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Sexually Motivated Serial Killers

Sexually Motivated Serial Killers

Sexual serial killers are usually very charismatic and can easily persuade their victims to go with them no matter the situation. They usually start as sex offenders. These types of serial killers are usually married and have children. They have a history of sexual and physical abuse during their childhood. It is thought that sexual serial killers have “mommy issues,” since their father had left when they were young, leaving the mother in charge of the caring. It is unknown if sexual serial killers were obsessed with pornographic images, but they enjoy living out their sexual fantasies that lead to murder. They usually only commit their fantasies on women, mainly prostitutes (Pakhomou, 2004).

There are two types of sexual serial killers, organized and disorganized with both usually leave a signature (Knight, 2007). Organized sexual serial killers plan their kills, by choosing a particular victim. As if they are stalking their pray. Watching their soon victims closely, choosing a particular kill destination, and a place to leave the dead body; usually in areas they know well. The disorganized sexual killers do not take the time to plan everything. They usually choose their victims on a whim. They tend to kill in areas that may be unfamiliar to them.

Sexual serial killers live in a world of negative and positive. The negatives do outweigh the positives, but it is uncertain how much or if this is even true. Sexual serial killers grew up with constant trauma, and being born of prostitutes (Knight, 2007). These types of killers tend to hide their “weaknesses.” They hide behind a mask of psychopathic narcissism of severe aggression.

Sexual serial killers enjoy inflicting pain upon their victims, they enjoy watching their victims struggle and cry for help. These killers “get off” on the pain they inflict, but many times, just the act of the torture that sexually arouses the killer. In some cases, the killer starts by molesting, raping, and then murdering their victims. These killers usually have obvious underlying sexual conflicts. Most of the time the killing itself is sexually gratifying (Schlesinger, 2004).

According to Schlesinger (2004), many sexually motivated killings are hard to define. First, there is no general definition to sexual serial killing. Second, many murders are labeled as sexually motivated, but actually are not, vice versa. Third, many statistics of the actual number of sexual murders have not been kept. Fourth, many of these offenders’ records are not accurate since these killers refuse to cooperate when it comes to talking about their history.

To the naked eye sexual killings seem to be motiveless, but theorists believe that there was some sort of motive. In the research, many theorists stated the motive was a seeking or revenge. Since many of these serial killers were brutally dominated growing up, they sought out women who tend to look similar to their mothers and wanted the sense of dominating them. It is still uncertain if this is true for motivation since it is often incomplete and inaccurate. These killers tend to lie and manipulate the people who interview them (Schlesinger, 2004).

Impulsive and Ritualistic

According to Hazelwood and Warren (2000), sexual crimes can be committed against a person, object, or an animal. Most of the sexual serial killers chose to act out their violent sexual fantasies against children, the elderly, or victims around their own age. These people usually only commit homosexual crimes or heterosexual crimes, they usually do not mix between the genders. These killers tend to feel no remorse or guilt after their sexual killing. They develop fantasies that seem complex, once the fantasy in their head no longer turns them on; they tend to want to act out their aggressionsbrain-share.

The impulsive sexual serial killer is the most common, but seems to be the less successful. The opportunistic and angry offenders tend to have the situation unplanned and usually have little sexual fantasy behind their motives. The impulsive sexual serial killer is motivated by their sense of entitlement and that everything within his or her environment is for the taking. This form of sexual serial killer tends to collect pornographic videos of a theme of bondage or rape. They prefer acting out on their lovers or choosing prostitutes as their victims, until that no longer fulfills them. This sort just wants control over their victims, but it is uncertain if the impulsive sexual killer is involved with paraphilic behaviors (Hazelwood et al, 2000).

The ritualistic sexual serial killer is lest common, but has more success and more difficult to identify. They hold the same motivation as the impulsive killer, such as anger, power, and control. This form of sexual serial killer has paraphilic behaviors; they tend to be interested in sexual fantasies that involve some sort of control (bondage, voyeurism, and sadism). They tend to be socially withdrawn from society, and when they do speak with others, they have a form of awkwardness in the social interactions. Many tend to be very charming and gregarious, to make it easier to charm their way into their victim’s lives. Many of these forms of sexual killers are much-respected members in their communities (Hazelwood et al, 2000).

Many of these sexual serial killers prefer similar victims. Meaning they hold similar characteristics. They prefer younger victims between the ages of 18 to 22, thin, and usually with shorter hair. Many sexual serial killers preferred victims that no one would be missing. They would recreate the situations from their sexual fantasies, and keep their victims as sex slaves until they no longer wanted them, then they would kill their victims. Many of these killers have no prior criminal record, and if they do, it is usually for sexual offenses, such as child molestation (Hazelwood et al, 2000).

Relationship to Victims

In some cases, the offender’s relationship to the victim is asymmetrical; it can involve stalking and possible voyeurism. The offender usually does not know their victim personally, and the victim does not know the offender. There are cases where the offender and victim have a mild relationship, meaning they maybe neighbors, work friends, or even have chatted at a bar. Sexual serial killers tend to kill within their own race. Many prefer victims in the average age of twenty-five, with male victims being in their younger twenties and females in their mid-twenties (Pakhomou, 2004).

According to Pakhomou (2004), there are three categories to victim relationships with the offender. The first is the no established relationship, which is the most common. This is also referred to as the ‘stranger.’ The victim just met the offender for the first time, both are not aware of each other’s backgrounds. They also know nothing of each other’s current life situations. The victims are usually picked up in a bar situation.

The second is the rudimentary relationship. This is also known as the ‘acquaintance.’ The victim and the offender have only known one another for a few days, maybe a short time longer. They are aware of each other’s whereabouts. They may even know a little bit about each other’s history, weather it may be true or not. This makes it easier to locate the victim, when the time comes for the sexual killing.

The third is the established relationship, also known as ‘correlative.’ This is where the victim and the offender have known each other for more than a few months, maybe even years. The offender and victim know a great deal about each other’s backgrounds. The offenders know the details where they work and hang out on a regular basis. This makes it easier to perform the sexual killings, since the offenders know more details.

Many of these victims were solicited to have sex with the offenders and/or lured by an offer of drugs. They prefer to kill people they do not have feelings for or complete strangers. Sexual serial killers never kill the ones they are close to; they may get violent sexually on their loved sexual partner. Their partner may think it is just normal “kinky” sex and not expect any true harm. Usually after the killer does have sexual relations with their sexual partner, the killer will leave the house in search of a murder victim to perform their true sexual acts for murder (Pakhomou, 2004).

Location Choice

It is believed from movies that sexual serial killers tend to kill mostly in places unknown to them. This is far from the truth; many tend to commit crimes in the areas that are well known to them. There are two types of sexual serial killers when it comes to location: the outdoorsmen, who perform their crimes exclusively in the outdoors. There is also the indoorsmen, as one can guess, performs their crimes indoors. A few are both the outdoorsman and the indoorsman (Pakhomou, 2004).

According to Snook, Cullen, Mokros, and Harbort (2005) sexual serial killers prefer to select victims near their homes. On average, the victim was picked up about 2 miles from the offender’s home. The body usually recovered about 15 miles from the offender’s home. The offender’s would hardly exceed more than 13 miles from home to picking up a victim. They also would not exceed over 25 miles for the body drop off point. When the killings become more, the bodies seem to move closer to the offender’s home.

The majority of sexual serial killers are organized killers; they tend to use vehicles to pick up their victims and to drop off the bodies. The disorganized killers rarely use vehicles and drop off the bodies near their homes, maybe in their own house. Many offenders learn from their past criminal acts. Some tend to venture as far as they can from their homes so not to be recognized in their own neighborhoods. The younger offenders have concentrated locations to commit their crimes and tend to kill closer to home (Snook et al, 2005).

It is found that the more intelligent sexual serial killers will travel farther away from their homes to drop of the body than ones who had lower IQs. Many of the higher IQ offenders are more organized in their planning on where to commit the act and to dispose of the body. The older ones tend to leave the bodies much closer to their homes.

Examples of Sexual Serial Killers in History

serial_killersPeter Kurten, also known as the Vampire of Dusseldorf (1913-1929), started as a child sadist. He would strangle and rape his female child victims, then after he would cut their throats. He would be charged with nine murders and seven attempts. He was said he would kill and rape anything that would move. The defense counsel described him as “the king of sexual delinquents, uniting nearly all perversions in one person, killing everything he found” (Castleden, 2005).

Fritz Haarman, Vampire of Hanover (1919), would go out at night picking up homeless and jobless boys. He would feed then as if they were his personal pets, but then would sexually abuse them. He would only murder a few of them when they did not expect it, only after biting their necks. After murdering the boys, he would then butcher them and cook their flesh, making pies out of them. Haarman trusted one other person to help him in selecting the victims, Hans Gans. It took a long while before police would look at Haarman as a suspect in the killings, for he was a trustable informant for the police department. It is said that Haarman raped and killed between 30 and 40 young boys (Castleden, 2005).

Gilles de Rais (1420-1440), at the age of sixteen he started to commit sexual killings. His victims were mainly young boys, with a few female victims. He would sodomize these boys before he would decapitate them. Most of all he enjoyed watching his servants butchering the children’s bodies. He was charged with at least 800 sexual murders of children (Castleden, 2005).

Albert Fish (1930s) was one of the oldest sexual serial killers. In over a period of twenty some years it is estimated that Fish sexually molested over 400 children. Fish admitted he committed so many sexual murders that he could not remember how many he committed. He was known to be found, by his son, naked and beating himself with a board covered in nails. Doctors took x-rays of his body and found he had inserted needles into his body and left them there (Castleden, 2005).

John Wayne Gacy (1968-1978), better known as Pogo the Clown who thought he was four different people. He freely admitted to sexually molesting, raping, and murdering 33 boys and young men. He noticed a sexual attraction to young men after he married his first wife in 1968 and started to become an aggressive homosexual. After he would molest and rape these young men, he would strangle or stab them to death. He then would hide the bodies in a crawl space in his house using a strong chemical to decompose the bodies faster (Castleden, 2005).

Fred and Rose West (1967-1994) a husband and wife sexual killer team who started sexually assaulting young girls. In most of the cases, they were cleared of charges because key witnesses would not testify. The West’s would cut off the fingers and toes of most of their child victims, when it came to start killing their victims. Their first known victim was Fred’s own eight-year-old daughter from his first marriage; they would tie, gag, and rape her. After that, they would begin their killing after realizing their victims were telling about the gruesome details they would be put through. There were a possible thirteen sexually murdered victims (Castleden, 2005).


There are many similarities with sexual serial killers. Many serial killers have an average IQ, they grow up with some sort of abuse in the home, and they have mother issues. It is rare that sexual serial killers are older than middle age; they usually are aged between the mid-twenties to early thirties. Sexual serial killers start by molesting children before they start adding murder to the equation. It is more common for sexual serial killers to be organized, since they can go many years before they become caught, they take time to think about where to pick up the victim, and what to do with the body.

The impulsive sexual serial killer is the more common of killers, since they pick out victims that would never be missed or young children and need to act when the victim is available. They tend to invite them to their house with charming, persuasive manners. This does not make sense since to be impulsive one has to be disorganized. It is not clear how a killer can be organized and impulsive. One thing is for sure, sexual serial killers hide behind a mask of terror, to hide from their childhood pain and dis-acceptance from their society.

Many sexual serial killers tend to know their victims without their victims knowing who they are. It is more common for the offender and the victim to be complete strangers, with the offender just knowing certain details from stalking. They tend to kill victims who are either their own race or whatever race is available to them. If they know their victim, they tend to be just violent sexually with them in acts of bondage. They would usually never kill ones they care for; many of their lovers never knew they were committing such acts.

It is proven that sexual serial killers find their victims not far from their residence. A few will travel away from home in fear of being caught. Sexual serial killers will hide the bodies closer to home than they travel to retrieve them. The bodies are usually only at farthest a few miles away from where they reside, the closest kept in their own home. It is rare to be attacked by a serial killer, but one thing is for sure, they are madmen and madwomen who hide themselves in darkness, thinking killing will rid of their demons.

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English Literature Essay: Epic Of Gilgamesh Analysis

gjlgamesh 2 lipAncient history tells many stories – some created on fantasy and some based on truth. Ancient Mesopotamia has its own share of stories and many of these tales focus on a man named Gilgamesh. The “Epic of Gilgamesh,” tells this man’s life story. Throughout the tale, Gilgamesh struggles with the concept of his own mortality and refuses to believe that his life will come to an end. Being two-thirds god, he perceives himself as a god-like creature. Ultimately however, Gilgamesh gains wisdom on his journey to discover immortality and painfully realizes that his goal is unattainable. His grim outlook on life forces him to accept his worst fear – that someday he will die.

In Gilgamesh’s youth, he was a ruler and was, for the most part, praised by the inhabitants of the city of Uruk. At this time, death did not concern him. He lived as if he were invincible. Later in the epic, a powerful man named Enkidu shows up in Uruk and helps put Gilgamesh’s power into balance. Together Enkidu and Gilgamesh set out on adventures and achieve many feats; however, one cannot forget why Enkidu was created in the first place. Enkidu was sent to Gilgamesh because his power was overstepping its bounds and “Gilgamesh would not leave [young girls alone]” (“The Epic of Gilgamesh” 50). Although overall a popular ruler, Gilgamesh is at one point portrayed as a demanding ruler that disregards the wishes of his subjects and rapes women as he pleases. In this regard, does Gilgamesh deserve immortality in the first place? This deeper philosophical question must be addressed before one begins to understand why immortality is an impossibility for Gilgamesh. Gilgamesh may have asked himself this question, which may have made him ponder his own worthiness of being immortal. These thoughts helped catalyze his fear that he would die just like the people he ruthlessly ruled over. In other words, the questionability of his morality might have driven his quest for eternal youth.

During one adventure, Enkidu and Gilgamesh go to the Cedar Forest and Humbaba, a monster tasked by the gods with guarding the forest, confronts them. After a long struggle, Humbaba begs for his life, but Gilgamesh, encouraged by Enkidu, kills him anyway. The gods find out and are angry at this defiance and ultimately kill Enkidu as punishment. After all, Humbaba was innocent and did not deserve to die. When Enkidu dies and “has turned to clay” in Gilgamesh’s arms, Gilgamesh, petrified that he will experience the same fate, “roam[s] open country for long distances; [as the] words of [his] friend Enkidu weigh upon [him]” (“The Epic” 104). When Enkidu dies, Gilgamesh goes into a depression and cannot stop mourning the loss of his friend. He talks to Enkidu’s body as if it was still alive and refuses to bury him. Gilgamesh is depressed and fearful for his own life for several reasons. He has had very few close friends in the epic that we know of and when his best friend dies, Gilgamesh does not know what to do without Enkidu and becomes delusional about his situation. Gilgamesh becomes more aware of his mortality because Enkidu’s strength matched his own when he was killed. Gilgamesh resolves to conquer death.

Gilgamesh is determined to live forever, and he begins to track down a mortal named Utnapishtim who was granted eternal life. Gilgamesh overcomes many obstacles to reach this man, some of which no mortal had ventured through before. Finally, when he meets Utnapishtim, Gilgamesh explains his desire to be immortal and his fear of death. Utnapishtim challenges him to “not sleep for six days and seven nights” (“The Epic” 116). He is determined to complete this challenge and prove to Utnapishtim and himself that he deserves immortality, however “sleep breathes over him like a fog,” and he is unable to stay awake (“The Epic” 116). Eventually he is awoken and thinks he has only been asleep for a few minutes. He is still full of despair confident that death is fast approaching. His journey ends in failure, but also leads to an important epiphany. He discovers that it is better to die happily than live in fear but it is unclear if he actually embraces this revelation. Regardless, his journey makes him a wiser ruler.

Death itself invokes fear. We know it exists but not where it leads. The mystery of death, combined with the Mesopotamian outlook, leave fear and sadness to cultivate in the mind of Gilgamesh. Gilgamesh says, “nobody sees the face of Death. Nobody hears the voice of Death” (“The Epic” 108). He goes on, nothing that “death [is a] picture [that] cannot be drawn” (“The Epic” 109). This form or force that is death cannot be explained. Gilgamesh believes that something that cannot be heard or seen but that can strike and kill at any moment is something to be feared. Death gives us no clues as to what happens after life. We can only speculate as to how this mysterious element operates. Ultimately, all we know is that the human body decomposes. This grim outlook, this hourglass of life constantly being depleted, leaves Gilgamesh feeling only empty and mournful.

Some argue that Gilgamesh has already achieved immortality. Although he is physically dead, his stories and journeys live on through the written word. His tale has been copied and translated into many texts and languages. In this sense, he has indeed gained everlasting life. He lives on not through his body but through ink and paper. However, when Gilgamesh sets out to find everlasting youth he is trying to escape a physical death so that he may exist on earth forever. Living metaphorically would not have been sufficient for Gilgamesh. Some of the legends portray Gilgamesh as a spiteful and violent ruler, yet Gilgamesh is no longer alive and cannot influence how his stories are interpreted. In this sense he has no control over his existence. Although we read about him today, he was ruler of the past, and is no longer alive in the present.

Gilgamesh prepares to leave Utnapishtim, still unsuccessful, afraid, and upset. However before he bids farewell, Utnapishtim reveals a secret of the gods. He informs Gilgamesh that there exists a thorny plant in the Apsu that restores youth. Upon hearing this Gilgamesh weighs himself down and dives into the sea to recover the plant. Even though Gilgamesh finds this plant, he does not consume it on the spot. He decides to wait and “give it to an elder to eat, and so try out the plant” (“The Epic” 119). However since it was never tested, one cannot be sure that the plant will do as it promises in the first place. When he discovers the plant is stolen, sadness takes over him as “tears flowed over his cheeks” (“The Epic” 119). Except for the death of Enkidu, this is the only time that Gilgamesh cries. Alone and afraid, Gilgamesh realizes that his last chance to find immortality has passed. However, there is no confirmation that the plant restores youth, so one cannot say with certainty that immortality exists in such a form. Although Gilgamesh was not able to try the plant himself, the snake which stole the plant may have experienced the plant’s effects. The night that the thorny plant was stolen by the snake; “it took it away, [and] it shed its scaly skin” (“The Epic” 119). This quote in the epic reveals an ambiguity. When the snake sheds its skin, it could be aging or getting younger. Because this is ambiguous, we cannot confirm that immortality existed in the form of a plant. Supposing the plant was actually effective, Gilgamesh would have logically dived back down to get more of the plant. This leaf of life is more symbolic and is utilized to show that immortality, like death, is not tangible. Gilgamesh is accustomed to fighting forces that he can see such as Humbaba, the Bull of Heaven, and other warriors. When he deals with immortality which has no physical form, Gilgamesh is disappointed and ultimately unprepared to fight the unknown.

Evidence clearly shows that Gilgamesh died a fearful man, vainly clutching the dream of immortality. When he saw powerful Enkidu die, he realized that he would see the same fate gilgamesh_vs_enkidu_by_kattelfodderand set out to change his destiny. However, does someone who slays an innocent beast and rapes innocent women really deserve to live forever? There is no proof in the epic that he admits his wrongdoings or that he feels any remorse. Regardless, he sets out to find Utnapishtim and prove to himself that he deserves to be young again. On all of his journeys, Gilgamesh can see himself aging, and he spends countless hours looking for something that does not exist. One can only wonder why Gilgamesh sought so strongly to be immortal when his life as a king, a judge, and an adventurer was ultimately successful.

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Critical Analysis Nursing Care for the Older Adult

Older-Adult-Care2_0Dementia is an umbrella term to describe a collection of symptoms that develop in association with a progressive disorder of the brain of which dementia of the Alzheimer’s type is the most common. Other forms of dementia include Lewy body dementia, Pick’s disease and (MID) multi-infarct dementia (Ramsay et al, 2005). The main features of dementia are a decline in memory, ability to learn and understand in a continuing progression. There are often changes in social behaviour, general motivation and the client’s ability to control their own emotions (Burgess, 2005). These changes vary from a gradual to more sudden onset that varies from individual to individual. In the early stages of dementia memory problems are often the most obvious sign (DH, 2009).

Mental health practitioners find that memory problems and other needs are only the beginning of the process in making a diagnosis. The doctor is required to check in what ways an individual is not functioning as they would expect. Assessments may be carried out at home in order to gain a clearer image of how the client is managing (Ramsay et al, 2005). The doctor will also need to know the client’s medical history including any physical illness and current medication. The doctor will also want to rule out depression as a cause of the memory problems. If the memory problems are attributed to depression, then treatment using an antidepressant could help substantially (Ramsay et al, 2005). Diagnosis is a scientific tool. Beyond that the carer requires an understanding of the client’s experience of having a problem or disorder, health and social care needs to be values based as well as evidence based. To translate this philosophy into practice requires that the assessment process be driven by the principles of partnership, holism and personalisation (Atkins et al, 2004). Assessment is a valid and integral part of any nursing intervention and must be performed in partnership with the client (RCN, 2004).

Following this, the next step is to consider involvement of various investigations, often carried out in hospital or in a clinic, including the use of blood testing, X-ray and if necessary, brain scanning to discover the cause of the symptoms (Ramsay et al, 2005).

To carry out a full assessment of the client’s problems, other practitioners are likely to play a part in the assessment as part of a multi-disciplinary team (MDT). Members of the team may include nurses, occupational therapists, psychologists, physiotherapists, social workers and doctors. Making a diagnosis is important as diagnosis affects the type of treatment used (Ramsay et al, 2005)

Difficulties that can occur in practice when attempting to engage with clients in an effective manner include; making all of the information that is being exchanged comprehensible to the client, finding methods to reduce frequency of forgetting that can occur, finding methods to encourage clients to feedback information – positive or negative to overcome any difficulties that many people can feel in clinical settings (Ley, 1997).

The reflective account outlines the importance of communication skills in practice where the nurse can be delivering care to individuals with very specific needs that must be attended to with privacy, comfort and dignity for the health and wellbeing of the patient. In the account it is clear that clients with dementia can find communication, mobility, and physical health problems difficult and in managing the care of clients with dementia although challenging, may be overcome through empathic understanding and best practice including evidence based care delivery. In relation to communication, the most suitable approach is the use of selective questioning, providing information, respecting personal dignity and being clear so that the client understands (Zimmermann, 1998).

Patient centred methods of care place demands on nurses because such a method involves responding to the cues from clients in which feelings and emotions are expressed. Nurses are required to develop the expertise to respond in an appropriate manner to the client’s feelings and emotions (Stewart et al, 1989). In order to provide high quality person centred care, the needs of each patient must be assessed individually to ascertain additional requirements that the client may have. Conversely, some clients will require less assistance than initially considered by the team. It is equally important to understand these needs in order to respect each client’s need for independence (Stewart et al, 1989). Best care can be defined by the underlying principles that communication should always be person centred (Oberg, 2003). Therefore the client should be provided with a quality standard of care that allows a sense of control over the treatment that is being provided. It is vital that the client is involved in their own care and treatment, not only does this maintain the comfort and dignity of the person, but prevents errors and miscommunication leading to an effective client/nurse relationship. In one study findings concluded that actively involving the patient in aspects of care and treatment often leads to earlier recovery and an improved quality of life (Stewart et al, 1989).

Overview of Care Practice – Reflection in Action

ageism 2In practice, a male client was confused as a result of his dementia. The client was an older adult who used a wheelchair and required assistance with mobility because of a leg amputation. Sometimes the client would try to leave his wheelchair which resulted in him falling to the floor. The client was unable to find the lavatory and was becoming increasingly frustrated by his inability to identify specific places. In addition the client became agitated and at times had difficulty with speaking. On one occasion the client called a nurse who responded to the patient, approaching him slowly from the front and greeted him, and asked “How can I help? Is everything ok?” The patient responded to the question with an answer “I need… I need to go to the…” The client repeated this statement several times with increasing sense of urgency but was unable to find the correct word to finish the sentence due to his level of confusion. The client experienced memory problems and episodes of agitation. Managing the client’s ability to be continent was another important consideration in the care of the individual as he used an attachment (catheter) and was occasionally incontinent of faeces (Johns, 2000; Schön, 1983; 1987).

The assessment phase of the nursing process is fundamental at this stage of the interaction so that the nurse was able to ascertain if the client required the use of the toilet (Kozier, 2004). The nurse asked the client if he needed to use the toilet. The client responded by nodding his head and saying “yes”. The planning phase of the nursing process is equally important at this stage. The nurse informed the client that he would show him the way and escorted the client to the toilet. When speaking to the client the nurse was careful to maintain eye-contact and speak slowly and calmly to ensure that the client would understand. Whilst being escorted the client explained that he had been incontinent of faeces. The client began apologising but the nurse reassured him and explained that he would get him some fresh clothes (Johns, 2000; Schön, 1983; 1987).

The nurse was able to provide comfort and maintain the dignity of the client as well as the client’s confidence in the nurse’s abilities. The client was reassured and an explanation of the procedure was provided to the person in a step-by-step process, asked if he understood and if he was agreeable. The client confirmed he was agreeable and began to converse with the nurse and appeared much more relaxed. The client responded with additional banter and appeared more content. The client was able to carry out more intimate aspects of his personal cleansing so that further consideration to preserving his dignity and independence was maximised. The nurse recommended that the client’s catheter bag was emptied on a more regular basis to aid comfort and reduce distress (Johns, 2000; Schön, 1983; 1987). The NMC (2008) guidelines stipulate that nurses maintain the respect, dignity and comfort of clients. After being washed the client was assisted with putting on clothing, explaining each step slowly, the client responded y following each step and no longer appeared agitated and was returned to the lounge in a wheelchair. The student reported the information to the rest of the team and discussed regular catheter care for the client.

Reflection on Action

elderly_careDuring the reflection in action (Johns, 2000; Schön, 1983; 1987) the nurse was able to quickly and effectively clean and change the client with comfort and dignity through implementation of the nursing process and incorporating the ideas of assessment, diagnosis and planning phases of care. The reflection on action (Schön, 1983; 1987) highlights what the nurse was trying to achieve and provides opportunity to consider alternatives for future practice. Care was delivered to the client using the Care Programme Approach (CPA) and the procedure implemented to offer a framework to complement policy documents and therefore allow the process to be followed. The approach allows mental health practitioners to provide a structured pattern of care throughout the process, assess client’s need, plan ways to meet the needs and check that the needs are being met (DH, 2007).

Those who experience dementia may find some tasks increasingly difficult such as everyday tasks of living, including washing and dressing without assistance or with finding the right words when talking. Interaction for the person can become increasingly difficult and distressing for the client in their relationship with others (Ramsay et al, 2005). Dementia care practice provides opportunities to mental health nurses on how to engage effectively with clients.

During the initial contact stages of any nurse and client interaction it is important that the nurse keeps the environment simplified and to eliminate noise that can distract the client (Zimmermann, 1998). It is useful if the nursing team minimises activity occurring in a shift change because a confused client may misunderstand nurses saying goodbye to each another and may wish to leave. Approaching the client slowly and making eye contact can reduce any risk of alarming the client (Zimmermann, 1998). Also the nurse should speak slowly and calmly with pauses so that the client responds to the content of the communication and not the mannerisms of the nurse (Zimmermann, 1998). These skills may help to reduce the client’s anxiety and confusion.

The National Service Framework (NSF) for older people sets out national standards and service models of health/social care that older people using mental health services can expect to receive, whether they are living at home, in care or are in hospital (DH, 2001; WAG, 2006). Older people are generally referred to as anyone aged sixty and over and the national ten year initiative is to ensure better health and social care services for people meeting the criteria. It includes older people with dementia, carers and ethnic minority groups. In addition, age discrimination and patient-centred care have been identified as two key areas. Including the NSF, there have been a number of campaigns to promote dignity in the care of older people, recognising that standards of care in some cases are poor and inadequate (DH, 2006a).

Unfortunately, there has been a lack of clarity associated with the notion of dignity and the appropriate minimum standards and/or recommendations that should be applied. For example, in an attempt to address the concerns of dignity the Department of Health published an online public survey around the views of dignity and care provision (DH, 2006a). Results of the survey reported that a many aspects of care were identified by older people as vital in maintaining dignity, such as respecting the person and communicating effectively.

The Lets Make It Happen NSF (2002) outlines eight standards of care that address issues such as age discrimination, person centred care, mental health and the promotion of health and active life in old age. The success of the NSF for Older People depends on how well it is being implemented. Lets Make It Happen follows the NSF for Older People in 2001 and focuses on examples of research and good practice through evidence based care provision, which demonstrates how implementing good practice can improve people’s quality of life and should also help to develop ideas for how the NSF might be implemented (Alzheimer’s Society, 2002).

In 2006, the Department of Health released a report: ‘A New Ambition for Old Age’, in an attempt to move the requirements outlined in the National Service Framework forward, and offers details of the next stage of healthcare reforms for older people. This documentation places older peoples’ needs as integral to care planning and delivery, with ‘respect’ and the maintenance of ‘dignity’ by recognising the existing issues around health related age discrimination (Department of Health 2006b). Furthermore, the Department of Health have established a set of benchmarking tools to ‘root out age discrimination’ and to ‘advance person-centred care’ (Department of Health 2007a). This is to be achieved, in the first place, by actively ‘listening to the views of users and carers about the services they need and want’ (Department of Health 2007a).

Within Wales the Care Programme Approach (CPA) is highly regarded as the cornerstone of the Government’s mental health policy and procedures. The framework was introduced in 2004 for the care of people with mental health issues who are accepted as clients by mental health services in an inpatient or community setting. All NHS Trusts in Wales participated in a review and all had processes in place to deliver CPA to clients (Elias & Singer, 2009). Although the review sample was small, findings were consistent across all the organisations, and demonstrated that CPA had not been implemented as effectively as it should. If this randomly selected sample is representative of all mental health services in Wales, there is a risk that services are failing clients and carers due to a lack of adequate risk management processes, a lack of focus on the outcome of patient interventions, and a lack of service planning and service models to safely and adequately meet client’s needs. Greater focus is needed on the assessment and management of risk (Elias & Singer, 2009).

Practitioners must be prepared and fully trained to fulfil the role of care co-ordinator. Information systems need to meet client needs rather than organisational priorities. The current system is very complex and bureaucratic particularly where CPA and the Unified Assessment (UA) have been integrated into a single process. A record management system needs to be developed that supports CPA and UA whilst also providing the least administrative burden for clinicians and practitioners (Elias & Singer, 2009).

A significant amount of evidence exists suggesting that providing care for a person with dementia is not only stressful, but can also have a negative impact on the carer’s mental health (Cooper et al, 1995). Recently, government policy has expressed the importance of offering support to carers. This has been highlighted by the Audit Commission report examining mental health services for older people (2000).

Research suggests that carer’s needs are multifaceted, and that support is needed at times of transition, for example diagnosis, admission of the person they are caring for to residential care and the death of the person with dementia. (Aneshensel et al, 1995). The need for more advanced training in the field of dementia care has been recognised for quite some time (Keady et al, 2003). NICE and the Social Care Institute for Excellence (SCIE) recently developed guidelines for supporting people with dementia and their carers (NICE & SCIE, 2007). The guidelines identified the main therapeutic interventions and when and why they should be used. The principal focus of care should involve maximising independent living skills and enhancing client function. This will involve assisting client’s to adapt and develop their skills to minimise the need for support (NICE & SCIE, 2007).

This should start in the early stages of the condition, and could involve a number of services and the client’s carers. Providing care in ways that promote independence is liable to take time, but it is the core intervention for people with dementia on a therapeutic basis. The NICE and SCIE (2006) guideline identified key interventions that should be utilized for maximising function. Care plans are vitally important and should include the activities that are important for maintaining independence. Care plans should take account of the individual’s type of dementia, their needs, interests, preferences and life histories (NICE & SCIE, 2006). Obtaining advice about client’s independent toilet skills is important. If the client experiences episodes of incontinence, any possible causes should be assessed and then treatment options tried before the team concludes that incontinence is permanent. Physical exercise should be encouraged when possible and facilitated in a safe environment, with assessment advice from a physiotherapist when required. As exercise is thought to help improve continence problems, loss of mobility and improve endurance, physical strength and balance in falls prevention (NICE, 2004) physical exercise should be promoted by all staff.

Therapeutic interventions for the cognitive symptoms of dementia are comprised of psychological and pharmacological treatments. However, providing supportive levels of care that encourage clients to maintain as much of their independent functions as possible is equally as important as any specific interventions for the cognitive symptoms of dementia (NICE, 2007; Moniz-Cook & Manthorpe, 2009).

Much has been written about medical and social models of dementia, some of which has implied that there are a number of different ways of looking at dementia, one as a disease model and one as a disability. Some of these differences are described in Tom Kitwood’s Dementia Reconsidered (Kitwood, 1999). Kitwood described the medical model as the ‘standard paradigm’, and argues eloquently that it is the wrong model to use. Dementia is an illness that causes a progressive decline in cognitive abilities and there are demonstrable changes to the brain. It is, however very important to remember that we are treating a person with dementia. How the condition presents depends on the clients’ personality, their relationships with others, and who they are as a person (Kitwood, 1999).

Nurses and GPs have cited inadequate professional training as one of the main factors influencing their ability to provide an optimal service to people with dementia (Iliffe & Drennan, 2001; Alzheimer’s Society, 1995). However, it is not known what method of training would equip them with the right range of knowledge and skills. Around 700,000 people in the UK have dementia, and this number is predicted to double to 1.4 million over the next 30 years (DH, 2009).


In summary, dementia is a debilitating disorder that is having a massive impact on mental health services. The introduction of numerous frameworks for the care of the older adult and other policy documents have set the standards expected of mental health professionals and backs up evidence based care with a high standard of principals and values (RCN, 2004; DH, 2009,). The number of people being diagnosed with a dementia is increasing, and although difficult to manage, through continued research, development and training of staff and practicing with empathy, treating clients with dignity and respect and upholding the core values of the nursing profession (NMC, 2008) dementia care services and service providers may transcend the potential difficulties that lay ahead. In these uncertain times it is comforting that the care of the older adult has not been forgotten.

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