# “Heartbreaking, Hardest Part of the Job”: A Qualitative Descriptive Study of Acute Care Nurses’ Work with Patients with Dementia Who Self-Neglect Their Hygiene

## TL;DR

This study explores how acute care nurses handle the ethical challenges of caring for dementia patients who refuse hygiene help and become aggressive.

## Contribution

The study introduces a qualitative descriptive approach to understanding nurses' ethical reasoning in dementia care scenarios involving self-neglect and aggression.

## Key findings

- Nurses use creative strategies to provide hygiene care while respecting patient autonomy.
- Barriers often prevent nurses from delivering their preferred care methods.
- Forced care is sometimes used, justified as necessary to minimize harm.

## Abstract

When nurses encounter people in institutional settings who are living with dementia and self-neglecting their hygiene, they are challenged to provide care that respects autonomy while upholding the ethical principles of beneficence and non-maleficence. This study aimed to understand how nurses respond when confronted with patients who decline assistance with personal hygiene and then became physically aggressive. Methods: A qualitative descriptive study employing think-aloud interviewing to explore nurses’ clinical reasoning about how they would proceed with the care of a patient living with dementia who self-neglects their hygiene. Results: Nurses describe many creative ways that they would work with patients to accomplish personal hygiene care in an ideal world. Participants also share the many barriers they experience to providing desired care and instances where they would force care with people who self-neglect their hygiene. Thematic analysis revealed six key themes: non-preferred approaches to care; preferred approaches to care; barriers to actualizing preferred approaches; responding to continued resistance to care; justified use of force; and efforts to minimize harm. Conclusions: This study highlights that ethical nursing practice in dementia care is not simply a matter of following through with best practices. It is an ongoing negotiation, carried out in environments that are often misaligned with nurses’ values.