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Social Network Analysis of Dementia Wards in Psychiatric Hospitals to Explore the Advancement of Personhood in Patients with Alzheimer’s Disease

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  • International Centre for Healthcare and Medical Education (ICHME) Bristol United Kingdom

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Background Little is known on investigating how healthcare teams in dementia wards act for promoting personhood in persons with Alzheimer’s disease (PWA). Objective The current research aimed to identify the social networks of dementia health carers promoting the personhood of PWA in acute or long-term dementia wards in public and private psychiatric hospitals. Method We used a mixed-method research approach. Ethnographic observations and two-mode Social Network Analysis (SNA) captured the role and social networks of healthcare professionals promoting PWA personhood, using SocNetv version 2.4. The social network graphs illustrated how professionals participated in PWA care by computing the degree of centrality (%DC) for each professional; higher values indicated more statistical significance of a professional role compared to others in the provision of personhood care. The categories of personhood were biological, individual, and sociologic. Nurses, doctors, ward managers, hospital managers, clinical psychologists, occupational therapists, care coordinators, physiotherapists, healthcare assistants, and family members were observed if they were promoting PWA personhood. Results The highest %DC in SNA in biological personhood was held by the ward nurses (36%), followed by the ward doctors (20%) and ward managers (20%). All professional roles were involved in 16% of cases in the promotion of individual personhood, while the hospital managers had the highest %DC (33%) followed by the ward managers and nurses (27%) in the sociologic personhood. Conclusion All professional roles were deemed to promote PWA personhood in dementia wards, although some limitation exists according to the context of the assessment.
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Current Alzheimer Research, 2019, 16, 505-517
505
RESEARCH ARTICLE
Social Network Analysis of Dementia Wards in Psychiatric Hospitals to
Explore the Advancement of Personhood in Patients with Alzheimer’s
Disease
Carlo Lazzari1,*, Yasuhiro Kotera2 and Hywel Thomas3
1Centre for Health Care and Medical Education, Bristol, United Kingdom; 2Centre for Human Sciences Research, Uni-
versity of Derby, United Kingdom; 3College of Human and Health Sciences, Swansea University, United Kingdom
A R T I C L E H I S T O R Y
Received: January 20, 2 019
Revised: March 27, 2019
Accepted: April 29, 2019
DOI:
10.2174/1567205016666190612160955
Abstract: Background: Little is known on investigating how healthcare teams in dementia wards act for
promoting personhood in persons with Alzheimer’s disease (PWA).
Objective: The current research aimed to id entify the social networks of dementia health carers promot-
ing the personhood of PWA in acute or long-term dementia wards in public and private psychiatric hospi-
tals.
Methods: We used a mixed-method research approach. Ethnographic observations and two-mode Social
Network Analysis (SNA) captured the role and social networks of healthcare professionals promoting
PWA personhood, using SocNetv version 2.4. The social network graphs illustrated how professionals
participated in PWA care by computing the degree of centrality (%DC) for each professional; higher
values indicated more statistical significance of a professional role compared to others in the provision of
personhood care. The categories of personhood were biological, individual, and sociologic. Nurses, doc-
tors, ward managers, hospital managers, clinical psychologists, occupational therapists, care coordinators,
physiotherapists, healthcare assistants, and family members were observed if they were promoting PWA
personhood.
Results: The highest %DC in SNA in biological personhood was held by the ward nurses (36%), fol-
lowed by the ward doctors (20%) and ward managers (20%). All professional roles were involved in 16%
of cases in the promotion of individual personhood, while the hospital managers had the highest %DC
(33%) followed by the ward managers and nurses (27%) in the sociologic personhood.
Conclusion: All professional roles were deemed to promote PWA personhood in dementia wards, al-
though some limitation exists according to the context of the assessment.
Keywords: Alzheimer, personhood, social network analysis, ethnography, dementia ward, mixed methods research.
1. INTRODUCTION
This current study illustrates how Social Network Analy-
sis (SNA) can capture health carers network promoting pa-
tient personhood in persons with Alzheimer’s disease (PWA)
resident in dementia wards in public and private psychiatric
hospitals in the United Kingdom (UK). Research predicts
that 850,000 people in the UK will develop dementia by
2021, amounting to 1% of the population [1]. People with
dementia occupy 25% of hospital beds and stay in the hospi-
tal longer than people without dementia; nonetheless, the
hospital stay can negatively impact on the physical health of
the person [2, 3]. In the policy paper of the United Kingdom
Prime Minister, it is reported that more than 1 million people
have been ‘trained to be dementia friends with over 400,000
*Address correspondence to this author at the Centre for Health Care and
Medical Education, Bristol, United Kingdom; Tel: 00447939919992;
E-mails: carlolazzari2015@gmail.com, carlolazzari@nhs.net
National Health Service staff been trained to support people
with dementia together with 100,000 social carers’ [4, 5].
Alzheimer’s disease accounts for about 50% of all demen-
tias, followed by vascular dementia (10-15%), mixed (10-
15%) and other forms of dementia (up to 100%) [6].
1.1. Challenges in Dementia Care
The major challenge for dementia health carers and their
PWA is to face cognitive impairments in dementia impacting
everyday life and adding additional anxiety and hardship
both to patients and their carers [7]. The NICE (National
Institute for Health Care Excellence, 2018) [8] indicates four
points for improving cognition in PWA: i) ‘cognitive reha-
bilitation’ as a set of tasks to reinforce activities of daily liv-
ing while strengthening strategies to balance impairments, ii)
‘cognitive stimulation’ exposing PWA to individual and
group tasks to improve intellectual and social skills, and iii)
‘cognitive training’ as exposure to particular cognitive tasks
within an array of complexity.
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506 Current Alzheimer Research, 2019, Vol. 16, No. 6 Lazzari et al.
Hence, the major tasks of healthcare professionals work-
ing with PWA are to implement remedial actions to slow
down their cognitive and social impairment and by exposing
PWA to a series of task-oriented activities. Other studies
moving to this direction mention the importance of the
stimulation of the Default Mode Network (DMN) which is
considered as the activated brain in resting state anatomically
linked to a network inclusive of the posterior cingulate cor-
tex, precuneus, medial frontal cortex, and bilateral inferior
parietal and posterior temporal areas and being linked to
social cognition [9]. The research group from De Marco et
al. utilized computer-based cognitive skills which kindled
DMN by exposing PWA to cognitive actions involving dif-
ferent neurocognitive tasks [10]. Neuroanatomical investiga-
tions provided evidence of significant associations between
task performance and grey-matter volume of multiple DMN
core regions which are progressively affected by Alz-
heimer’s disease [11].
Cognitive stimulation requires joint effort of different
dementia health carers. In fact, due to the complexity of
PWA cognitive, social and physical demands it can occur
that several dementia health carers synchronously (all to-
gether at the same time) or asynchronously (individually on
shared goals) can address one particular need (e.g., nurses
and doctors in a hospital) or, instead, only one professional
attends to multiple aspects and needs in the same patient
(e.g., a home carer). Besides, a collaborative practice can be
both intraprofessionals supported by the collaboration of
professionals with the same role, or interprofessional where
different professionals (e.g., doctors, nurses, social workers)
collaborate to address PWA needs [12]. Cognitive and social
stimulation and activation all belong to the corpus of activi-
ties meant to promote patient’s personhood as herein de-
scribed.
1.2. Personhood and Collaborative Care
The concept of personhood considers a person with Alz-
heimer as individual who has identities that are not only bio-
logical but also psychological, social, historical, moral, relig-
ious, legal, financial, and civil [13]. The Oxford Online Dic-
tionary defines personhood as ‘The quality or condition of
being a person’ [14]. The Stanford Encyclopaedia of Phi-
losophy online reports that ‘personhood’ answers the ques-
tions ‘What is to be a person?’ and ‘What is necessary to
count as a person?’ [15]. Hence the personhood of a PWA is
promoted by recognizing how is the world for persons with
dementia, to realize the circumstances they find themselves
in, and to interpret the world how they understand it [16].
Kitwood defines personhood as the meaning or importance
that is conferred to a person by others in the setting of a con-
nection and bond [17]. When addressing multiple needs in
PWA, dementia carers usually refer to PWA’s personhood
which comprises three critical domains: ‘biological, individ-
ual and sociologic personhood’ [18]. Specifically, person-
hood is reinforced when the biological and physical condi-
tions for PWA are optimal; when individual personhood in-
corporates the personal ideals, historical responsibilities, and
the individual and is sustained by communication with staff;
sociologic personhood is strengthened by community rela-
tions, positions, association to organizations and so on [18].
Therefore, the promotion of personhood and cognitive
stimulation and activation all require the participation of
diverse experts (e.g., nurses, doctors, psychologists, physio-
therapists, health care assistants, and other healthcare profes-
sionals) each one with the know-how necessary to attend to
the multifaceted aspects of Alzheimer’s disease [19, 20].
World Health Organization defines collaborative practice as
the activity of several healthcare professionals from diverse
specializations who collaborate to deliver wide-ranging serv-
ices to convey the best treatment to common patients [21].
Most of the times such collaboration entails that health car -
ers in interprofessional teams can address several needs in
PWA according to an integrated care plan which is discussed
and approved during multidisciplinary team meetings.
Hence, PWA require a complex array of specialist support
from different professionals addressing multiple needs like
pain, feeding and hydration, medication, bladder and bowel
activity, activities of daily living, self-care, prevention of
falls, mobilization, posture, etc. [22]. The authors of the cur-
rent study suggest that making a patient autonomous on
these skills belongs to a process of cognitive and social
stimulation and rehabilitation. Alzheimer’s disease also pre-
sents with multiple psychological and behavioral symptoms
which include ‘disinhibited behavior, delusions, hallucina-
tions, anxiety, depression or mania, and sleep disturbances’
[23]. NICE suggests actions to promote PWA awareness,
self-sufficiency, and comfort, for instance with groups sec-
tions, group reminiscence, occupational therapy, managing
agitation and aggression, dealing with anxiety and depres-
sion, dealing with multiple physical needs [24].
Hence, to meet this increased demand for dementia care,
policymakers suggest reinforcing team expertise, interpro-
fessional trust, and the understanding of care by helping staff
to focus on shared healthcare pathways [25-28]. The Na-
tional Institute for Health and Care Excellence (NICE) sus-
tains that carers’ participation is more successful when of-
fered as team actions [24]. Furthermore, outcome measures
help to personalize care pathways and support patient care by
improving the cohesiveness of the team [29, 30]. Addition-
ally, to make sure that PWA gain entirely from the participa-
tion of different experts, dementia care leaders need to have
clear reasons and the prerequisites for a specific specialized
contribution and what demands will be addressed [31]. So-
cial and cognitive stimulation and rehabilitation can improve
through constant behavioral observation of the outcomes in
PWA care and setting goals in the treatment they receive
[32]. Nonetheless, due to the complexity of tasks needed for
the activation of cognitive and social skills in PWA, efforts
of dementia health carers should be coordinated, while per-
forming different actions for the promotion of patients per-
sonhood in a climate of mutual acceptance, self-reflection,
transformation, and search for novel options in patient care
[25]. Hence, to improve patient’s safety and quality of life, it
is crucial that each member of the team can work according
to a shared care plan while adopting genuine friendliness,
care and involvement with a patient, creating a calming envi-
ronment and deference for the patient regardless of his or her
physical and mental condition [33]. Furthermore, care plans
to improve personhood should involve family members,
friends and others linked to the PWA, including all the carers
[34].
Social Network Analysis of Personhood Advancement in Alzheimer’s Disease Current Alzheimer Research, 2019, Vol. 16, No. 6 507
Patients in the advanced stages of illness still require
cognitive stimulation comprising multifaceted actions to
address complex needs like encouraging food and fluid in-
take, changing of incontinence pads, helping patients in
washing and dressing, monitoring the risk of falls, improving
sleep pattern, reducing day sedation, and regular physical
check [35]. Multidisciplinary effort and care skills remain
paramount for addressing diverse needs and patient person-
hood while patient-centered care entails different levels of
coordinated actions addressed to PWA [36]. For instance, in
organizations defined by Kitwood as type B, there is shared
participation in dementia care and teamwork of people
whose ideas are united and whose skills are released in at-
taining a mutual aim [17]. Also, centeredness is based on
collective accountability about the care of a PWA along with
a common understanding of the kind of support to be pro-
vided and an emphasis on the intricate link between self,
patients, and families [36]. Hence, there is an increased
benefit to the patient and patient care when health workers
are coordinated in their efforts by sharing a common care
plan [26].
1.3. Social Network Analysis
One way to investigate the social network of dementia
health carers into PWA wards in psychiatric hospitals is th e
use of Social Network Analysis (SNA). SNA started from
the studies of Moreno and Jennings who developed two
methods, ‘sociometry’ representing the quantitative method
for understanding the behaviour of groups of people and the
role persons play in the group, and ‘sociograms’ that capture
the pictorial configuration of individuals in the groups and
their relationships with other persons in the social network
[37]. Characteristics of social networks are ‘nodes’ that rep-
resent units or persons that interact with each other via some
form of ‘ties’ or with a specific category of activity [37, 38].
These interactions can be illustrated in the social network
graph. In a two-mode matrix there are two sets of nodes that
interact whereas, in the one-mode, nodes refer to the same
category (Fig. 1) [39].
In the two-mode network, the research is interested in
knowing who is doing what regarding a target action, for
instance, which category of healthcare professionals use cer-
tain skills in patient care. Therefore, in the two-mode net-
works, there are two diverse categories of nodes and the ties
occur only within these two different nodes (e.g., Per-
son×Action) but not within the same category of nodes
which is instead present in the one-mode networks (e.g., Per-
son×Person) [38]. For instance, in the two-mode network,
the researcher can illustrate that some professional roles are
involved more than others in attending to specific patients’
needs. The configuration of the network is represented by a
set of nodes or actors and the events they attend hence gen-
erating an ‘incidence matrix’ which provides the outcome of
Actors × Events cross-matching [37] The relationships be-
tween nodes in a social network are illustrated by arrows
going from one actor to another actor or category (as in the
two mode-matrix) [38] (Fig. 1). An outgoing arrow starts
from the actor/node that is initiating the action, information
or relationship towards an actor/node which is receiving the
information, action, relationship; in this case the arrowhead
will point to the ingoing actor; in case the relationship is
reciprocal the arrows are ingoing/outgoing between the two
nodes with arrowheads pointing to both actors [39]. SNA can
be designed by asking the actors to identify a category of
interest for the research conducted (e.g., the most liked co-
worker or the most liked brand of a product) [40].
A concept in SNA is that of centrality regarding ‘contri-
bution the node makes to the structure of a network’ [41].
For instan ce, if some healthcare professionals are more fre-
quently involved in some form of personhood in PWA, they
have a more central role compared to their colleagues that
perform less frequently the targeted clinical skill. In this
case, it is reported that some individuals are more centralized
than others who occupy a more peripheral position concern-
ing a target parameter [42]. Hence, with the visual analysis
of the social network, researchers can assess who occupies a
core or central position in the network, and who, instead is at
the periphery of it [43]. Moreover, as in the example of
healthcare professionals performing some skills, in ‘degree
Fig. (1). One-mode (left) and two-mode (right) social network. In the one-mode reported, there are three actors while the nurse interacts with
the other two members of staff. In the two-mode network, the links connect a nurse to two activities. The one-mode is linked to the same
category of actors while in the two-mode, actors of the social network perform some activity; hence there are two categories of nodes.
social worker
Nurse
doctor
Activity 1
Nurse
Activity 2
508 Current Alzheimer Research, 2019, Vol. 16, No. 6 Lazzari et al.
centrality’ the SNA counts and provides a visual account of
how many ties are directed from one person/node to a tar-
geted action via network ties and with a factor called ‘out-
degree’ [44] (Fig. 2). Other two major qualities of a network
are a ‘core’ where nodes are strongly linked and a ‘periph-
ery’ where there are fewer ties within each other or with
other nodes in the network [45]. SNA can be used for en-
dorsing transformations within healthcare organizations [46].
Furthermore, not only SNA explores collateral influences
among social units or nodes but also the contribution of each
social unit as an entity and as a group of participants [47].
Fig. (2). Example of a two-mode (two-nodes) social network where
each professional is linked to one or more activities. In the figure,
the nurse occupies a more central position because s/he is perform-
ing more activities compared to the social worker and doctor who
are only attending to one task each.
1.4. Ethnographic Research
To collect data for SNA, observational studies can pro-
vide some insight into how actors perform in a social net-
work. For instance, as most of the actions for PWA care are
implemented as visible behaviors, their occurrence can be
flagged by ethnographic observational research [48]. The
advantage of ethnographic research is that it can classify
behaviors that cannot be anticipated by the existing studies
[48]. Besides, ethnography provides detailed and up-to-date
explanations collected through extended observations and
exchanges with the target population in their setting, with the
opportunity to test the vigor of hypotheses by using extended
site visits [49]. Also, ethnography illustrates the common
interpretation of what is essential and significant to the peo-
ple under observation [50]. With a researcher as a participant
observer, during ethnographic research, it is possible an ex-
pert assessment of a target behavior by a person who be-
comes the member and thus participant of the setting under
investigation [51]. Ultimately, ethnography reduces the bias
of standard survey questionnaires in which conflicts can ex-
ist between what is observed in staff behavior and their ver-
bal explanations of it [47].
2. MATERIAL AND METHODS
2.1. Aims and Objectives
The aim of the current study is to identify the network of
healthcare intervention in dementia wards and to what ex-
tend the degree of centrality in the provision of services to
PWA can promote their personhood. The objective is to
identify who is doing what in terms of promoting PWA per-
sonhood. The objective is also to use Social Network Analy-
sis to provide a snapshot representation of health carer-to-
task links and practice in dementia wards. Preliminary and
unpublished observations from the authors of the current
study could identify two major typologies of interventions to
promote tasks linked to the advancement of personhood in
PWA. In a task-oriented approach to cognitive and social
stimulation and rehabilitation, several professionals, working
in the same team, individually or in collaboration, address
one or more aspects of patients’ personhood. In an alterna-
tive, in a carer-oriented approach, the same dementia health
carer independently addresses several tasks in promoting
PWA personhood (Fig. 3).
Fig. (3). Task-oriented (above) and carer-oriented (below) ap-
proaches in interprofessional practice in Alzheimer’s disease. In the
task-oriented social network, several professionals attend synchro-
nously (all at the same time) or asynchronously (on an individual
basis) to a specific task in patient care. In the carer-orien ted ap-
proach, the same dementia carer attends to multiple tasks in patient
personhood, and other professional figures might or might not par-
ticipate in the chores.
social worker
nurse
doctor
Activity 1
Activity 3
Activity 2
Activity 4
social worker
dementia doctor
occupational therapist
care coordinator
physiotherapist
family member
dementia nurse
dementia nurse
task 7
task 6
task 5
task 3
task 4 task 2
task 1
Task 1 in PWA
Social Network Analysis of Personhood Advancement in Alzheimer’s Disease Current Alzheimer Research, 2019, Vol. 16, No. 6 509
2.2. Ethnographic Observation
The current study used a mixed-method research ap-
proach. The first part of the study involved ethnographical
observations. The activities recorded the category of person-
hood attended, what activity was performed to attend to the
targeted personhood, and the professional involved. The
principal author’s position did not influence the observations
as a participant observer, and dementia doctor into the wards
examined [48]. The ethnographic observation allowed an-
swering the question, ‘Who is doing what in promoting
PWA personhood?’ If at least one professional was observed
as applying the targeted skill in personhood, then this event
was captured as occurring and recorded as ‘1’ or ‘mostly
present.’ Instead, if none of the professionals were observed
or rarely observed as applying the skill, then this event was
recorded as ‘0’ and as ‘mostly absent.’ The length of obser-
vations was daily for a period of 3 to 6 months inside each
dementia ward with full participation of the main observer
into the ward routines. The Social Network Analysis pro-
vided a qualitative and quantitative representation of task-
oriented and carer-oriented care into the psychiatric wards
treating patients with Alzheimer’s dementia as the ethno-
graphic research portrayed it.
2.3. Experimental Design and Data Collection
The convenience sample was represented by dementia
healthcare professionals linked to the target locations, all
represented by old age and dementia psychiatric wards in
private and public hospitals in several health care settings.
The days of the observations were standard weekdays, Mon-
day to Friday from 9:00 hours to 17:00 hours. The observing
author, who is also the lead author (CL), used a logbook to
record activities performed by the dementia teams inclusive
of the main variables: personhood attended, sub-type of per-
sonhood attended, and professionals involved. During the
performed actions, or shortly after, the tasks performed and
the professionals involved were recorded on the logbook. As
the leading author was also one of the senior doctors, the
accuracy of observations was also audited for quality im-
provement and for implementing the care of PWA. A period
of preliminary observations and online perusal of job de-
scriptions for the roles observed helped in refining the be-
havioral and organizational aspects in care that could be ob-
servable and pertinent to the current study.
2.4. The Setting and Population
Target patients in these wards were in intermediate or
advanced stages of Alzheimer’s disease. One of the wards
assessed was in a public psychiatric hospital, and two were
in private mental hospitals. The lead author (CL) of the cur-
rent research worked as a dementia doctor and was the active
participant of the ward culture to collect the self-reflective
ethnographic observations. Each ward included about 14
beds. Each of the three teams observed for the current re-
search comprised one dementia consultant, one senior doc-
tor, one junior doctor, one ward manager, four dementia
nurses, one clinical psychologist, one occupational therapist,
one physiotherapist, one hospital manager, one family mem-
ber, and one healthcare assistant, hence 14 professionals in
each team for a total of 42 dementia professionals and 42
patients observed.
2.5. Statistical Methods in SNA
One strategy of qualitative analysis is the description of
relationships and configurations within data [52]. The quali-
tative aim of the study was to capture patterns in the data
under investigations [53] through the visual analysis of the
social graphs.
SNA is both a quantitative and qualitative method. The
quantitative method offers the numerical representation of
the degree of centrality (DC) of each professional figure
(node/professional) regarding its contribution to each cate-
gory of patient personhood (node/personhood). Instead, the
qualitative analysis aimed to create the figurative representa-
tion of partnership in care to promote PWA personhood by
capturing the centrality or periphery of each professional role
in addressing a specific aspect of personhood.
SNA estimates the degree of centrality (DC) which is
represented by the raw number of ties (contribution) of a
healthcare professional with the aspect/s of personhood in-
vestigated. Degree centrality is also expressed as a percent-
age (%DC) where 0% corresponds to no centrality while
100% expresses maximum centrality and contribution of a
professional role in the provision of service to address the
type of personhood under investigation. Hence, dementia
health carers who are linked to many tasks in PWA person-
hood will also have more centrality (%DC) compared to oth-
ers; they will also have a %DC which will be closer to 100%
[37]. The Z score relative to %DC frequency was calculated
together with the statistical significance of one proportion
with the Software Medcalc [54]. The null hypothesis Ho for
the percentages was 50% of the observed frequency. Fre-
quencies that significantly separated from Ho were consid-
ered statistically significant either because on the lower or
higher level of DC.
The software used for SNA was SocNetv 2.4 [55]. In the
quantitative study, the Social Network Analysis computed
the DC of each professional figure in implementing the
PWA’s levels of personhood. The DC score is the sum of
weights of outbound edges (performed personhood action)
from each node or professional to the sub-category of per-
sonhood; in this study, the DC expressed the times a profes-
sional was involved in the cited personhood skill, while
%DC expressed the rate of involvement out of 100% of the
professional in that category of personhood [55].
The visual analysis of the sociogram provided the figura-
tive layout of all actors involved in each category of person-
hood [56]. The main steps in SNA included all the following
[57]:
Step 1: identification of all the actors and actions in-
volved in the dual-mode network.
Step 2: identifying the relationship between actors; as
the current research is two-mode social network analy-
sis, actors (first node) will be matched with an identified
targeted action in personhood (second node) according
to the equation Actor×Action.
510 Current Alzheimer Research, 2019, Vol. 16, No. 6 Lazzari et al.
Step 3: in a contingency table each node/actor is
matched with the corresponding node/action indicating
with ‘1’ if the actor is involved and ‘0’ if the actor is not
involved in the identified action.
Step 4: analysis of the network characteristics and ‘cen-
trality’ of each node/actor in providing the targeted
node/action in personhood.
2.6. Focus Groups
The categories generating the aspects of personhood were
extracted by the main author’s observations in dementia
wards and discussed during online peer-discussions and fo-
cus-groups at the University of Derby. Focus groups are par-
ticularly important to define the insights, approaches, and
beliefs of participants about problems, organizations, and
prospects [58]. In a focus group, represented by online de-
mentia modules at the University of Derby, learners can de-
bate spontaneously by exchanging their thoughts, ideas, and
practices [59].
In the current study, peers were represented by experts in
dementia, and post-graduate students coming from
healthcare professions. In the year 2018-2019, the leading
author was supervised at the University of Derby in research
projects, research papers, and peer discussions focusing on
dementia care and personhood. The categories of personhood
extracted from the ethnographic observations were explored
for face and content validity as to what degree they could be
representative of PWA personhood. The findings were then
confronted in further peer-reviewed papers and conferences
and peer-discussions for further validation. Each category
was matched with similar findings from the existing litera-
ture in search of similarities. Those categories that did not
receive enough validation in peer-discussions and from the
literature were rejected. The moderators for focus groups
were exper ts in dementia care. Once all peers agreed that a
category extracted fully represented a type of personhood in
dementia, it was included in the current research. Face valid-
ity was also possible as the author’s peers involved in the
discussion were covering all the professional figures found
in dementia wards. Hence, during formal debates, each pro-
fessional provided confirmation that specific aspects of per-
sonhood included in the current study were sufficiently rep-
resentative of what he or she was doing when caring for
PWA. The same process occurred in the dementia wards
where the author was an active participant.
The key professional figures working with PWA in the
psychiatric dementia wards were:
[RN] ward nurse
[WM] ward manager
[MD] ward doctor
[HM] hospital manager
[OT] occupational therapist
[CLP] clinical psychologist
[PHT] physiotherapist
[CCO] care coordinator
[FAM] family member
[HCA] healthcare assistant.
The types of personhoods promoted in PWA were:
1) [BP] Biological Personhood where dementia profession-
als perform the following:
[BP1] provide regular physical check-ups (blood tests,
blood pressure, peripheral glucose, heart rate, peripheral
oxygen saturation, temperature) daily or weekly;
[BP2] professionals apply proper manual handling when-
ever mobilizing a patient;
[BP3] complete regular food and fluid intake charts and
feed the patient;
[BP4] monitor constipation, bowel and bladder move-
ments on charts, replace incontinence pads and urinary
catheters;
[BP5] monitor urinary and chest infections once a week
or when the patient changes in the clinical presentation;
[BP6] monitor the risk of falls and act accordingly (e.g.,
reduce sedative medication) to prevent them;
[BP7] help the patient reduce the risk of choking and use
proper food thickeners when needed;
[BP8] promote outdoor activities whenever possible;
[BP9] encourage small exercises to reduce skeletomuscu-
lar atrophy and pressure ulcers;
[BP10] pharmacological treatment of psychological and
behavioral symptoms of dementia (PBSD).
2) Individual Personhood [IP] where dementia professionals
perform the following:
[IP1] consider personal or historical values or choices in
the communication or actions towards the patient (e.g.,
past spiritual habits);
[IP2] create dementia-friendly wards and display the pa-
tient’s photos and belongings in his or her room;
[IP3] communicate empathically with patients, even if
they can no longer communicate: e.g., use empathic
touch and redirect the patient’s attention;
[IP4] ensure that communal areas are spacious and well
lit;
[IP5] ensure that patients have plenty of activities and
sensory objects, books with images, music, and leisure.
3) Sociologic Personhood [SP] where dementia profession-
als perform the following:
[SP1] authorize and encourage family members to regu-
larly visit the patient; they are helped with transport and
directions whenever needed ;
[SP2] organize family and friend reunions in dedicated
areas of the hospital;
[SP3] promote and coordinate patients’ leaves to the lo-
cal area and shopping centers;
[SP4] promote school meetings to increase local commu-
nity awareness;
Social Network Analysis of Personhood Advancement in Alzheimer’s Disease Current Alzheimer Research, 2019, Vol. 16, No. 6 511
[SP5] involve local charities to arrange meetings with
people of the same age if PWA can attend;
[SP6] involve the family in the decisions and during revi-
sions of care plans;
The likelihood action of each node/professional will be
either not involved in any sub-category of partnership, in
some of them or all of them.
3. RESULTS
The professional role more frequently involved (the
highest degree of centrality in SNA) in biological person-
hood was the ward nurse (%DC = 36%, Z = 2.74, p ≤ 0.01),
followed by the ward doctor (%DC = 20%) and ward man-
ager (%DC = 20%) (Tables 1-3). In the interprofessional
promotion of individual personhood, all the professional
figures were involved (DC = 16%), while in the sociologic
personhood, the hospital manager had the highest degree of
centrality (DC = 33.33%; Z = 2.45, p ≤ 0.01) followed by the
ward manager and nurse (DC = 26.66%) (Tables 1-3). The
visual analysis of the social networks provided the pictorial
representation of the centrality of each professional figure in
each personhood. In the case of biological personhood (Fig.
4), the most central figure was the nurse (RN), followed by
the ward manager (WM) and the ward doctor (MD). In the
case of individual personhood (Fig. 5), all professional roles
were central and provided support for the advancement of
patients’ personhood. In the case of sociologic personhood
(Fig. 6), almost all professional figures were involved, al-
though the clinical psychologist (CLP) and healthcare assis-
tant (HCA) were rarely involved in the settings explored.
4. DISCUSSION
The results of the current research captured the network
of dementia health carers promoting PWA personhood. As
the social analysis found, collaborative care is not distributed
among the carers of PWA. In fact, although all aspects of
personhood could be attended by all professionals working
in dementia wards in public and private psychiatric hospitals,
some of these professionals appear to cover more central
positions in the provision of services especially when the
basic physical needs had to be attended although there was
no restriction on who could provide a basic service to PWA.
Hence, in terprofessional practice is more partial when pa-
tient needs are complex and require experienced dedication
like attending to physical needs, controlling bowels and
bladder function, changing incontinence pads, actively wash-
ing patients, and other activities. These actions could be
named ‘hard practice.’ Instead, in ‘soft practice,’ like com-
municating with patients, activating ludic activities, promot-
ing outdoor walks, there was more dispersed practice and
each member of the team was equally involved. The last
activities more closely resembled a cognitive and social
stimulation.
Therefore, SNA has offered further insight into the net-
work of the involvement in dementia wards in psychiatric
hospitals providing care to PWA. The SNA has also shown
the centrality of some professional roles in the promotion of
specific types of personhood. The biologic personhood ap-
peared a specific activity, mostly attended by qualified nurs-
ing and medical staff. This form of personhood is primarily
directed in maintaining the PWA in acceptable physical con-
ditions, in reducing the risk of falls, in avoiding dehydration,
in reducing the risk of urinary and respiratory infections, and
in lowering the likelihood of choking due to dysphagia. This
form of personhood is mostly found in psychiatric wards,
public or private, linked to hospitals.
In the individual personhood, all the professional figures
were involved. This activity mostly comprises actions per-
formed to consider PWA personal and historical values, the
effort to make dementia-friendly wards and to communicate
empathically with patients. Also, in the sociologic person-
hood, all the professionals were involved in encouraging
family visits into the ward or family reunion during patient’s
leave, in promoting extended leaves from hospital when the
presentation allowed it, in raising community awareness
about Alzheimer’s disease, and in having the family as an
active participant in the care plans involving a family mem-
ber with Alzheimer’s dementia. The unobtrusive ethno-
graphic study has advanced extended observations without
interrupting clinical routines in the wards, and by gently cap-
turing routine behaviors as one of the researchers was a par-
ticipant observer. Furthermore, SNA has improved the
analysis of how the actions of interprofessional teams coor-
dinate inside Alzheimer’s wards by capturing the centrality
or periphery of specific professional roles in the advance-
ment of PWA personhood.
The authors of the current research observed that when
team collaboration, support, and enough human resources
were present in the wards, and when all jobs descriptions
were filled, then all aspects of personhood could be attended.
SNA has also offered the opportunity to capture team density
in providing each different section of service to PWA. How-
ever, as emerging in the current research, the centrality of
some professionals and the peripheral intervention of others
could be used to address the policies of changes. Nonethe-
less, increased centralization of one task in the same profes-
sionals could make them as less prone to access subsidiary
and vital information and influences that can derive by those
who are more isolated and at the periphery of the social net-
work, these last roles made redundant in providing a targeted
service [60]. Nonetheless, the centrality of an actor in the
social network entails a more favorable position in the provi-
sion of a service or action [60] in the current research indi-
cated by outbound ties connecting the actors to the targeted
actions of personhood.
As in the current study, different aspects of personhood
require skills that place several professionals at the core of
the network for providing specific care. The visual analysis
of the social network can thus be an instrument to indicate
areas of reinforcement (e.g., with particular training) of those
professionals that have fewer skills or clearance to address a
specific area of PWA personhood. Hence, SNA has provided
an insight of who are the gatekeepers [57] in delivering a
service also because networks with a high number of profes-
sionals occupying a central position have a lower frequency
for external referrals [43]. Our research has also shown that
apart from biological personhood which requires specific
skills to address patient’s needs, almost all professionals
were occupying a central position in the network for other
512 Current Alzheimer Research, 2019, Vol. 16, No. 6 Lazzari et al.
Table 1. Outcomes in partnership in Alzheimer’s care according to the professional role as from the ethnographic observation.
Personhood Activity of the Health Carer Professional Role Involved
[BP1] provides regular physical check-up [RN]nurse; [MD]doctor; [HCA]healthcare assistant
[BP2] applies proper manual handling [RN]nurse; [PHT] physiotherapist; [HCA]healthcare assistant
[BP3] uses fluid intake charts [RN]nurse; [HCA]healthcare assistant
[BP4] monitors bodily functions [RN]nurse; [HCA]healthcare assistant
[BP5] monitors urinary and chest infections [RN]nurse; [WM]ward manager; [MD]doctor
[BP6] monitors and reduce risk of falls [RN]nurse; [WM]ward manager [MD]doctor
[BP7] reduces the risk of chocking [RN]nurse; [WM]ward manager; [MD]doctor;
[PHT]physiotherapist
[BP8] uses pharmacological treatment of BPSD [RN]nurse; [WM]ward manager [MD]doctor;
[BP] Biological personhood:
[BP9] controls side effects of medications [RN]nurse; [WM]ward manager; [MD]doctor
[IP1] considers personal and historical values [RN]nurse; [WM]ward manager; [MD] doctor; [CLP] clinical
psychologist; [CCO] care coordinator; [FAM] family member;
[HCA] healthcare assistant
[IP2] creates dementia friendly wards [HM]hospital manager; [OT]occupational therapist
[IP] Individual personhood:
[IP3] communicates empathically with patient [RN]nurse; [WM]ward manager; [MD]doctor; [HM]hospital
manager; [OT]occupational therapist; [CLP]clinical psycholo-
gist; [PHT]physiotherapist; [CCO]care coordinator;
[FAM]family member; [HCA]healthcare assistant
[SP1] encourages visits of family members [RN]nurse; [WM]ward manager; [MD]doctor; [HM]hospital
manager; [CCO]care coordinator
[SP2] organises family reunions [RN]nurse; [WM]ward manager;[HM]hospital manager;
[OT]occupational therapist; [CCO]care coordinator
[SP3] promotes and coordinates patient’s leaves [RN]nurse; [WM]ward manager; [MD]doctor; [OT]occupational
therapist; [CCO]care coordinator
[SP4] promotes community awareness [HM]hospital manager; [OT]occupational therapist
[SP5] involves local charities for PWA meetings [HM]hospital manager; [OT]occupational therapist;
[FAM]family member
[SP] Sociologic personhood:
[SP6] involves family members in care plans [RN]nurse; [WM]ward manager; [MD]doctor; [HM]hospital
manager; [FAM]family member
Table 2. Incidence Matrix extracted from Table 3.1 for biological personhood (BP), individual personhood (IP) and sociological
personhood (SP) indicating with ‘1’ a professional involved most of the time, and with ‘0’ a professional rarely or not in-
volved.
RN WM MD HM OT CLP PHT CCO FAM HCA
BP1 1 0 1 0 0 0 0 0 0 1
BP2 1 0 0 0 0 0 1 0 0 1
BP3 1 0 0 0 0 0 0 0 0 1
BP4 1 0 0 0 0 0 0 0 0 1
BP5 1 1 1 0 0 0 0 0 0 0
BP6 1 1 1 0 0 0 0 0 0 0
BP7 1 1 1 0 0 0 1 0 0 0
BP8 1 1 1 0 0 0 0 0 0 0
BP9 1 1 1 0 0 0 0 0 0 0
(Table 2) contd….
Social Network Analysis of Personhood Advancement in Alzheimer’s Disease Current Alzheimer Research, 2019, Vol. 16, No. 6 513
RN WM MD HM OT CLP PHT CCO FAM HCA
IP1 1 1 1 0 0 1 0 1 1 1
IP2 0 0 0 1 1 0 0 0 0 0
IP3 1 1 1 1 1 1 1 1 1 1
SP1 1 1 1 1 0 0 0 1 0 0
SP2 1 1 0 1 1 0 1 1 0 0
SP3 1 1 1 0 1 0 0 1 0 0
SP4 0 0 0 1 1 0 0 0 1 0
SP5 0 0 0 1 1 0 0 0 1 0
SP6 1 1 1 1 0 0 0 0 1 0
Table 3. SNA for the degree of centrality for professionals involved in promoting personhood in PWA.
Personhood Profession DC1 %DC2 Z score
RN 9.000 36.000 2.743
MD 5.000 20.000 1.05
WM 5.000 20.000 1.05
HM 0.000 0.000 1.05
OT 0.000 0.000 1.05
CLP 0.000 0.000 1.05
PHT 2.000 8.000 0.21
CCO 0.000 0.000 1.05
FAM 0.000 0.000 1.05
Biological personhood:
HCA 4.000 16.000 0.63
RN 2.000 16.667 0.70
MD 2.000 16.667 0.70
WM 2.000 16.667 0.70
HM 2.000 16.667 0.70
OT 2.000 16.667 0.70
CLP 2.000 16.667 0.70
PHT 1.000 8.333 0.17
CCO 2.000 16.667 0.70
FAM 2.000 16.667 0.70
Individual personhood:
HCA 2.000 16.667 0.70
RN 4.000 26.667 1.75
MD 3.000 20.000 1.05
WM 4.000 26.667 1.75
HM 5.000 33.333 2.453
OT 4.000 26.667 1.75
CLP 0.000 0.000 1.05
PHT 1.000 6.667 0.35
CCO 3.000 20.000 1.05
FAM 3.000 20.000 1.05
Sociologic personhood:
HCA 0.000 0.000 1.05
1DC=Degree of Centrality of each professional;
2%DC=percentage of DC of each professional;
3p<=0.01
514 Current Alzheimer Research, 2019, Vol. 16, No. 6 Lazzari et al.
Fig. (4). Social network of the professionals involved in biological
personhood. The nurses, doctors and ward managers appear at the
center of the network. Although attending to biological personhood
requires desirable but not essential skills, not all the dementia carers
were involved in this aspect hence placing them more at the periph-
ery of the network.
Fig. (5). Social network of the professionals involved in individual
personhood. All the professionals were involved in this aspect of
personhood with the physiotherapist observed slightly more at the
periphery of the network. The concentration at the center indicates
that teamwork is aware of how to implement this aspect of person-
hood.
types of personhood, hence ensuring that each member of the
team was involved in patient-centered care.
Fig. (6). Social network of the professionals involved in the socio-
logic personhood. Social and cognitive activation of p atient’s skills
are attended by all professionals in the dementia ward. There is
even distribution of tasks although few professionals were not ob-
served as attending to these skills probably due to the requirements
of their own role.
Therefore, one global conclusion is that in the contexts
examined, there was shared participation of all professionals
in maintaining the personhood of PWA. It was assumed that
the psychiatric dementia wards observed adopted Kit-
whood’s type B organizational model with personnel sharing
of values and skills within the team; here, joint participation
in patient care is assumed to be also promoted when there is
a mutual trust and when team members become used to the
procedures, patients, staff, and policies [6]. High core den-
sity in the social network indicated that each member of th e
multidisciplinary team knew the procedures, other team
members, patients, families, environment, and facilities.
Hence, in the observed hospital wards, staff could attend to
the three forms of personhood simultaneously hence occupy-
ing central positions in the social network unless their job
specifications did not require them to attend to a specific
type of personhood.
Consequently, having different dementia healthcare pro-
fessionals working in synergy in patient’s personhood can
facilitate the activation of different cognitive and social skills
in PWA while stimulating increased connectivity in the
DMN network. More likely to trigger DMN would be a col-
laborative approach with an extended network of profession-
als working on different cognitive, social, and physical de-
mands of patients, avoiding network gaps while promoting
holistic care to PWA. As reported in the introduction, acti-
vating the cognitive skills that are still intact will have an
indirect effect also on other cognitive abilities that are more
vulnerable to Alzheimer’s Dementia, this process of activa-
tion being called ‘connectivity’ [11]. An advantage of cogni-
tive stimulation is that it bears no adverse reactions making it
suitable for PWA who already present with multiple illnesses
and medications [65].
BP1
BP2
BP3
BP4
BP5 BP6
BP7
BP8
BP9
RN
MD
WM
HCA
FAM
CCO
PHT
CLP OT
HM
IP3
IP2
IP1
PHT
RN
HCA
FAM
HM
RN
CCO
WM
OT
MD
FAM
HCA
SP1 SP2
SP3
SP4
SP5
SP6
MD
RN
OT
HM
CCO
PHT
CLP
WM
Social Network Analysis of Personhood Advancement in Alzheimer’s Disease Current Alzheimer Research, 2019, Vol. 16, No. 6 515
4.1. The Methodological Approach
Beyond the subset examined and within the extent of the
aims of the current study, SNA provided a pictorial and so-
ciometric interpretation on how healthcare professionals in
multidisciplinary teams provide care to shared patients; simi-
larly, SNA has opened new insights into ways in which care
can be improved and offered openings for social changes
[61]. The findings of the current study can advocate SNA in
other settings of healthcare as a valid instrument for repre-
senting joint synchronous and asynchronous care of patients
when professional health carers are pursuing a shared care
plan. This last venue is encouraging for novel studies as
SNA in not frequently used for the scoping of representing
interprofessional practice [62]. As also emerging from the
findings of the curren t research, SNA can help researchers
study the causes of social selection and influence [63]. Prac-
tical applications of SNA can help health organizations to
reach their missions in patient quality of care while endors-
ing the reasons for allocating more resources to improve care
[64].
4.2. Limitations of the Current Study
The limitation of the current research is linked to the fact
that the results are only applicable to the wards explored and
cannot be generalized to other settings as policies might
change regarding professional duties in different wards and
regions. Furthermore, there might be differences when the
findings are applied to residential homes with less personnel
on the ground. Besides, the hypothesis of the different par-
ticipation of several professionals in promoting patient per-
sonhood and centrality in the network can be also attributed
to the experience in the task and not linked exclusively to a
specific professional role. Lastly, although not all healthcare
professionals were involved in some forms of personhood,
they could be indirectly promoting each of its forms by sup-
porting colleagues who occupied more central positions in
the social group, but this was not captured by SNA analysis.
These unmeasured/uncontrolled variables should be consid-
ered when i) interpreting the findings of the current study,
and ii) planning further studies.
CONCLUSION
The promotion of the personhood in PWA requires coor-
dinated actions of all the healthcare professionals working in
dementia wards. In the settings examined, all professionals
were aware of the multifaceted aspects of personhood in
PWA although not all the professionals addressed them
while they had the skills to do so. Therefore, the current
study proposes to extend the analysis of health carers’ im-
plementations of PWA personhood and to use SNA as an
instrument to capture the nature and degree of their interven-
tions, and to identify areas of reinforcement for improving
quality of care and safety for PWA. The findings of the cur-
rent research can be extended to other settings working with
PWA, and can contribute to the organizational allocation of
human resources to promote personhood in PWA. Likewise,
the findings can help to empower PWA professionals and
augment PWA safety and quality of care.
LIST OF ABBREVIATIONS
SNA = Social Network Analysis
PWA = Persons with Alzheimer’s Disease
DMN = Default Mode Network
ETHICS APPROVAL AND CONSENT TO PARTICI-
PATE
According to the requirements of the Medical Research
Council and the NHS Health Research Authority, the current
research did not need national clearance in the UK.
HUMAN AND ANIMAL RIGHTS
No Animals/Humans were used for studies that are base
of this research.
CONSENT FOR PUBLICATION
Local managers and participants observed in the hospitals
where the research took place gave their verbal consensus to
publication at the condition that no identifiable data was dis-
closed.
AVAILABILITY OF DATA AND MATERIALS
The data supporting the findings of the article is available
in the current study only. Therefore, researchers, hospitals
and users interested in the data will be provided with the link
to access the present article or will access it via search en-
gines.
FUNDING
None.
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or
otherwise.
ACKNOWLEDGEMENTS
Declared none.
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... Most research has focussed on the interprofessional practice between doctors and nurses [62]. Previous research from the authors suggests that integrated care of PWA more than other geriatric specialties can be implemented only when healthcare workers cooperate to address synchronously − all at the same time on a specific task as in inpatient settings − or asynchronously − different carers at different moments as in community settings − different aspects of PWA personhood [63]. Studies of interprofessional geriatric care suggest that collaboration is vital for chronic dementia and its requirements are integrated and holistic care provided and advanced only by working collaboratively and not in silos management [64]. ...
... Studies of interprofessional geriatric care suggest that collaboration is vital for chronic dementia and its requirements are integrated and holistic care provided and advanced only by working collaboratively and not in silos management [64]. Besides, collaborative care does not develop intuitively [65], while there is limited research on the practical configuration of interprofessional care in inpatient and outpatient geriatric settings for PWA [63]. More than any other medical setting, interprofessional care of PWAs is a pivotal action to promote their biological (e.g., reduction of risk choking), individual (e.g., communicating empathically), and sociologic (e.g., involving community meetings) personhood [66]. ...
... Interprofessional practice in psychogeriatric inpatient sees the same professional as promoting different aspects of PWA personhood, or on the contrary, different professionals advancing the same aspect of PWA personhood independently from their professional specification [63]. If collaborative care is vital for addressing PWA with multiple needs, the model proposed cannot always be replicated in other specialties and healthcare sectors where more specific divi-sions of the tasks and skills are required to complete a task. ...
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... There has been a growing interest in using SNA to capture interprofessional team relationships and provide pictorial and numerical models to characterise relationship typologies 14 . The dynamics of interprofessional teams have been explored through ethnographic studies in mental health hospitals. ...
... The pooled expertise of individuals working together in a small group facilitates interprofessional learning 26 . Healthcare workers practicing in psychiatric care have the chance to develop their emotional intelligence and empathy abilities via progressive collaboration in interprofessional teams, which spread across the group, resulting in better patient-centred care skills 14 . In fact, through emotional intelligence, healthcare workers can mature better compassion towards their patients 27 . ...
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... their study It was observed that it is the older adults' perception of the quality of social interaction that influences the likelihood of depression. In 2019, Lazzari et al. [21] Analyzed social networks in Alzheimer's wards of a hospital to examine personality development in Alzheimer's patients. ...
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