Situated clinical reasoning: distinguishing acute confusion from dementia in hospitalized older adults

Occupational Therapy Utilization in Veterans With Dementia: A Retrospective Review of Root Cause Analyses of Falls Leading to Adverse Events

INTRODUCTION

Falls in persons with dementia are associated with increased mortality. Occupational therapy (OT) is a rehabilitation discipline, which has, among its goals, the promotion of safety and fall prevention in older adults and those with dementia. The purpose of this study was to evaluate root cause analysis (RCA) data to identify causes of falls with adverse events in patients with dementia who were referred to or receiving OT services within the Veterans Health Administration (VHA).

METHODS

This study used retrospective review of RCAs within the National Center for Patient Safety database for the VHA. The RCA database was searched using these terms: falls with adverse events, dementia, and OT. Descriptive statistical analysis of demographic information, location, occurrence of orthopedic fracture, and mortality was used. All root causes were qualitatively categorized using thematic analysis of determined causes.

RESULTS

Eighty RCAs were included in analysis. Mean age of veterans included was 80 years; 96% were male; 76% resulted in hip fracture; and 20% died as a result of the fall. Occupational therapy evaluations occurred within 7 days of admission to VHA and falls most frequently occurred within 4 days of OT evaluation. Most common causes included inappropriate or lack of equipment (21%), need for falls/rehabilitation assessment (20%), compliance/training to fall protocol of all staff (19%), and behavior/medical status (17%).

CONCLUSIONS

Earlier identification for OT evaluation need may improve access to services, and use of proper equipment to decrease frequency of falls may improve patient safety for older adults with dementia.

Harnessing nursing to diminish ageism

BACKGROUND

The common practice of making fun of aging and older people demonstrates that ageism towards older people is socially acceptable. It is so accepted that even those of us who are aging or have moved into the 'third act' believe and fear the negative stereotypes that growing old is linked with physical and mental deterioration, dependence, and less social value. Ageism is evident in work places, family relationships, when older people purchase goods and services, in health and social institutions and extends throughout professions that work with older people.

OBJECTIVES

We explore how nurses-the largest group of healthcare professions- may be inadvertently perpetuating negative perceptions about older people in nursing practice, nursing education, and through common misconceptions about what gerontological nursing means.

METHODS

This is discussion paper using the literature.

RESULTS

We suggest that nursing education is well situated to diminish negative perspectives of ageing by incorporating theories of life-course and harmonious aging into the holistic perspective of individuals that nursing is well known for.

CONCLUSIONS

Greater understanding about the diversity of ageing and the context that have influenced older persons could encourage nurses to treat them holistically with dignity, which would ultimately improve older people's experiences. Improving older persons' experiences is like paying it forward, as we all are ageing and if we are to have a different experience when we are old, it is necessary to diminish stereotypes about ageing, and work towards inclusion of older people in social and healthcare institutions.

IMPLICATIONS FOR PRACTICE

It is important for nurses, particularly those in nursing education, to support the incorporation of a life course and harmonious view of aging in which the social, political, and environmental context of individuals are viewed as part of the difference of ageing.

Development of a Tool for the Assessment of Nurses' Attitudes Toward Delirium

BACKGROUND AND PURPOSE

The prevalence of delirium during hospitalization is high in older patients and there is evidence of staff regarding them as unpopular or a burden. This study aims to develop an instrument examining nurses' attitudes toward patients with delirium.

METHODS

Stages included (a) content identification, (b) content development, (c) content critique, (e) pilot study with a test-retest reliability, (f) field study consisting of psychometric testing of the internal consistency and construct validity.

RESULTS

The Cronbach's alpha was 0.89 and the stability reliability was acceptable. The factor analysis resulted in three factors explaining a total of 56.5% of the variance. hese factors are "beliefs," "behavior," and "emotions," explaining 37.025%, 12.792%, and 5.652% of variance.

CONCLUSIONS

The Attitude Tool of Delirium (ATOD) is a reliable and valid instrument for the assessment of attitudes toward delirium.

The educational needs of nursing staff when working with hospitalised older people

OBJECTIVES

To examine nursing staffs' geriatric knowledge, perceptions about interprofessional collaboration and patient-centred care, and perceived learning needs related to working with hospitalised older people.

METHOD

A triangulation mixed methods design was used. A survey was administered to nursing staff that contained the Knowledge About Older Patients Quiz, the patient-centered Care measure and the Modified Index of Interdisciplinary Collaboration measure. Interviews were conducted to understand nursing staffs' learning needs. Survey data were analysed using descriptive statistics. Interview data were analysed using content analysis. Survey and interview data were then compared and contrasted.

RESULTS

Twenty-two nursing staff (response rate 26%) completed surveys and 14 participated in interviews. The mean knowledge about older patients score was 22.95, indicating moderately high gerontological knowledge. The mean scores on the patient-centered Care measure and Modified Index of Interdisciplinary Collaboration were moderately high at 3.75 and 3.86, respectively. Themes developed from analysis of the interview data were as follows: complex vulnerable population, clinical care concerns and working as a team. In spite of scores on knowledge surveys, nursing staff identified learning needs related to managing the responsive behaviours of older patients with cognitive impairment, chemical and physical restraints, mobility and continence.

CONCLUSIONS

There was an incongruence between survey and interview data as nursing staff reported gaps in their knowledge despite moderately high scores on the Knowledge about Older People Quiz. Further research is needed to understand additional factors that influence nurses' educational needs.

Development of a Self-Report Checklist to Assess Dementia Care by Nurses in Hospital Settings

Nurses working at general hospitals face difficulties in providing dementia care. The current study examined aged care nurses' dementia care practices in the hospital setting and developed a dementia care checklist that nurses can use to review their own care practice. A self-administered questionnaire was given to 676 participants; responses were collected from 595 participants. Exploratory factor analysis identified six factors (e.g., patient understanding prompted by concern and interest for the patient, respect for patients' voluntary behavior, early detection of abnormalities) among the questionnaire's 28 items. This analysis provided a framework for the checklist and verified that it had satisfactory internal consistency and construct validity. The frequency of care practices varied with participants' knowledge of dementia care requirements, satisfaction with their own dementia care practice, confidence in their ability to judge patients' physical condition, and cooperation with colleagues. This checklist might improve dementia care in hospital settings. [Res Gerontol Nurs. 2018; 11(2):91-102.].

Professional Socialization: A Grounded Theory of the Clinical Reasoning Processes That RNs and LPNs Use to Recognize Delirium

Delirium is an acute disorder of attention and cognition. It affects half of older adults in acute care settings and is a cause of increasing mortality and costs. Registered nurses (RNs) and licensed practical nurses (LPNs) frequently fail to recognize delirium. The goals of this research were to identify the reasoning processes that RNs and LPNs use to recognize delirium, to compare their reasoning processes, and to generate a theory that explains their clinical reasoning processes. Theoretical sampling was employed to elicit data from 28 participants using grounded theory methodology. Theoretical coding culminated in the emergence of Professional Socialization as the substantive theory. Professional Socialization emerged from participants' responses and was based on two social processes, specifically reasoning to uncover and reasoning to report. Professional Socialization makes explicit the similarities and variations in the clinical reasoning processes between RNs and LPNs and highlights their main concerns when interacting with delirious patients.

Intensive Care Unit Nurses' Beliefs About Delirium Assessment and Management

Delirium, the most frequent complication of hospitalized older adults, particularly in intensive care units (ICUs), can result in increased mortality rates and length of stay. Nurses are neither consistently identifying nor managing delirium in these patients. The purpose of this study was to explore ICU nurses' identification of delirium, actions they would take for patients with signs or symptoms of delirium, and beliefs about delirium assessment and management. In this cross-sectional study using qualitative descriptive methods guided by the theory of planned behavior, 30 ICU nurses' responses to patient vignettes depicting different delirium subtypes were explored. Descriptive and content analyses revealed that nurses did not consistently identify delirium; their actions varied in different vignettes. Nurses believed that they needed adequate staffing, balanced workload, interprofessional collaboration, and established policy and protocols to identify and manage delirium successfully. Research is needed to determine if implementing these changes increases recognition and decreases consequences of delirium.

The consequences of using advanced physical assessment skills in medical and surgical nursing: A hermeneutic pragmatic study

Aims and objectives

The aim of this study was to explore the consequences of the nurse's use of advanced assessment skills on medical and surgical wards.

Background

Appropriate, accurate, and timely assessment by nurses is the cornerstone of maintaining patient safety in hospitals. The inclusion of “advanced” physical assessment skills such as auscultation, palpation, and percussion is thought to better prepare nurses for complex patient presentations within a wide range of clinical situations.

Design

This qualitative study used a hermeneutic pragmatic approach.

Method

Unstructured interviews were conducted with five experienced medical and surgical nurses to obtain 13 detailed narratives of assessment practice. Narratives were analyzed using Van Manen's six-step approach to identify the consequences of the nurse's use of advanced assessment skills.

Results

The consequences of using advanced assessment skills include looking for more, challenging interpretations, and perseverance. The use of advanced assessment skills directs what the nurse looks for, what she sees, interpretation of the findings, and her response. It is the interpretation of what is seen, heard, or felt within the full context of the patient situation, which is the advanced skill.

Conclusion

Advanced assessment skill is the means to an accurate interpretation of the clinical situation and contributes to appropriate diagnosis and medical management in complex patient situations.

Relevance to clinical practice

The nurse's use of advanced assessment skills enables her to contribute to diagnostic reasoning within the acute medical and surgical setting.

Factors that contribute to underrecognition of delirium by registered nurses in acute care settings: a scoping review of the literature to explain this phenomenon

AIMS AND OBJECTIVES

In order to obtain more information regarding this phenomenon, a scoping review of the literature was undertaken to analyse current research on the recognition of delirium by registered nurses in acute care settings.

BACKGROUND

Delirium is often manifested as a sign of an underlying undiagnosed condition that requires immediate intervention and is frequently manifested in acute care settings. Unfortunately, registered nurses often do not recognise delirium and its occurrence goes under-reported.

DESIGN/METHODS

Based on six inclusion criteria, a search in numerous databases using terms such as delirium detection, recognition and diagnosis by registered nurses was undertaken. Eight quantitative studies were deemed relevant and analysed for this scoping review.

RESULTS

Seven major categories emerged: the fluctuating nature of delirium, the impact of delirium education on its recognition, communication barriers, inadequate use of delirium assessment tools, lack of conceptual understanding of delirium, delirium as a burden and the likeness of delirium and dementia. A brief summary of the findings in each category is reported here.

CONCLUSIONS

The scoping review revealed that delirium remains underrecognised by registered nurses, which potentially contributes to reduced quality of nursing care for clients experiencing this condition. Further research on delirium and the processes that registered nurses use to recognise it is timely and will facilitate the development of evidence-based interventions to manage it.

RELEVANCE TO CLINICAL PRACTICE

While acute care registered nurses have historically reported dramatic changes in cognitive and neuro-biological functions in ill older adults, the literature highlighted in this scoping review revealed the following: (1) the need for further research to validate delirium assessment tools and, (2) the need for education and training for registered nurses on the use of these assessment tools to promote early recognition and thereby decrease the incidence of delirium in older adults.

Mixed-methods approach to understanding nurses' clinical reasoning in recognizing delirium in hospitalized older adults

A mixed-methods study was conducted to enhance understanding of nurses' clinical reasoning in recognizing delirium in the hospitalized older adult. Paired nurse and researcher ratings of the confusion assessment method in 103 medical-surgical patients were analyzed to determine the rate of agreement in detecting delirium and to identify a purposive sample of nurses to be interviewed about the patients with delirium who were under their care. Nurses' clinical reasoning in recognizing and underrecognizing delirium was investigated using semistructured interviews. The incidence of delirium was 13%, with poor agreement (95% CI [0.05, 0.64], p < 0.05) between the researchers and the nurses in detecting delirium. Sixteen nurses were interviewed and transcripts were analyzed with grounded theory. Confusion was the primary causal factor for recognizing symptoms of delirium. The findings explicated a framework that forms the basis for generating testable assumptions to improve nurses' recognition of delirium.

Best practice for the management of older people with dementia in the acute care setting: a review of the literature

Aim.  This paper reviews the theoretical and research-based literature related to the management of people with chronic confusion as a consequence of dementia in the acute care setting. Background.  People aged 65 years and over are at increased risk of poor outcomes when admitted to the acute care setting as a result of comorbity and mismanagement of their chronic confusion. The challenge of caring for people with dementia in acute care is one that requires special attention. Results.  The theoretical literature outlines a number of principles of care necessary for best practice in the care of people with dementia. A number of different models of care are reported in the literature and some evaluative research has been undertaken to assess the benefits of the different models. Conclusion.  There are a number of interventions that if put into place in acute care may improve care of people with dementia and reduce the burden of care. There is emerging evidence that interventions such as staff education, skilled expertise, standardized care protocols and environmental modification help to meet the needs of people with dementia in acute hospital settings. This paper adds to our current understanding of management of dementia in the acute care setting, an area that demonstrates the need to move from descriptive to intervention studies to ensure evidence for care of persons with a dementing condition.

Strategies to improve delirium recognition in hospitalized older adults

As 24-hour caregivers, nurses' detection of delirium is critical to physician diagnosis because of the waxing and waning of delirium-related clinical features. However, nurses fail to accurately interpret delirium-related clinical features more than 30% of the time.

How nurses understand and care for older people with delirium in the acute hospital: a Critical Discourse Analysis

Delirium is a common presentation of deteriorating health in older people. It is potentially deleterious in terms of patient experience and clinical outcomes. Much of what is known about delirium is through positivist research, which forms the evidence base for disease-based classification systems and clinical guidelines. There is little systematic study of nurses' day-to-day practice of nursing patients with delirium. The aim was to uncover the kinds of knowledge that informs nurses' care and to explicate the basis of that knowledge. Critical Discourse Analysis is underpinned by the premise that powerful interests within society mediate how social practices are constructed. Links were made between the grammatical and lexical features of nurses' language about care in interviews and naturalistic settings, and the healthcare context. Care focused on the continuous surveillance of patients with delirium by nurses themselves or vicariously through other patients, and containment. Nurses influenced by major discourses of risk reduction and safety, constructed patients with delirium as risk objects. The philosophy of person-centred and dignified care advocated in nursing literature and government policy is an emerging discourse, though little evident in the data. The current dominant discourses on safety must give space to discourses of dignity and compassion.

Developing effective educational approaches for Liaison Old Age Psychiatry teams: a literature review of the learning needs of hospital staff in relation to managing the confused older patient

BACKGROUND

Deficiencies in the knowledge, skills and attitudes of all healthcare professionals working within the general hospital contribute towards the suboptimal care of older hospitalized patients with confusion. In the U.K., policy dictates that Liaison Old Age Psychiatry teams deliver effective education to general hospital clinical staff. The purpose of this paper is to review the literature concerning the learning needs of healthcare professionals in relation to managing confusion in the older patient in order to inform effective educational approaches for Liaison Old Age Psychiatry teams.

METHODS

A broad range of medical and educational databases were searched. Identified English language studies were selected for further analysis if they had a specific educational focus in the hospital setting and then further subdivided into intervention and naturalistic studies. The impact of intervention studies was evaluated by Kirkpatrick's system. Learning needs, as determined from the naturalistic studies, were mapped to identify themes.

RESULTS

13 intervention studies were identified. Despite a high level of effectiveness for educational interventions, it was unclear what the active components were. A further 23 naturalistic studies were identified; their findings focused on knowledge gaps, diagnostic behaviors and experiences, attitudes and training issues. Few studies specifically researched learning needs or the educational role of liaison teams. Conspicuous by its absence was reference to relevant educational theories.

CONCLUSIONS

The findings of this review can be incorporated in the planning of local curricula by Liaison Teams in order to design educational strategies. There is a need for further research, especially studies exploring the learning needs of all healthcare professionals.

Factors determining nurses' clinical judgments about hospitalized elderly patients with acute confusion

Acute confusion(AC)/delirium is a common clinical phenomenon in hospitalized elders that is often overlooked or misdiagnosed by nurses of various cultural backgrounds. The aim of this study was to better understand factors affecting nurses' clinical judgments regarding the detection of AC in elderly Taiwanese patients. Nurses from two hospitals in Taiwan (n = 654, response rate = 71.3%) participated in the study. A two-level hierarchical linear model analysis was used to examine the data. The characteristics of patients explained the most variance of the model (86.2%), with characteristics of nurse participants and their health organizations accounting for 13.8% of the variance. Patient characteristics of age, infection, hydration, and hypoactive subtypes of AC, as well as a nurse's strong belief in traditional Chinese values, such as respect for elders, hard work, modesty, noncompetitiveness, and respect for tradition, were positively associated with difficulty detecting acute confusion. Findings of this study indicated that the accuracy of nurses' clinical judgments in detecting AC were most related to characteristics of patients.

The virtual gateway: opening doors in delirium teaching and learning

Delirium is a common, serious and potentially preventable problem. It is argued here that knowledge and skills for effective assessment and treatment of delirium cannot be considered 'specialist'. Rather, delirium is a problem that requires a healthcare team approach to assessing patients, identifying risks or symptoms and reducing precipitating factors. Research from the preceding decade suggests that the clinical reality is falling short of this ideal with the result that many cases of delirium go undetected and many precipitating factors are not reduced where this is indeed possible. This presents a challenge for the education of nursing and medical students and for the development of qualified staff in practice. The current paper outlines an educational approach, e-learning, which increases access for learners, integrates knowledge and skill development and promotes active, problem-based learning.

Types of nursing knowledge used to guide care of hospitalized patients

AIM

This paper is a report of a study to identify the types of nursing knowledge used to guide care of hospitalized patients.

BACKGROUND

The history of nursing knowledge is discerned in three distinct moments. The first historical moment conceives nursing knowledge as the acquisition of a set of descriptive rules, the second as the development of dualist explanatory theories and the third as the production of critical and/or integrative understandings. It remains unclear how these different types of knowledge are implemented in practice and how they affect the care of hospitalized patients.

METHOD

A secondary qualitative analysis was conducted in 2007 on original data collected in 2002. The data were read with focus on the knowledge used by participants to confront practice situations. They were interpreted, classified and indexed to identify types of knowledge nurses use to care for hospitalized patients.

FINDINGS

Five discrete types of nursing knowledge that nurses use in practice emerged: personal practice knowledge, theoretical knowledge, procedural knowledge, ward cultural knowledge and reflexive knowledge.

CONCLUSION

All three moments in the history of nursing knowledge were found to be concurrently present in nursing practice. Ward cultural knowledge and procedural knowledge reflect the rule-based descriptive knowledge of the first moment, theoretical knowledge and personal practice knowledge reflect the explanatory dualist knowledge of the second moment and reflexive knowledge reflects the critical and integrative knowledge of the third moment.

Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study

BACKGROUND

Nurses' clinical reasoning is of great importance for the delivery of safe and efficient care. Pressure ulcer prevention allows a variety of aspects within nursing to be viewed.

OBJECTIVE

The aim of this study was to describe both the process and the content of nurses' reasoning during care planning at different nursing homes, using pressure ulcer prevention as an example.

DESIGN

A qualitative research design was chosen.

SETTINGS

Seven different nursing homes within one community were included.

PARTICIPANTS

Eleven registered nurses were interviewed.

METHOD

The methods used were think-aloud technique, protocol analysis and qualitative content analysis. Client simulation illustrating transition was used. The case used for care planning was in three parts covering the transition from hospital until 3 weeks in the nursing home.

RESULT

Most nurses in this study conducted direct and indirect reasoning in a wide range of areas in connection with pressure ulcer prevention. The reasoning focused different parts of the nursing process depending on part of the case. Complex assertations as well as strategies aiming to reduce cognitive strain were rare. Nurses involved in direct nursing care held a broader reasoning than consultant nurses. Both explanations and actions based on older ideas and traditions occurred.

CONCLUSIONS

Reasoning concerning pressure ulcer prevention while care planning was dominated by routine thinking. Knowing the person over a period of time made a more complex reasoning possible. The nurses' experience, knowledge together with how close to the elderly the nurses work seem to be important factors that affect the content of reasoning.

Recognizing Delirium Superimposed on Dementia: Assessing Nurses’ Knowledge Using Case Vignettes

Delirium is a serious and prevalent problem that occurs in many hospitalized older adults. Delirium superimposed on dementia (DSD) occurs when a delirium occurs concurrently with a pre-existing dementia. DSD is typically underrecognized by medical and nursing staff. The current study measured nursing identification of DSD using standardized case vignettes, and the Mary Starke Harper Aging Knowledge Exam (MSHAKE). Results revealed that the nurses in this study had a high level of general geropsychiatric nursing knowledge as measured by the MSHAKE, yet had difficulty recognizing DSD compared to dementia alone and delirium alone. Only 21% were able to correctly identify the hypoactive form of DSD, and 41% correctly identified hypoactive delirium alone in the case vignettes. Interventions and educational programs designed to increase nursing awareness of DSD symptoms could help to decrease this gap in nursing knowledge.

Thinking like a nurse: a research-based model of clinical judgment in nursing

This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.

Early detection and prevention of delirium in older patients with cancer

Delirium poses a common and multifactorial complication in older patients with cancer. Delirium independently contributes to poorer clinical outcomes and impedes communication between patients with cancer, their family and health care providers. Because of its clinical impact and potential reversibility, efforts for prevention, early recognition or prompt treatment are critical. However, nurses and other health care providers often fail to recognize delirium or misattribute its symptoms to dementia, depression or old age. Yet, failure to determine an individual's risk for delirium can initiate the cascade of negative events causing additional distress for patients, family and health care providers alike. Therefore, parameters for determining an individual's risk for delirium and guidelines for the routine and systematic assessment of cognitive functioning are provided to form a basis for the prompt and accurate diagnosis of delirium. Guidelines for the prevention and treatment of delirium are also discussed.

Detecting acute confusion in older adults: Comparing clinical reasoning of nurses working in acute, long-term, and community health care environments

In an article on a previous study involving hospitalized older adults (McCarthy, 2003), it was argued that the theory of situated clinical reasoning explains why nurses often fail to recognize acute confusion. Further, the theory illuminates how nurses' perspectives toward health in aging affect the ways they regard and ultimately deal with older people in this particular clinical situation. The purpose of the current study was to challenge and refine the theory by exploring the influence of different care environments on clinical reasoning related to acute confusion. Following a period of participant observation, a purposive sample of 30 nurses, 10 each from a teaching hospital, a long-term facility, and a home care agency, participated in semistructured interviews. Dimensional analysis provided the methodological framework for data collection and interpretation. The results reinforce prior findings that the ability of nurses to recognize acute confusion and to distinguish it from dementia can be attributed to their personal philosophies about aging. Care environment was identified as a factor that influenced clinical reasoning in limited ways under certain conditions and within certain contexts.