Nurses' assessment of elderly patients in hospital

Achieving dignified care for older people through practice development: A systematic approach

This paper presents the results of a one-year practice development project undertaken in a rehabilitation ward for older people with the intention of developing the quality of rehabilitation practice and of exploring the potential for nurses to work as case managers.

The baseline data showed that the culture of the ward reflected a custodial approach to patient care, a lack of effective clinical leadership and poor understanding of the rehabilitation needs of older people. It was concluded that changes to practice were needed before a case management approach to care could be considered. A systematic practice development approach was adopted, incorporating pre- and post-development evaluation methods. A comparison ward was used to compare the impact on clinical practice of the change strategies used.

The ensuing development strategy focused on facilitating nurses and other members of the multidisciplinary team to question their own attitudes, beliefs and values and to begin to challenge clinical practice. Ongoing work was aimed at implementing cultural and structural changes agreed by the multidisciplinary team, supported by research evidence, in order to establish new norms of clinical practice and leadership. As a result of the project, the ward team was in a much better position to develop a case management approach to patient care, and to implement the development needs identified within the post-evaluation data.

Comparison of two tools developed to assess the needs of older people with complex care needs

Abstract

Greater standardisation of assessments of older people with complex care needs is a requirement of UK policy. This study explores the practicability and validity of two assessment tools, Minimum Data Set Resident Assessment Instrument (MDS-RAI) and EASY-Care. Participants, aged 65 years or over, living in care homes or awaiting hospital discharge, were assessed using randomly allocated paired instruments. Client evaluation questionnaires on the practicability of the tools were completed. Short Form 12 (SF12) questionnaires were administered to assess participants’ health status. Registered nurses undertook data collection and participated in two focus groups designed to explore the practicability of the tools. Statistical tests were applied to quantitative data to assess practicability and validity. Thematic content analysis was used to analyse focus group transcripts. In all, 238 assessments were completed. Older people and assessors generally reported that both tools were practicable, with EASY-Care preferred to MDS-RAI for practicability measures including ease of use, usefulness and acceptability. Focus groups illustrated the significance of professional judgement when using structured tools. Both tools were reasonable indicators of activities of daily living, but there were shortcomings in measurements of cognitive performance and depression. Both instruments require development to fully capture the older person’s perspectives of needs and to test the validity of key measures.

Developing personal relationships in care homes: realising the contributions of staff, residents and family members

Personal relationships are an integral part of living, working and visiting in care homes, but little research has made relationships the main focus of enquiry, and there have been few studies of the perspectives of residents, staff and family members. The study reported here sought to redress this neglect. Using a constructivist approach, the nature and types of relationships between residents, staff and family members were explored in three care homes in England using combined methods including participant observation, interviews and focus groups. The data collection and analysis occurred iteratively over 21 months and three types of relationships were identified: ‘pragmatic relationships’ that primarily focus on the instrumental aspects of care; ‘personal and responsive relationships’ that engage more fully with the particular needs of individual residents; and ‘reciprocal relationships’ that recognise the roles of residents, staff and family members in creating a sense of community within the home. This paper explores the contributions made by staff, residents and family members in the development of these relationships. The findings enhance our understanding of the role of inter-personal relationships in care home settings and of the factors that condition them. The implications for developing improved practice in care homes are also considered.

`Introducing yourself to strangers'

The aims of this study were to explore the practicability of two instruments developed to assess older people with complex care needs and to assess compliance with criteria for assessment tools that require tools to be person-centred and to support rather than replace professional judgement. Nurse assessors undertook assessments of older people living in a care-home setting or awaiting discharge from hospital, using EASY-Care and Minimum Data Set Resident Assessment Instrument (MDS-RAI). The results suggest that both tools are practicable and useful in enabling older people to identify their needs. EASY-Care was preferred to identify both health and social-care needs. It was considered to be more person-centred in that open-ended questions allowed people to describe their circumstances in their own words. Its style made it easier to develop rapport with older people and encouraged them to talk and to disclose information beyond the immediate scope of the tool itself. Nevertheless some questions provoked anxiety and assessors needed to use their professional judgement in order to achieve a person-centred, appropriate assessment. MDS-RAI appeared to be more useful in identifying nursing or medical issues. But it did not always reveal a complete picture of the person's care needs and situation. Some nurses suggested that MDS-RAI was useful in circumstances where, in their professional judgement, older people were not being realistic in discussing their needs and their expectations for future care. The findings identify how nurses can use tools to support their assessment skills.

Transitions in care homes: towards relationship‐centred care using the ‘Senses Framework’

Long‐term care in general, and care homes in particular, have never enjoyed high status as a place to live and work. This remains the case. In large part this marginalised position is due to the continued failure to value the contribution that care homes make to supporting frail and vulnerable older people. In order to promote a more positive vision of what can be achieved in care homes, this paper argues for the adoption of a relationship‐centred approach to care. The need for such a model is described, and how it might be applied using the ‘Senses Framework’ is considered. It is argued that adopting such a philosophy will provide a clearer sense of therapeutic direction for staff working in care homes, as well as more explicitly recognising the contribution that residents and relatives can make to creating an ‘enriched environment’ of care.

On paternalism, autonomy and best interests: Telling the (competent) aged-care resident what they want to know

This paper has been derived from a review of literature from a recent qualitative study that explored the meaning of truth-telling within the care provider-aged resident dyad in high-level (nursing home) care of elderly people. In the literature reviewed here, paternalism (as benevolent decision-making in another's best interests) is critically analysed. Autonomy is then described and its function in promoting health is underscored. Furthermore, this paper specifically challenges nurses to consider their capacity to really know another's best interests--particularly in the nursing home. Finally, a very simple recommendation is proposed for determining and managing the (competent) aged-care resident's informational disclosure preferences: ask them.

Determining older people's needs for care by Registered Nurses: the Nursing Needs Assessment Tool

AIMS

This paper reports a study to determine an appropriate framework for assessing older people's needs for nursing within the policy of 'free nursing', and to attempt to identify valid, reliable and usable assessment tool for determining this eligibility.

BACKGROUND

In 2001, the United Kingdom government introduced 'free nursing care' legislation, eligibility for which was subject to a nursing needs assessment. This paper outlines the search for and subsequent development of an appropriate tool for assessing older people's eligibility for free nursing care in Northern Ireland.

METHODS

Following a systematic search of the literature, existing tools used in ascertaining older people's nursing needs were identified. Each tool was systematically assessed in accordance with criteria of validity, reliability, usability, comprehensiveness of assessment and ability to quantify nursing care needs. From the findings, an assessment instrument, Nursing Needs Assessment Tool was subsequently developed and tested. Paired assessments of older people were undertaken independently by assessor dyads and evaluated statistically. Assessors' opinions on the usability of the instrument were sought through a focus group.

RESULTS

One hundred and ten paired assessments were returned (63%). Overall there was 65% agreement between assessors. Kappa scores indicated good levels of inter-rater reliability. Correlation co-efficient measures reinforced these results. Findings from the focus group confirmed the validity, usability and comprehensiveness of the tool.

CONCLUSIONS

The Nursing Needs Assessment Tool is a reliable, valid and usable instrument. This has major implications for the standardization of assessment for older people.

Residents' rights and nurses' ethics in the Australian nursing home

BACKGROUND

This article is derived from a more extensive review of literature for a qualitative study that explored the meaning of truth-telling within the care provider--aged resident dyad in high-level (nursing home) aged care.

AIM

This paper describes through the literature, work practices and the culture of the nursing home as promoting instrumental care, therefore prioritizing doing-for over being-with. The nursing home, starved of time and staff, silences and isolates the aged care resident in an environment that is, arguably, rarely homelike.

CONCLUSION

The appraisal of the nursing home offered here means that a number of residents' rights are at risk and care providers (notably registered nurses and the personal care assistants) risk contravening the Code of Ethics for Nurses in Australia.

Beyond person-centred care: a new vision for gerontological nursing

Currently considerable emphasis is placed on the promotion of person-centred care, which has become a watchword for good practice. This paper takes a constructively critical look at some of the assumptions underpinning person-centredness, and suggests that a relationship-centred approach to care might be more appropriate. A framework describing the potential dimensions of relationship-centred care is provided, and implications for further development are considered.

Care and the older person with cancer

Care of older people with cancer has received relatively little attention in the literature and this area of caring practice has yet to be firmly established in professional discourse. References to the increasing proportion of older people in the population are common, as are references to the problems associated with old age, whether these are seen as medical, or as inevitable consequences of natural processes. Health care for older people has sometimes been reported to be routinized or basic, and as taking little account of individual perspectives, and the 'discourse of senescence' represents a tendency to understand old age and the aged body in terms of degeneration and deterioration. Here, it is argued that older people are often portrayed as separate and diminished, and have little control over the definition of themselves as users of health services. This represents a constraint upon the possibilities of caring practice. Divesting ourselves of the 'discourse of senescence' may be a fundamental part of developing caring practice for older people with cancer in the future.

Clinical specialty and organizational features of acute hospital wards

Ward clinical specialty is a variable which has been largely ignored in studies of nursing organization and effectiveness. Analysis of data collected from a nationally representative sample of 83 acute medical, surgical and orthopaedic hospital wards demonstrates that while wards had similar staffing resources, differences exist in the likelihood of adopting a nursing organizational system with devolved authority, in nurses' views of prevailing hierarchical attitudes, and their perceived influence over a range of organizational features of the ward. Medical wards were more likely to have developed organizational practices associated with increasing nursing autonomy.

Mid-range theory building and the nursing theory-practice gap: a respite care case study

Nursing, with its historical roots in practice, has tended to have an uneasy relationship with theory. Whilst the benefits of theory to nursing have been propounded by many commentators, it remains that theory all too rarely informs nursing practice. This paper argues for the development and utilization of mid-range theories as representing a solution to this problem. The advantages of such an approach are illustrated by the application, testing and refinement of Chenitz's theory of relocation to a hospital-based respite care scheme for the frail elderly.