and reliability can be varied, but trustworthiness and transferability of the findings evidenced by the uniqueness of results and is reinforced by agreement of the findings between nurses in different groups and across the countries. Ethical approval was obtained from relevant sources for all studies. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

1.5 Conclusion

Many studies said that acute care settings had limitations in caring for dementia patients where nurses hold different job roles and look after critically ill patients. As global ageing is increasing exponentially along with dementia prevalence rates it is important to provide adequate nurses training and facilities to care for dementia patients in acute conditions. Hence the writer aims to explore the experiences of nurses in caring for dementia patients with challenging behaviour and to contribute findings to improve quality care .

Chapter 2: Methodological issues in research

2.1 Introduction:

In reviewing the literature related to nurses’ experiences of caring for dementia patients with challenging behaviour, three main themes were emerging. It has been identified that nurses are the frontline workers in the acute hospital with dementia patients and there were not much study done about the experiences of nurses in relation to caring and their knowledge of dementia care. Therefore a gap has been identified in the literature. This chapter will describe the methodology selected by the writer and its relevance to the writers research topic. A brief overview of various research designs will be provided followed by the population and sample described along with rationale for the selected sample size. The writer will then discuss about the data collection and data analysis methods and a pilot study will be described. Ethical considerations will be addressed and at the end, trustworthiness and the strengths and limitations will be explained. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

2:2 Aim of the study:

The proposed research aims to explore the experiences of nurses in caring for dementia patients with challenging behaviour to find out about the barriers and to improve care standards for dementia patients.

2:3 The Research Question:

What are the nurses’ experiences in caring for dementia patients with challenging behaviour?

2:4 Research Methodology

Nursing research is a systematic inquiry structured to build trustworthy evidence to important issues of nurses and their clients and research methods are the techniques used by researchers to collect and scrutinize the information relevant to the question (Polit & Beck 2014). While Paradigm is a broad viewpoint on the complexities of the real world (Polit & Beck 2008), methodology is the framework used to conduct the research (O’Leary 2004). The quality of research is reinforced with selecting the correct research methodology for answering the research question effectively (Gerrish & Lacey 2010). Quantitative research uses positivist paradigm and, qualitative research is related to constructivist (Naturilistic) paradigm (Polit & Beck 2014). NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

Quantitative research seeks to present a world view which is objective and involves variables which can be quantified and manipulated whereas qualitative research looks to get the opinions, experiences of participants and the meanings of their perspective on the research topic is looking for (Watson et al. 2008). Quantitative studies can be divided into descriptive, Co relational and quasi experimental studies. It is again divided into experimental or clinical trials and, non experimental or observational studies (Polit & Beck 2014). Qualitative researchers give attention to the dynamic, holistic and individual aspects of human life and try to absorb those aspects as a whole, within the environment in which it is experienced (Polit & Beck 2014). Qualitative study can be divided into three categories: grounded theory, which describe the key social and psychological processes which occur in the social setting wherein ethnography learn from members of the cultural groups, to realise their world view and, describes their customs and norms. Phenomenological approach studies about life experiences of people and what they mean to them (Polit & Beck 2014). Parahoo (2006) says that phenomenology is based on the philosophy of Husserl (descriptive), in contrast Heideggerian phenomenology looks into the individual personal history and psychological make up to understand the way in which how they experiences phenomena (interpretive). The aim of the proposed research is to explore the experiences of nurses caring for dementia patients with challenging behaviour, therefore the writer finds qualitative research method using the Husserlian phenomenological approach as appropriate to the study. Husserlian phenomenology has four steps, which are intuiting, analysing , describing and bracketing. By using ‘bracketing ‘which leaves writer’s perceptions, prejudices and beliefs away to get the description of respondents’ experiences in pure form (Polit & Beck 2014). NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay

The research will be undertaken as part of a PG diploma in Nursing and the time scale will be over 9 months.( Appendix 2 )

2.5 Population, sample and sampling

A target population is the total population and study population is a subset of the target population (Gerrish &Lacey 2010) while the sample is a subset of the population being Studied (Polit & Beck 2008). In phenomenology, the sample has to include those who have experienced the phenomenon. So the writer plans to use nurses who care for dementia patients. Sampling is the process of selecting a portion of the population to represent the entire population (Polit & Beck 2008). Qualitative researchers look to identify the key individuals, events or settings that provide a rich source of data and are not so concerned about identifying the total population in developing the sample frame (Gerrish & Lacey 2010). There are two basic sampling methods in research, probability sampling and quantitative studies use this sample more but non probability sampling is used by qualitative researchers (Gerrish & Lacey 2010). The writer has chosen a purposive sample for this study, which is a form of non probability sampling and researchers’ knowledge of the population employed to select the sample (Polit & Beck 2008). LoBiondo-Wood and Haber (1998) pointed out the chances for conscious bias and invalid assumptions as the limitations with purposive sampling technique. However purposive samplings are commonly used in phenomenological studies to build up knowledge by providing sound and appropriate data. A sample of 10 nurses working in an acute geriatric ward in an academic teaching hospital in Ireland and regularly caring for dementia patients with challenging behaviour deemed appropriate for the study. NURS 6550 – Advanced Practice Care of Adults in Acute Care Settings Essay