Older people's and relatives' experiences in acute care settings: systematic review and synthesis of qualitative studies

An emergency department transitional care team prevents unnecessary hospitalization of older adults: a mixed methods study

INTRODUCTION

Older adults with acute functional decline may visit emergency departments (EDs) for medical support despite a lack of strict medical urgency. The introduction of transitional care teams (TCT) at the ED has shown promise in reducing avoidable admittances. However, the optimal composition and implementation of TCTs are still poorly defined. We evaluated the effect of TCTs consisting of an elderly care physician (ECP) and transfer nurse versus a transfer nurse only on reducing hospital admissions, as well as the experience of patients and caregivers regarding quality of care.

METHODS

We assessed older adults (≥ 65 years) at the ED with acute functional decline but no medical indication for admission. Data were collected on type and post-ED care, and re-visits were evaluated over a 30-day follow-up period. Semi-structured interviews with stakeholders were based on the Consolidated-Framework-for-Implementation-Research, while patient and caregiver experiences were collected through open-ended interviews.

RESULTS

Among older adults (N = 821) evaluated by the TCT, ECP and transfer nurse prevented unnecessary hospitalization at the same rate (81.2%) versus a transfer nurse alone (79.5%). ED re-visits were 15.6% (ECP and transfer nurse) versus 13.5%. The interviews highlighted the added value of an ECP, which consisted of better staff awareness, knowledge transfer and networking with external organizations. The TCT intervention in general was broadly supported, but adaptability was regarded as an important prerequisite.

CONCLUSION

Regardless of composition, a TCT can prevent unnecessary hospitalization of older adults without increasing ED re-visiting rates, while the addition of an ECP has a favourable impact on patient and professional experiences.

Patient and Medical Unit Staff Experiences of Proactive and Integrated Consultation-Liaison Psychiatry in The HOME Study: A Qualitative Investigation

BACKGROUND

Consultation-liaison (C-L) psychiatry services aim to help general hospital staff provide better care for their patients. Recently, many inpatient C-L psychiatry services have adopted proactive and integrated approaches to achieve this aim. Despite these developments, there have been no interview-based studies of patients' and staff members' experiences of the new approaches.

OBJECTIVE

To gain an in-depth understanding of patients' and medical unit staff members' experiences of a proactive and integrated C-L psychiatry service for older medical inpatients (Proactive Integrated C-L Psychiatry [PICLP]).

METHODS

We conducted an interview-based qualitative study with thematic analysis. The participants were patients and staff who had experienced PICLP during The HOME Study, a randomized trial that evaluated PICLP in 24 medical units of three UK general hospitals.

RESULTS

We conducted 97 interviews: 43 with patients or their proxies (family members who were interviewed on behalf of patients with significant cognitive impairment) and 54 with staff members of all relevant disciplines. Patients and staff both described how PICLP was a helpful addition to medical care and discharge planning. It enhanced the medical unit team's ability to address psychological, psychiatric, and social needs and provide patient-centered care. They welcomed proactive biopsychosocial assessments and the broader perspective that these offered on patients' complex problems. They also valued the integration of C-L psychiatrists into the unit teams and their daily contact with them. For patients, it fostered a therapeutic relationship and helped them to be more engaged in decisions about their medical care and discharge planning. For staff, it enabled ready access to psychiatric expertise and training opportunities. The few reported experiences of PICLP being unhelpful were mainly about the greater number of clinicians involved in patients' care and a lack of clarity about professional roles in the integrated team.

CONCLUSIONS

We found that older inpatients and medical unit staff experienced PICLP as both acceptable and generally helpful. Our findings add to the existing evidence for the benefits of proactive and integrated C-L psychiatry services.

Understanding family carer experiences and perceptions of engagement in delirium prevention and care for adults in hospital: Qualitative systematic review

AIM

To identify, describe and synthesise what is known about family carers' experiences and perspectives of engagement in delirium prevention and care for adults in hospital.

DESIGN

Systematic review and synthesis of qualitative evidence.

DATA SOURCES

Comprehensive literature search within PubMed, CINAHL, EMBASE, Scopus, Cochrane Central and PsycInfo databases to August 2022. Peer reviewed original qualitative research published in English.

METHODS

Data were extracted using Covidence systematic review software. Methodological quality was reviewed against the Critical Appraisal Skills Program (CASP) Qualitative Checklist. Thematic synthesis was used to develop analytical themes. Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) framework was applied to findings.

RESULTS

Of 3429 records identified, 29 met criteria for final inclusion. Studies included a range of settings (intensive care, medical and surgical wards) and family carer types (spouse, daughter, parent and friend). Three primary themes Shared Caregiving, Partnership and Support, Communication for Shared Understanding and three cross-cutting contextual themes Care Transitions, Family Carer Context and Hospital Context were identified. Family carers have mixed experiences of involvement in delirium care and prevention. Family carer engagement in care impacted perceptions of care quality and their own self-efficacy. Where person-centred care expectations were not met, some family carers adopted compensatory or care contingency strategies. Information sharing and timely support from hospital staff who understood the carer context supported carer involvement. Supportive physical environments and addressing power imbalances allowed greater engagement.

CONCLUSION

Family carers often wish to be involved in delirium prevention and care, but need to be recognised as individuals, listened to, informed and supported to optimise their contribution.

IMPACT

The review findings can guide health professional and decision makers to optimise family carer involvement in delirium care programs.

PROTOCOL REGISTRATION

PROSPERO [CRD42020221854].

REPORTING

ENTREQ. No Patient or Public Contribution.

Stakeholders' experiences of comprehensive geriatric assessment in an inpatient hospital setting: a qualitative systematic review and meta-ethnography

BACKGROUND

Comprehensive geriatric assessment (CGA) is considered the gold standard approach to improving a range of outcomes for older adults living with frailty admitted to hospital. To date, research has predominantly focused on quantitative syntheses of the international evidence with limited focus on qualitative synthesis of stakeholder perspectives. This review aims to resolve this research gap by identifying and synthesising qualitative studies reporting multiple stakeholders' experiences of inpatient CGA.

METHODS

A systematic search of five electronic databases was conducted. Qualitative or mixed methods studies that included qualitative findings on the experiences of CGA in an inpatient hospital setting from the perspective of healthcare professionals (HCP), older adults, and those important to them were included. The protocol was registered on PROSPERO (Registration: CRD42021283167) and the 10-item Critical Appraisal Skills Programme checklist was used to appraise the methodological quality of included studies. Results were synthesised as a meta-ethnography.

RESULTS

Eleven studies, which reported on the experiences of 153 HCPs, 91 older adults and 57 caregivers were included. The studies dated from 2011 to 2021 and three key themes were identified: (1) HCPs, older adults and caregivers report conflicting views on CGA as a holistic process, (2) most HCPs, but only some older adults and caregivers view CGA goalsetting and care planning as collaborative, and (3) all stakeholders value care continuity during the transition from hospital to home but often fail to achieve it.

CONCLUSION

While HCPs, older adults, and caregivers' values and ambitions related to CGA broadly align, their experiences often differ. The identified themes highlight organisational and relational factors, which positively and negatively influence CGA practices and processes in an inpatient hospital setting.

Values and tensions of a health education program based on evidence-based medicine: a qualitative study

Aim

This study explored how patients, caregivers, clinicians, designers, and funders who worked collaboratively on a health education program experienced its design. The program was based on evidence-based medicine and knowledge transmission.

Subject and methods

Through exploratory qualitative research, the authors conducted 21 semistructured interviews, collected six nonparticipatory observations, and conducted a documentary analysis. Data were analyzed using thematic analysis, producing rich descriptions about the participants’ experiences. The researchers’ interpretations were validated through peer review.

Results

Three themes were revealed by the findings: background, values, and tensions. All participants had a range of assumptions about this experience regarding which evidence-based recommendations should be prioritized and disseminated to patients/caregivers in program implementation. These assumptions were based on participants’ beliefs about how people make evidence-informed decisions, allowing them to take charge of their health. The authors found a gap between these assumptions and the purposes of the educational program.

Conclusion

Although health education programs aim to foster patients’ informed decision making and health empowerment, in our case we found some assumptions that were not in line with the objectives of the educational program. We hypothesize that some gaps in the program design, derived from different assumptions, such as (a) conflicts of particular interests, (b) knowledge gaps about health-disease processes, and (c) power asymmetries between doctors and patients/caregivers, could hinder the goals of health education (e.g., engagement) in the practice of evidence-based medicine.

Sharing decision-making between the older person and the nurse: A scoping review

BACKGROUND

Sharing decision-making is globally recognised as an important concept in healthcare research, policy, education and practice which enhances person-centred care. However, it is becoming increasingly evident shared decision-making has not been successfully translated into everyday healthcare practice. Sharing decision-making has strong links with person-centred practice. Core to person-centredness and shared decision making, is the need to recognise that as we age, greater reliance is placed on emotion and life experience to inform decision making processes. With the world's ageing population, older persons facing more complex decisions and transitions of care, it is more important than ever it is understood how shared decision-making occurs.

OBJECTIVES

This scoping literature review aims to find out how sharing decision making between nurses and older persons in healthcare settings is understood and presented in published literature.

METHODS

This scoping review utilised the Arksey and O'Malley methodological framework, advanced by Levac et al. Electronic databases and grey literature were searched, returning 362 records which were examined against defined inclusion criteria. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

RESULTS

Twenty-two records met inclusion criteria for the review. Results indicate while shared decision-making is included in research, education and policy literature, it has not been effectively translated to inform practice and the relationship between a nurse and an older person. The records lack definitions of shared decision-making and theoretical or philosophical underpinnings. There is also no consideration of emotion and life experience in decision-making and how nurses 'do' shared decision-making with older persons.

CONCLUSIONS

The findings demonstrate sharing decision-making between nurses and older persons is not well understood in the literature, and therefore is not translated into nursing practice. Further research is needed.

Older patients' perceptions of the quality of acute cancer care: An integrative review-A mixed-method approach

AIM

This integrative review aimed to describe the perceptions of the quality of care of older patients (aged 65 and above) living with cancer in acute-care settings.

METHODS

We identified relevant research suitable for inclusion criteria through systematic searches of the PubMed®, EBSCOhost Academic Search Premier®, Scopus® and Web of Science® databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework and the Synthesis Without Meta-analysis (SWiM) guidelines were used to conduct the research and report the results. The quality of the studies was evaluated using the modified Critical Skills Appraisal Programme (CASP) checklist.

RESULTS

A total of 24 studies met the inclusion criteria. The data analysis revealed that care quality could be described through three distinct themes: individuality, a sense of security and respectful encounters.

CONCLUSION

The perceptions of older people living with cancer regarding the quality of acute care have not been extensively covered in the literature. Health- and age-related challenges, patients' overall life situation, clear, realistic information about care and the future and respect during encounters should be given attention.

IMPLICATIONS FOR PRACTICE

Patient-centred and tailored care, considering the heterogeneity of the population and support for independence, is needed.

Reducing delayed transfer of care in older people: A qualitative study of barriers and facilitators to shorter hospital stays

INTRODUCTION

Growing numbers of older patients occupy hospital beds despite being 'medically fit' for discharge. These Delayed Transfers of Care amplify inefficiencies in care and can cause harm. Delayed transfer because of family or patient choice is common; yet, research on patient and family perspectives is scarce. To identify barriers to, and facilitators of, shorter hospital stays, we sought to understand older people's and caregivers' thoughts and feelings about the benefits and harms of being in hospital and the decisions made at discharge.

METHODS

A multimethod qualitative study was carried out. Content analysis was carried out of older people's experiences of health or care services submitted to the Care Opinion online website, followed by telephone and video interviews with older people and family members of older people experiencing a hospital stay in the previous 12 months.

RESULTS

Online accounts provide insight into how care was organized for older people in the hospital, including deficiencies in care organization, the discharge process and communication, as well as how care was experienced by older people and family members. Interview-generated themes included shared meanings of hospitalization and discharge experiences and the context of discharge decisions including failure in communication systems, unwarranted variation and lack of confidence in care and lack of preparation for ongoing care.

CONCLUSION

Poor quality and availability of information, and poor communication, inhibit effective transfer of care. Communication is fundamental to patient-centred care and even more important in discharge models characterized by limited assessments and quicker discharge. Interventions at the service level and targeted patient information about what to expect in discharge assessments and after discharge could help to address poor communication and support for improving discharge of older people from hospital.

PATIENT OR PUBLIC CONTRIBUTION

The Frailty Oversight Group, a small group of older people providing oversight of the Community Aging Research 75+ study, provided feedback on the research topic and level of interest, the draft data collection tools and the feasibility of collecting data with older people during the COVID-19 pandemic. The group also reviewed preliminary findings and provided feedback on our interpretation.

'Localism and intimacy, and… other rather imponderable reasons of that sort': A qualitative study of patient experience of community hospitals in England

Debates over the value and contribution of community hospitals are hampered by a lack of empirical assessment of the experience of patients using these services. This paper presents findings from a study which included a focus on patient and family-carer experiences of community hospitals in England. We adopted a qualitative design involving nine case study hospitals. Data collection included interviews with patients (n = 60), carers (n = 28) and staff (n = 89). Through patients and carers highlighting the value of community hospitals feeling 'close to home', providing holistic and personalised care and supporting them through difficult transitions, the study confirms the importance of functional and interpersonal aspects of care, while also highlighting the importance of social and psychological aspects. These included having family, friends and the community close, maintaining social connections during periods of hospital treatment, and feeling less anonymous and anxious when attending the hospital due to the high levels of familiarity and connectedness. Although the experiences uncovered in this study were not uniformly positive, patients and carers placed a high overall value on the care provided by community hospitals, often arguing that these were distinctive when compared to their experiences of using other health and care services. The study suggests the need to weigh the full range of these dimensions of patient experience-functional, interpersonal, social and psychological-when assessing the role and contribution of community hospitals.

The Upside of Negative Emotions: How Do Older Adults From Different Cultures Challenge Their Self-Growth During the COVID-19 Pandemic?

Background and Objective

The outbreak of Coronavirus Disease 2019 (COVID-19) has raised increased challenges for older adults' personal growth in diverse cultural settings. The aim of this study was to analyze negative emotions and their role on older adults' self-growth in Mexico, Italy, Portugal, and Spain, during the COVID-19 pandemic. For this purpose, a cross-national qualitative research was carried out.

Methods

Data were collected from 338 community-dwelling participants aged 65 years and older, using a semi-structured interview protocol. Older adults were asked about negative emotions that significantly contribute to their self-growth during the COVID-19 pandemic. Content analysis was used to identify key themes.

Results

Seven main negative emotions (fear, sadness, anger, grief, boredom, loneliness, and shame) significantly contributed to seven themes of self-growth, across the samples: sharing difficult experiences with others, supportive partner, spiritual practices, engagement with life, generativity, volunteering activities, and intimacy and sexual satisfaction. Sharing difficult experiences with others was most pertinent to Mexican (13.9%) and to Italian (3.0%) participants, and a supportive partner to Portuguese (12.1%), and to Spanish participants (6.5%).

Conclusion

The findings of this study indicate that negative emotions during the COVID-19 pandemic contributed to their older adults' self-growth. This study highlighted the cultural diversity of experiences during the pandemics and underlined the upside of negative emotions and its relation to older adults' self-growth during this period.

Coproducing and Implementing Person-Centered Key Performance Indicators in Ambulatory Cancer Nursing

BACKGROUND

Policy advocates person-centered healthcare for people living with cancer. Although nurses and patients alike recognize that a good care experience cannot be measured solely by clinical outcomes, the difficulty in finding indicators that measure the delivery of effective person-centered care remains a challenge.

OBJECTIVE

The aim of this study was to explore the impact of a coproduced implementation project using the person-centered nursing key performance indicators to support the development of person-centered practice across ambulatory chemotherapy units.

METHODS

The study adopted an evaluation approach derived from work of the Medical Research Council. A mobile app was used to collect and analyze 3 cycles of data using 4 measurement tools, with the aim of informing quality improvement activities. Six implementation teams were recruited from chemotherapy units across a region in the United Kingdom. Qualitative interviews were used to evaluate the experience of participants.

RESULTS

Data analysis revealed 4 themes: building relationships that nurture the care experience, inspiring nursing staff to flourish, shaping practice and service changes through the nature of the conversations, and becoming person-centered through coproduction.

CONCLUSION

This study provides evidence of the value of implementing these person-centered key performance indicators using a model of coproduction in cancer nursing. The data generated by the key performance indicators offer valuable feedback to nurses that can inform the development of person-centered practice and contribute to an enhanced patient experience.

IMPLICATIONS FOR PRACTICE

This study provides an innovative and transferable approach for implementing relevant and appropriate key performance indicators within cancer nursing, which can contribute to developing person-centered cultures.

A Psychometric Evaluation of the Family Collaboration Scale and an Investigation of How the Close Family of Frail Older Patients Perceive the Collaboration with Healthcare Professionals on Acute Medical Wards at Hospitals in Sweden

The inclusion of family members in the acute care of older persons with complex needs results in better coordination of care and reduces the frequency and/or duration of rehospitalisation. Therefore, healthcare professionals need a tool to assess the collaboration with family members on acute hospital wards. The aims were to test the psychometric properties of the Swedish version of the Family Collaboration Scale (FCS), to investigate family members' perception of collaboration with healthcare professionals on acute medical wards in Sweden and to compare the data with the corresponding Danish results. Three hundred and sixty family members of frail patients aged 65 or older from 13 acute medical wards answered the FCS questionnaire. In addition to descriptive statistics, psychometric methods were applied. The internal consistency of the Swedish version of the FCS was excellent, and confirmatory factor analysis revealed that its factor structure was equivalent to that of the original Danish FCS. The respondents' ratings indicated better perceived collaboration than in the Danish case. Older age than 60 was associated with worse collaboration with healthcare professionals regarding Influence on discharge than younger respondents. Those with compulsory and health or nursing education showed better collaboration. The Swedish version of the FCS should be further evaluated for its retest reliability and as an outcome measure in intervention studies.

Individualised Care Scale-Nurse: Construct validity and internal consistency of the Spanish version

BACKGROUND

Individualising the provided care is mandatory in nursing and is essential in clinical practice. Therefore, there is a need to develop accurate instruments to evaluate the quality of care. Moreover, there is no validated instrument to assess nurses' views of individualised care in Spanish-speaking countries.

AIM

To assess the construct validity and internal consistency of the Spanish version of the Individualised Care Scale-Nurse.

METHODS

A cross-sectional study including 108 nursing professionals (40.84 ± 9.51 years old, 86.1% female) was used to validate the Spanish Individualised Care Scale-Nurse version. A forward-back translation method with an expert panel and a cross-sectional study was used for transcultural adaptation and psychometric validation purposes. Psychometric properties of feasibility, reliability and validity were assessed. Construct validity was examined through a confirmatory factor analysis and fit indices of the overall model were computed. Internal consistency was explored through McDonald's omega and Cronbach's alpha coefficients among other correlation measures.

RESULTS

The back-translation concluded both Spanish and English Individualised Care Scale-Nurse versions to be equivalent. The original structure of the Individualised Care Scale-Nurse was verified in the Spanish version through the confirmatory factor analysis (factor loadings >0.3; acceptable fit indices: SRMR ≈ 0.08, CFI ≈ 0.9, RMSEA ≈ 0.09 after posteriori modifications). McDonald's omega exceeded 0.7 for both subscales and complete scales revealing an adequate internal consistency.

CONCLUSIONS

The Spanish version of the Individualised Care Scale-Nurse has exhibited good properties of homogeneity and construct validity for its use in practice and research in health care systems.

Engaging in resuscitation status conversations in psychiatry: A qualitative study of nurses' perspectives

WHAT IS KNOWN ON THE SUBJECT?: Discussion and documentation of a patient's resuscitation status are essential aspects of any hospital admission, and yet, they seldomly occur in psychiatry. Nurses play an important role in resuscitation status determination by being an information broker, supporter and advocate. Persons with mental illness may be competent to engage in the determination of their resuscitation status and deserve the same respect and autonomy as other patients during this process. There are no published qualitative studies exploring healthcare providers experiences in initiating resuscitation status conversations in the psychiatric setting. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: An in-depth qualitative understanding of the complexity of resuscitation status determination in psychiatry. The shared experiences of nurses enacting their role in resuscitation status determination with patients admitted to psychiatry. The challenges of implementing a 'one-size fits all' approach to resuscitation status policies, and the ways in which depression and/or suicidal ideation influence the process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Role clarity and improved communication between providers about resuscitation status determination in psychiatry are needed. Hospital policies for resuscitation status determination must account for the psychiatric context to ensure patients' goals of care are known and upheld. Nurses working in psychiatry should initiate and more readily engage in resuscitation status conversations. ABSTRACT: Introduction Patients with mental illness experience stigma and marginalization, which affects the quality of their health care. In most settings, end-of-life decisions, including goals of care, must be discussed with all patients upon hospital admission, including determining cardiopulmonary resuscitation preferences in the event of a medical emergency. Despite this requirement, these conversations do not routinely occur in inpatient psychiatry. By default, patients become a 'full code status', mandating life-sustaining interventions. Aim To explore how and why resuscitation status conversations occur, or do not occur, in inpatient psychiatry from the perspectives of healthcare providers. Method Qualitative descriptive study using focus groups with nurses working in psychiatry. Results Nurses' experiences with initiating and engaging in resuscitation status conversations related to Working in Psychiatry, which represents the current practices and the participants' views of the nursing role; Caring for Psychiatric Patients, which describes how fluctuating competency and suicidality influence determination; and The Influence of Physical Health Status, which details how differences in physical health status affect how healthcare providers engage in resuscitation status determination. Discussion Although the importance of completing resuscitation status conversations with patients admitted to psychiatry was expressed by participants, they seldomly occur. There is ambiguity about when and how to determine patient wishes. Implications for practice Tailored strategies are needed to ensure patients' rights to self-determination are upheld when they are admitted to psychiatry. Nurses working in this setting would benefit from education, training and support to adequately initiate and engage in these conversations.

Perceptions of Care Quality during an Acute Hospital Stay for Persons with Dementia and Family/Carers

OBJECTIVES

to report on acute hospital care experiences for persons with dementia and family/carers in a pilot study (PiP) of person-centred care compared with usual care.

METHODS

participants were recruited from one acute aged care ward and one mixed medical/surgical ward. One-on-one interviews occurred soon after discharge using a semi-structured interview guide framed by person-centred principles whereby the person is: V-valued; I-treated as an individual; P-perceived as having a unique identity; and S-supported socially and psychologically. Data were analysed deductively with reference to these a priori principles.

RESULTS

11 consented persons with dementia and 36 family/carers participated. A total of eight core VIPS concepts were derived from the data. While many occasions of person-centred care occurred, there was variability in staff expertise, interest and aptitude for dementia care work. Neglect of person-centred principles more frequently occurred for the usual care group, where staff failed to place the person and their family/carer at the centre of service.

CONCLUSIONS

person-centred services for persons with dementia requires that hospital executive equip staff with the relevant knowledge, skills and support to adhere to person-centred care guidelines. Hospitals must address workplace cultures and procedures that favour organisational systems over person-centred services.

What matters to people aged 80 and over regarding ambulatory care? A systematic review and meta-synthesis of qualitative studies

The growing percentage of the population aged 80 and over is challenging for healthcare systems, as frailty and other complex health issues are common in this age group. In order to provide patient-centered ambulatory healthcare, their preferences and expectations need to be explored. Therefore, the aim of this study was to systematically search for and synthesize qualitative evidence on how people aged 80 and over believe ambulatory healthcare (medical and nursing care) should be delivered to them. Medline, PsycINFO, CINAHL, Web of Science Core Collection and Google Scholar were searched for full research reports of qualitative studies focusing on the preferences, wishes, needs, expectations and experiences of people aged 80 and over regarding ambulatory medical and nursing care. The results were screened by two independent reviewers using a two-step approach. The included studies were meta-synthesized using Thomas and Harden’s ‘thematic synthesis’ approach in order to gain a new, second-order interpretation of the findings of the primary studies. In the intermediate synthesis step, 14 aspects of healthcare structures and care relationships were identified as relevant. Based on these, three underlying wishes were found: feeling safe, feeling like a meaningful human being, and maintaining control and independence. The results of this review are in line with other research, such as reviews focusing on the preferences of the younger age group (65–80). However, the importance of aspects of care relationships as an integral part of favorable ambulatory healthcare and the wish to be strengthened as a meaningful human being are emphasized more strongly.

Informal caregivers' quality of life and management strategies following the transformation of their cancer caregiving role: A qualitative systematic review

Objectives

Globally, informal caregivers caring for cancer patients meet challenges within their caregiving role, which significantly influence their quality of life. This qualitative systematic review aimed to analyze how cancer caregiving influence the quality of life of informal caregivers and the management strategies of informal caregivers for their role as cancer caregivers.

Methods

Following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement, Wanfang database, the China National Knowledge Infrastructure (CNKI), CINAHL, MEDLINE, PubMed, Cochrane Library, PsycARTICLES and PsycINFO, and grey literature in English and Chinese from 1 May 2009 to 31 December 2019 were searched. Quality of included studies was assessed by the Critical Appraisal Skills Programme (2018) Qualitative Checklist and thematic synthesis was conducted.

Results

Of the 8,945 studies identified, 6 studies met the inclusion criteria. One analytical theme relating to the QoL of informal caregivers following cancer caregiving was identified: "challenges of caregiving". In terms of the management strategies to the role of cancer caregivers, two analytical themes were identified: "self-adjustment" and "seeking for formal and informal support".

Conclusions

Cancer caregiving influences informal caregivers' QoL significantly and informal caregivers develop diverse coping strategies to deal with the difficulties occurred while balancing the relationship between their own lives and caregiving. However, professional and policy support remain inadequate for informal caregivers that require the need for improvement in terms of health care professionals and policymakers.

About me but without me? Older adult's perspectives on interpersonal communication during care transitions from hospital to seniors' residence

BACKGROUND

Transitions in care can be stressful for an older adult. While communication protocols between health care professionals during transitions have been thoroughly studied, there is a need to better understand how older adults transitioning perceive interpersonal communication. Relying on Communication Accommodation Theory, the goal of this study is to explore Canadian older adults' perspectives of interpersonal communication during care transition from acute care in a hospital to a residence and assess if and how communication could improve health and well-being. Using a longitudinal exploratory design, 13 older adults (M_Age = 84 years) transitioning from acute hospital care to a residence were interviewed at three time points: (1) in the hospital, (2) upon arriving at the residence and (3) in the residence, 2-3 months later. A total of 30 interviews were analyzed using thematic content analysis. Five main themes emerged from participants' descriptions of their transition and communication with health care professionals: (1) Interpersonal Communication or Information, (2) Gratefulness & Burden, (3) Acceptance & Resilience, (4) Maintaining Autonomy and (5), Level of satisfaction. Most participants described being informed rather than being an active participant during the transition process. Most also accepted the transition and tried to reduce the burden on family notably by finding ways to maintain autonomy. A major finding of this study is the lack of interpersonal communication taking place during the transition process, which increased older adults' feeling of uncertainty about the future. Many were unclear on why this move was taking place and where they were going. Providing a space for older adults to communicate their perspectives could attenuate the negative outcomes stemming from stressful care transitions.

Qualitative analysis of challenges and enablers to providing age friendly hospital care in an Australian health system

BACKGROUND

With ageing global populations, hospitals need to adapt to ensure high quality hospital care for older inpatients. Age friendly hospitals (AFH) aim to establish systems and evidence-based practices which support high quality care for older people, but many of these practices remain poorly implemented. This study aimed to understand barriers and enablers to implementing AFH from the perspective of key stakeholders working within an Australian academic health system.

METHODS

In this interpretive phenomenenological study, open-ended interviews were conducted with experienced clinicians, managers, academics and consumer representatives who had peer-recognised interest in improving care of older people in hospital. Initial coding was guided by the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Coding and charting was cross checked by three researchers, and themes validated by an expert reference group. Reporting was guided by COREQ guidelines.

RESULTS

Twenty interviews were completed (8 clinicians, 7 academics, 4 clinical managers, 1 consumer representative). Key elements of AFH were that older people and their families are recognized and valued in care; skilled compassionate staff work in effective teams; and care models and environments support older people across the system. Valuing care of older people underpinned three other key enablers: empowering local leadership, investing in implementation and monitoring, and training and supporting a skilled workforce.

CONCLUSIONS

Progress towards AFH will require collaborative action from health system managers, clinicians, consumer representatives, policy makers and academic organisations, and reframing the value of caring for older people in hospital.

Family caregivers' perceived level of collaboration with hospital nurses: A cross-sectional study

Aim

To describe the extent of perceived collaboration between family caregivers of older persons and hospital nurses.

Background

Collaboration between hospital nurses and family caregivers is of increasing importance in older patient's care. Research lacks a specific focus on family caregiver's collaboration with nurses.

Method

Using a cross‐sectional design, 302 caregivers of older patients (≥70 years) completed the 20‐item Family Collaboration Scale with the subscales: trust in nursing care, accessible nurse and influence on decisions. Data were analysed with descriptive statistics and bivariate correlations.

Results

Family caregivers rated their level of trust in nurses and nurses' accessibility higher than the level of their influence on decisions. Family caregivers who had more contact with nurses perceived higher levels of influence on decisions (p ≤ .001) and overall collaboration (p ≤ .001).

Conclusion

Family caregivers' collaboration with nurses can be improved, especially in recognizing and exploiting family caregivers as partner in the care for older hospitalized persons and regarding their level of influence on decisions.

Implications for Nursing Management

Insight into family caregivers' collaboration with nurses will help nurse managers to jointly develop policy with nurses on how to organise more family caregivers' involvement in the standard care for older persons.

Admiral Nursing-A Model of Specialist Dementia Care in Acute Hospitals

Introduction

The rising prevalence of dementia has led to increased numbers of people with dementia being admitted to acute hospitals. This demand is set to continue due to an increasingly older population who are likely to have higher levels of dependency, dementia, and comorbidity. If admitted to the hospital, people with dementia are at higher risk of poor outcomes during and following a hospital admission. Yet, there remains a significant lack of specialist support within acute hospitals to support people with dementia, their families and hospital staff.

Methods

Admiral Nurses are specialists that work with families affected by dementia and provide consultancy and support to health and social care colleagues to improve the delivery of evidenced based dementia care. Historically, Admiral Nurses have predominantly been based in community settings. In response to the increasing fragmentation of services across the dementia trajectory, the Admiral Nurse model is evolving and adapting to meet the complex needs of families impacted upon by dementia inclusive of acute hospital care.

Results

The Admiral Nurse acute hospital model provides specialist interventions which improve staff confidence and competence and enables positive change by improving skills and knowledge in the provision of person-centred dementia care. The role has the capacity to address some of the barriers to delivering person centred dementia care in the acute hospital and contribute to improvements across the hospital both as a result of direct interventions or influencing the practice of others.

Conclusion

Improving services for people with dementia and their families requires a whole system approach to enable care coordination and service integration, this must include acute hospital care. The increasing numbers of people with dementia in hospitals, and the detrimental effects of admission, make providing equitable, consistent, safe, quality care and support to people with dementia and their families a national priority requiring immediate investment. The inclusion of Admiral Nursing within acute hospital services supports service and quality improvement which positively impacts upon the experience and outcomes for families affected by dementia.

Parents and carers' experiences of seeking health information and support online for long-term physical childhood conditions: a systematic review and thematic synthesis of qualitative research

OBJECTIVE

To systematically review and synthesise qualitative research exploring parents/carers' experiences of seeking online information and support for long-term physical childhood conditions.

DESIGN

Systematic review and thematic synthesis of qualitative research.

DATA SOURCES

Medline, CINAHL, Embase, PsycINFO and the International Bibliography of the Social Sciences were searched from inception to September 2019. We used thematic synthesis to analyse findings.

ELIGIBILITY CRITERIA

Primary research papers presenting qualitative data collection and analysis, focusing on parents/carers' experiences of seeking health information and support from online resources for long-term physical childhood health conditions. No language restrictions were placed.

RESULTS

23 studies from seven countries met inclusion criteria and were included in the synthesis. Included studies presented data collected through interviews/focus groups with 559 parents/carers; free-text surveys and essays with 26 parents/carers and 2407 messages from online support groups. Parents/carers developed a variety of strategies to obtain information and support online, based on personal preferences, appraisal of trustworthiness, perceived needs and previous experiences online. Many parents sought the benefits of online information and support, which included reassurance and validation from online communities, and feeling they had greater knowledge about their children's conditions. Some concerns and perceived risks were discussed, which often stemmed from prior unsatisfactory experiences of seeking information and support online, consultations with health professionals and seeing distressing stories online.

CONCLUSION

Most parents/carers were successful in obtaining information and support online. Many continued to share experiences with other parents/carers online. The need for information was particularly apparent early after diagnosis of the condition, whereas the need for peer support continued. The potential concerns and perceived risks with information and support online were especially apparent among parents/carers of children with life-limiting long-term conditions. Findings may be useful for health professionals to facilitate discussions regarding use of online resources, and researchers designing online health resources for parents/carers.

PROSPERO REGISTRATION NUMBER

CRD42018096009.

The importance of families in nursing care: attitudes of nurses in the Netherlands

INTRODUCTION

Positive attitudes towards family involvement in nursing care are essential for improving the involvement of and collaboration with patients' families. The aim of this study is to explore nurses' attitudes towards the importance of families in nursing care.

METHOD

Using a cross-sectional design, hospital and homecare nurses completed the Families Importance to Nursing Care (FINC-NA) scale, Dutch language version, consisting of four subscales. Data were analysed using descriptive statistics and regression analyses.

RESULTS

A total of 426 hospital and homecare nurses were eligible for analysis (mean (SD) age 42 years (13), 93% female). The mean (SD) attitude of nurses was 63.8 (12) (100-point scale) on the FINC-NA. Less than half of the nurses (44%) considered family as a collaboration partner, and 37% of nurses stated that families should be invited to actively participate in planning patient care. The nurses' attitudes were explained by years of work experience in nursing, work setting and existing policy regarding families in patient care.

CONCLUSION

This study identifies areas of improvement regarding to nurses' attitudes towards the importance of families in nursing care in order to establish a more family-focused approach in nursing care. Nursing policies should facilitate working with families as part of regular nursing processes. Furthermore, the importance of family involvement in care should be an explicit matter of concern for nursing educational institutions and for policy making within healthcare organisations.

Characteristic patterns of emergency ambulance assignments for older adults compared with adults requiring emergency care at home in Sweden: a total population study

BACKGROUND

Since the vast majority of older adults in Sweden live in their private homes throughout life, the emergency medical services need to adapt accordingly. Hence, we aimed to describe characteristic patterns of dyadic staffed emergency ambulance assignments for older adults aged > 70 years compared with adults aged 18-69 years requiring emergency care at home in Sweden.

METHODS

A descriptive retrospective study was performed using anonymized registry data from the emergency medical services in a region of Sweden during 2017-2018. One-sample χ² test, one-way analysis of variance, and binary logistic regression models were used for investigating group differences. Variables for analysis were age, gender, clinical assessments, on-scene time, priority levels, result of response, and temporal patterns.

RESULTS

Of all included emergency ambulance assignments (n = 28,533), 59.9% involved older adults, of which 53.8% were women. The probability for older adults to receive the highest priority was decreased for both dispatch (p < 0.001, odds ratio [OR] 0.63, 95% confidence interval [CI] 0.59-0.66), and transport priorities (p < 0.001, OR 0.74, 95% CI 0.68-0.80). Older adults were more likely to receive dispatch priority levels 2 (p < 0.001, OR 1.48, 95% CI 1.40-1.56), and 3 (p < 0.001, OR 1.73, 95% CI 1.46-2.06). The older adults were similarly more likely to receive transport priority level 3 (p < 0.001, OR 1.40, 95% CI 1.28-1.52) compared with adults. Age had a small but additive effect in relation to on-scene time (p < 0.001, R² = 0.01, F = 53.82). Distinguishing initial clinical assessments for older adults were circulatory, respiratory, trauma, infection, and nonspecific assessments. Emergency ambulance assignments for older adults were more frequently occurring on Mondays (p < 0.001, χ² = 232.56), and in the 08:00-11:59 interval (p < 0.001, χ² = 1224.08).

CONCLUSION

The issues of the lower priority level preponderance, and the decreased probability for receiving the highest priority warrant further attention in future research and clinical practice.

In-PREP: a new learning design framework and methodology applied to a relational care training intervention for healthcare assistants

BACKGROUND

'Older People's Shoes' is a training intervention designed for healthcare assistants (HCAs) to improve the relational care of older people in hospital. The intervention formed part of a broader evaluation, in this paper we describe its development from a learning design and methodological perspective.

METHODS

Learning theory and an instructional design model were key components of the In-PREP (Input, Process, Review and Evaluation, Product) development methodology used in the design of the 'Older People's Shoes' training intervention to improve the delivery of relational care by front-line hospital staff. An expert panel, current evidence, and pedagogical theory were used to co-design a training programme tailored to a challenging work environment and taking account of trainees' diverse educational experience. Peer review and process evaluation were built into the development model.

RESULTS

In-PREP provided a methodological scaffold for producing evidence-based, peer-reviewed, co-designed training. The product, 'Older People's Shoes', involved a one-day Train the Trainers event, followed by delivery of a two-day, face-to-face training programme by the trainers, with accompanying handbooks underpinned by a range of digital resources. Evaluation found the approach met learner needs, was applicable in practice and won approval from trainers.

DISCUSSION

In-PREP enables high quality learning content, alignment with learner needs and a product that is relevant, practical and straightforward to implement.

Understanding and improving experiences of care in hospital for people living with dementia, their carers and staff: three systematic reviews

Background

Being in hospital can be particularly confusing and challenging not only for people living with dementia, but also for their carers and the staff who care for them. Improving the experience of care for people living with dementia in hospital has been recognised as a priority.

Objectives

To understand the experience of care in hospital for people living with dementia, their carers and the staff who care for them and to assess what we know about improving the experience of care.

Review methods

We undertook three systematic reviews: (1) the experience of care in hospital, (2) the experience of interventions to improve care in hospital and (3) the effectiveness and cost-effectiveness of interventions to improve the experience of care. Reviews 1 and 2 sought primary qualitative studies and were analysed using meta-ethnography. Review 3 sought comparative studies and economic evaluations of interventions to improve experience of care. An interweaving approach to overarching synthesis was used to integrate the findings across the reviews.

Data sources

Sixteen electronic databases were searched. Forwards and backwards citation chasing, author contact and grey literature searches were undertaken. Screening of title and abstracts and full texts was performed by two reviewers independently. A quality appraisal of all included studies was undertaken.

Results

Sixty-three studies (reported in 82 papers) were included in review 1, 14 studies (reported in 16 papers) were included in review 2, and 25 studies (reported in 26 papers) were included in review 3. A synthesis of review 1 studies found that when staff were delivering more person-centred care, people living with dementia, carers and staff all experienced this as better care. The line of argument, which represents the conceptual findings as a whole, was that ‘a change of hospital culture is needed before person-centred care can become routine’. From reviews 2 and 3, there was some evidence of improvements in experience of care from activities, staff training, added capacity and inclusion of carers. In consultation with internal and external stakeholders, the findings from the three reviews and overarching synthesis were developed into 12 DEMENTIA CARE pointers for service change: key institutional and environmental practices and processes that could help improve experience of care for people living with dementia in hospital.

Limitations

Few of the studies explored experience from the perspectives of people living with dementia. The measurement of experience of care across the studies was not consistent. Methodological variability and the small number of intervention studies limited the ability to draw conclusions on effectiveness.

Conclusions

The evidence suggests that, to improve the experience of care in hospital for people living with dementia, a transformation of organisational and ward cultures is needed that supports person-centred care and values the status of dementia care. Changes need to cut across hierarchies and training systems to facilitate working patterns and interactions that enable both physical and emotional care of people living with dementia in hospital. Future research needs to identify how such changes can be implemented, and how they can be maintained in the long term. To do this, well-designed controlled studies with improved reporting of methods and intervention details to elevate the quality of available evidence and facilitate comparisons across different interventions are required.

Study registration

This study is registered as PROSPERO CRD42018086013.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 43. See the NIHR Journals Library website for further project information. Additional funding was provided by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Psychometric properties of the Persian language person-centered climate questionnaire - Patient version (PCQ-P)

Background

Person-centered care is a valuable approach to improve the quality of care of the elderly and is a starting point for maintaining the dignity of people needing care.

Objectives

This study aimed at translation, cultural adaptation, and validation of the Persian version of the Person-centered Climate Questionnaire–Patient questionnaire in elderly patients admitted to the Eastern Guilan hospitals from 2017-2018.

Design

This research was a cross-sectional study. The Persian version of Person-centered Climate Questionnaire –Patient version was completed by 200 older adults admitted to different wards of the hospitals. They were selected through convenient sampling. Data were collected in 5 hospitals affiliated to Guilan University of Medical Sciences, East of Guilan located in the north of Iran, from November 2017 to February 2018.

Methods

This study was carried out in two phases. In the first phase, the original questionnaire with 17 items was translated from English into Persian using Forward-Backward translation method. In the second phase, the psychometric properties of the questionnaire were evaluated using face, content, and construct validity, as well as reliability (internal consistency and stability). Data were analyzed via SPSS software v.16.

Results

The results of exploratory factor analysis (EFA) led to retaining 17 items with three factors of “Safety”, “Hospitality”, and “Everydayness” which explained 47.69% of the total variance. Cronbach's alpha coefficient was calculated for each factor (0.85, 0.70, and 0.64, respectively) as well as the whole instrument (0.85), to ensure internal consistency. Stability was confirmed by calculating the intra-class correlation coefficient as 0.99.

Conclusions

The current study found support for assessing the person-centered climate from the perspective of the elderly patients by using the Persian version of the Person-centered Climate Questionnaire–Patient that has an appropriate cultural adaptation, validity, and reliability.

Effectiveness of an Acute Care for Elders unit at a long-term care facility for frail older patients with COVID-19

The Acute Care for Elders (ACE) is a model of care addressed to reduce the incidence of loss of self-care abilities of older adults occurring during hospitalization for acute illness.

This observational study aimed to describe the effectiveness of an ACE unit at a long-term care facility to prevent functional decline (decrease in the Barthel Index score of >5 points from admission to discharge) in older adults with frailty (Clinical Frailty Scale score ≥5) and symptomatic COVID-19.

Fifty-one patients (mean age: 80.2 + 9.1 years) were included. Twenty-eight (54.9%) were women, with a median Barthel index of 50 (IQR:30–60) and Charlson of 6(IQR: 5–7), and 33 (64.7%) had cognitive impairment.

At discharge, 36(70.6%) patients had no functional decline, 6 (11.7%) were transferred to hospital and 4(7.8%) died.

An ACE unit at a long-term care facility constitutes an alternative to hospital care to prevent hospital-associated disability for frail older patients with COVID-19.

Systems Approach Is Needed for In-Hospital Mobility: A Qualitative Metasynthesis of Patient and Clinician Perspectives

OBJECTIVE

To describe how different key stakeholders (ie, interprofessional clinical care team and patients) perceive their role in promoting in-hospital mobility by systematically synthesizing qualitative literature.

DATA SOURCES

PubMed, Ovid MEDLINE, Ovid PsychInfo, and Cumulative Index to Nursing and Allied Health were searched using terms relevant to mobility, hospitalization, and qualitative research. A total of 510 unique articles were retrieved and screened for eligibility.

STUDY SELECTION

Eligible qualitative studies included stakeholder perspectives on in-hospital mobility, including patients, nursing staff, rehabilitation staff, and physicians. Eleven articles remained after inclusion/exclusion criteria were applied.

DATA EXTRACTION

At least 2 authors independently read, coded, and derived themes from each study. We used a team-based inductive approach to thematic synthesis informed by critical realism and the socioecological model. Reciprocal translation unified convergent and divergent constructs across primary studies. Investigator triangulation enhanced interpretation.

DATA SYNTHESIS

Three primary themes emerged: (1) patient, family, and clinician expectations shape roles in in-hospital mobility; (2) stakeholders' role in mobility depends on hospital environment, infrastructure, culture, and resources; and (3) teamwork creates successful in-hospital mobility, but lack of coordination and cooperation leads to delay in mobilizing. Studies suggested that while mobility is an essential construct in the professional role of clinicians and in the personal identity of patients, the ability of stakeholders to realize their role in mobility is highly dependent on the hospital physical and cultural environment, administrative support, clarity in professional roles, and teamwork.

CONCLUSIONS

Interventions designed to address the problem of low hospital mobility should take a systems approach and consider allocation of resources, clarity around professional responsibilities, and elevation of patient and clinician expectations surrounding mobility.

Older adults experiences with ambulation during a hospital stay: A qualitative study

Older adults often lose their ability to independently ambulate during a hospital stay. Few studies have investigated older adults' experiences with ambulation during hospitalization. The purpose of this study was to understand older adults' perceptions of and experiences with ambulation during a hospital admission. A qualitative study using Inductive Content Analysis was conducted. Community-dwelling older adults (N = 11) were recruited to participant in five focus group meetings each lasting 90 min. All individuals participated in each focus group. Participants described high complexity in deciding whether or not they could ambulate. Six categories were identified: Uncertainty, Restriction Messaging, Non-Welcoming Space, Caring for Nurse and Self, Feeling Isolated, and Presenting Self. This study provides a detailed understanding of older adults' experiences and perceptions of a hospital stay. Findings from this study can serve as a foundation for future interventions to improve older adult patient ambulation during hospitalization.

How Much Is One Life Worth? The Right to Equity Healthcare for Improving Older Patients’ Health Infected by COVID-19

Ageism has a tremendous negative impact on elderly persons and society. Discrimination against the elderly is a driver of health and social inequalities. The COVID-19 pandemic has posed new social and health challenges regarding resource scarcity and shortfalls. Under these difficult circumstances, discourses excluding, and discrimination against, older people have aroused. This article gathers evidence on hospital healthcare experiences of older people infected by COVID-19 during the pandemic outbreak in Spain and it analyzes elements that have positively influenced older patients’ perceived health and well-being. We conducted nine qualitative in-depth interviews in Madrid—one of the regions of Spain most affected by COVID-19—with older people that were hospitalized and recovered from COVID-19, family members of old patients infected with COVID-19, and nurses that attended infected older patients. Findings show the challenging experiences faced by older people who were hospitalized due to COVID-19, on the one hand, and the relevance of transformative aspects related to family relationships, solidarity actions, and humanized care that overcame age discrimination, favoring social and equity healthcare for the elderly on the other hand.

Perspectives about dignity during acute care for older people and their relatives: A qualitative study

AIMS AND OBJECTIVES

The aim of the study was to enhance understanding about dignified care from older peoples' and their carers' perspectives. The information will contribute to the development of a tool to measure older peoples' dignity during hospitalisation.

BACKGROUND

Older people are a vulnerable cohort at risk of loss of dignity during acute hospitalisation arising from environmental, behavioural and patient factors. It is not clear how older people and their relatives define dignified care in acute care settings.

DESIGN

An interpretative descriptive method was used.

METHODS

A purposive sample of older people (at least 65 years) who had been hospitalised in acute care and subsequently transferred to sub-acute care, and their relatives, were invited to participate. The study was undertaken in one sub-acute ward in a regional healthcare organisation in Victoria, Australia. Individual interviews were audio-recorded then transcribed. Data were analysed using thematic content analysis. The COREQ checklist was used to document reporting of the study.

RESULTS

Individual interviews were conducted: 24 patients and 12 relatives. Three main themes were identified: "Involve me in decisions about my care and treatment," "Keep me safe when I am vulnerable" and "Treat me as an individual and with respect." Older people want to be involved in decisions about their care and treatment and to receive adequate, suitable information. They feel vulnerable during hospitalisation and want to feel safe when speaking up about concerns. Individual acknowledgement is an important aspect of dignity.

CONCLUSIONS

Older people and their relatives identified specific elements of care that uphold or threaten dignity during acute hospitalisation. Nurses play a major role in upholding dignity for older people in hospital.

RELEVANCE TO CLINICAL PRACTICE

Clinicians may benefit from systematic dignity-related training. Specific strategies to enhance older persons' dignity, including communication skills training and continence management need to be developed, implemented and evaluated.

Nurses' perceptions of self-management and self-management support of older patients during hospitalization

Four focus group interviews were held with nurses, recruited from eight wards of two general hospitals, to explore nurses' perceptions of self-management and self-management support of older patients during hospitalization. A thematic analyze of the interview transcripts was conducted. Regarding nurses understanding of self-management two perceptions emerged namely 'being self-reliant' and 'being in control'. In terms of their understanding self-management support three perceptions emerged: encouraging patients to perform activities of daily living (ADL); stimulating patient participation; and increasing patients' awareness. We also found seven themes relating to nurses' beliefs regarding older patients' self-management and self-management support during hospitalization. Results indicate that nurses have a limited understanding of self-management and do not fully understand what is expected from them with regards to inpatients' self-management. It is feasible to argue that addressing nurses' beliefs can influence nurses intention and behavior regarding supporting older inpatients' self-management.

Admission Decision-Making in Hospital Emergency Departments: The Role of the Accompanying Person

In resource-stretched emergency departments, people accompanying patients play key roles in patients’ care. This article presents analysis of the ways health professionals and accompanying persons talked about admission decisions and caring roles. The authors used an ethnographic case study design involving participant observation and semi-structured interviews with 13 patients, 17 accompanying persons and 26 health care professionals in four National Health Service hospitals in south-west England. Focused analysis of interactional data revealed that professionals’ standardization of the patient–carer relationship contrasted with accompanying persons’ varied connections with patients. Accompanying persons could directly or obliquely express willingness, ambivalence and resistance to supporting patients’ care. The drive to avoid admissions can lead health professionals to deploy conversational skills to enlist accompanying persons for discharge care without exploring the meanings of their particular relationship with the patients. Taking a relationship-centered approach could improve the attention to accompanying persons as co-producers of health care and participants in decision-making.

A phenomenological-hermeneutic study exploring caring responsibility for a chronically ill, older parent with frailty

Aim

To provide lifeworld insights into experiences of adult children with caring responsibility for an 80+-year-old chronically ill parent with frailty.

Background

Informal care is common in Nordic welfare countries; however, little is known about adult children's experience of caring responsibility in this setting.

Design

A phenomenological-hermeneutic study based on Reflective Lifeworld Research.

Methods

Diaries and semi-structured interviews with 12 adult children.

Results

Caring responsibility is identified as "a condition of life, filled with uncertainty." Three constituents contribute to this phenomenon: (a) balancing love, duty and reciprocity; (b) being the parent's advocate and manager; and (c) experiencing concerns and bodily strain.

Conclusion

Adult children work hard to provide care and enhance the well-being of their parent. Heidegger's concept 'Fürsorge' may help us understand how by showing how caring responsibility means balancing different roles vis-à-vis the parent, one's own life and the health and social systems. Caring responsibility changes the relationship between parent and child.

Older adult experience of care and staffing on hospital and community wards: a cross-sectional study

Background

Recent major concerns about the quality of healthcare delivered to older adults have been linked to inadequate staffing and a lack of patient-centred care. Patient experience is a key component of quality care - yet there has been little research on whether and how staffing levels and staffing types affect satisfaction amongst older adult hospital inpatients. This study aimed to evaluate the association between registered nurse and healthcare assistant staffing levels and satisfaction with care amongst older adult hospital inpatients, and to test whether any positive effect of higher staffing levels is mediated by staff feeling they have more time to care for patients.

Methods

Survey data from 4928 inpatients aged 65 years and older and 2237 medical and nursing staff from 123 acute and community medical wards in England, United Kingdom (UK) was collected through the Royal College of Psychiatrist’s Elder Care Quality Mark. The cross-sectional association between staffing ratios and older adult patient satisfaction, and mediation by staff perceived time to care, was evaluated using multi-level modelling, adjusted for ward type and with a random effect for ward identity.

Results

Higher numbers of patients per healthcare assistant were associated with poorer patient satisfaction (adjusted β = − 0.32, 95% CI − 0.55 to 0.10, p < 0.01), and this was found to be partially mediated by all ward staff reporting less time to care for patients (adjusted β = − 0.10, bias-corrected 95% CI − 1.16 to − 0.02). By contrast, in both unadjusted and adjusted models, the number of patients per registered nurse was not associated with patient satisfaction.

Conclusions

Older adult hospital patients may particularly value the type of care provided by healthcare assistants, such as basic personal care and supportive communication. Additionally, higher availability of healthcare assistants may contribute to all ward staff feeling more able to spend time with patients. However, high availability of registered nurses has been shown in other research to be vital for ensuring quality and safety of patient care. Future research should seek to identify the ideal balance of registered nurses and healthcare assistants for optimising a range of outcomes amongst older adult patients.

"You've got to keep moving, keep going": Understanding older patients' experiences and perceptions of delirium and nonpharmacological delirium prevention strategies in the acute hospital setting

AIMS AND OBJECTIVES

To explore older inpatients' experiences and perceptions of delirium and nonpharmacological delirium prevention strategies (NDPS).

BACKGROUND

Delirium is a distressing and serious complication in hospitalised older adults. NDPS (supporting nutrition, mobility and cognitive participation) have strong supporting evidence. Few studies have explored older inpatients' perspectives of these strategies. This information may assist staff to better support patient participation in NDPS.

DESIGN

Qualitative study using an interpretive descriptive (ID) methodological approach to explore older patient's experience of delirium and NDPS.

METHODS

Structured interviews of inpatients aged over 65 years across 6 medical and surgical wards explored patients' experiences and perceptions of delirium and prevention activities related to nutrition, mobility and cognition; and barriers and enablers to participation. Reporting used COREQ.

RESULTS

Twenty-three participants were included (12 male, 11 reported delirium experience). Participants reported a range of physiological, emotional and psychological responses to delirium, hearing about delirium was different to experiencing it. Most participants were aware of the benefits of maintaining nutrition and hydration, physical activity and cognitive engagement in hospital. Barriers included poor symptom control, inflexible routines and inconsistent communication, whilst enablers included access to equipment, family involvement, staff encouragement and individual goals. These were organised into themes: outlook, feeling well enough, hospital environment, feeling informed and listened to, and support networks.

CONCLUSION

A more patient-centred approach to delirium prevention requires consideration of older people's values, needs, preferences and fit within the hospital environment and routines. Feeling informed, listened to and receiving support from staff and family carers can improve older inpatients' engagement in NPDS to prevent delirium in hospital.

RELEVANCE TO CLINICAL PRACTICE

Nurses are ideally placed to improve patient participation in NDPS through holistic assessment and care, addressing symptoms, providing clear information about delirium and delirium prevention, and facilitating family carer support and patient interactions.

Promotion of mobility among hospitalised older adults: An exploratory study on perceptions of patients, carers and nurses

BACKGROUND

Hospitalisation of an older adult due to acute medical illness can result in adverse events and accelerate loss of independence despite recovery from the illness. Promoting mobility during hospitalisation can help to mitigate the risks of functional decline. Understanding the perspectives on the barriers and the maintenance of mobility is essential in the development of effective strategies.

AIMS

To explore the perceptions of patients and their carers, as well as the nurses on promotion of mobility among hospitalised adult older patients.

METHODS

A qualitative descriptive study design with purposive and convenience sampling approach was undertaken. A total of fourteen patients, six carers and ten nurses from a general medical ward of an acute care tertiary public hospital in Singapore were recruited over the period of November 2017 to February 2018. Face to face semi-structured interviews were conducted and audio-recorded. The interview transcripts were coded and an inductive content analysis approach was adopted to generate categories of sub-themes and themes through the open coding process.

RESULTS

Four main themes were generated: (1) perceived and induced fear of falling; (2) challenges in initiation of mobility; (3) influence of premorbid status and physical condition on activity level; and (4) strategies to promote mobility.

CONCLUSION

Recognition of the importance of mobility as well as the detrimental effects of prolonged bed rest during hospitalization is an essential first step toward developing successful interventions to promote mobility in the Asian context. Improvements need to be made to help overcome the various barriers and challenges in the mobilization of the older patients in the acute care settings. Nurses and other members of the care team can help to increase the confidence of patients and among family carers (in providing assistance during mobility) by role modelling and provision of walking aids as well as risk-based education.

Identifying features associated with higher-quality hospital care and shorter length of admission for people with dementia: a mixed-methods study

Background

Concerns have repeatedly been expressed about the quality of inpatient care that people with dementia receive. Policies and practices have been introduced that aim to improve this, but their impact is unclear.

Aims

To identify which aspects of the organisation and delivery of acute inpatient services for people with dementia are associated with higher-quality care and shorter length of stay.

Design

Mixed-methods study combining a secondary analysis of data from the third National Audit of Dementia (2016/17) and a nested qualitative exploration of the context, mechanism and outcomes of acute care for people with dementia.

Setting

Quantitative data from 200 general hospitals in England and Wales and qualitative data from six general hospitals in England that were purposively selected based on their performance in the audit.

Participants

Quantitative data from clinical records of 10,106 people with dementia who had an admission to hospital lasting ≥ 72 hours and 4688 carers who took part in a cross-sectional survey of carer experience. Qualitative data from interviews with 56 hospital staff and seven carers of people with dementia.

Main outcome measures

Length of stay, quality of assessment and carer-rated experience.

Results

People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission. This is a challenging task when patients have complex needs, and requires named staff to take responsibility for co-ordinating the discharge and effective systems for escalating concerns when obstacles arise. When trust boards review delayed discharges, they can identify recurring problems and work with local stakeholders to try to resolve them. Carers of people with dementia play an important role in helping to ensure that hospital staff are aware of patient needs. When carers are present on the ward, they can reassure patients and help make sure that they eat and drink well, and adhere to treatment and care plans. Clear communication between staff and family carers can help ensure that they have realistic expectations about what the hospital staff can and cannot provide. Dementia-specific training can promote the delivery of person-centred care when it is made available to a wide range of staff and accompanied by ‘hands-on’ support from senior staff.

Limitations

The quantitative component of this research relied on audit data of variable quality. We relied on carers of people with dementia to explore aspects of service quality, rather than directly interviewing people with dementia.

Conclusions

If effective support is provided by senior managers, appropriately trained staff can work with carers of people with dementia to help ensure that patients receive timely and person-centred treatment, and that the amount of time they spend in hospital is minimised.

Future work

Future research could examine new ways to work with carers to co-produce aspects of inpatient care, and to explore the relationship between ethnicity and quality of care in patients with dementia.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 22. See the NIHR Journals Library website for further project information.

Perceptions of inpatients and nurses towards the importance of nurses' caring behaviours in rehabilitation: A comparative study

AIMS

This study was conducted to describe and compare nurses' and inpatients' perceptions of caring attitudes and behaviours in rehabilitation.

METHODS

A comparative descriptive design was used. Perceptions of caring attitudes and behaviours were compared between 34 nurses working in rehabilitation and 64 elderly patients, using the Caring Nurse Patient Inventory-23, to explore Watson's carative factors through four dimensions. Patients' and nurses' ratings of importance for each dimension were compared. The study data were collected from 8 November 2017 to 5 May 2018.

RESULTS

Patients' and nurses' responses showed high scores in terms of their perceptions of caring, with nurses having the higher scores, and significant differences were found between patients and nurses. Patients scored items linked to clinical aspects of caring as the most important, whereas nurses scored items linked to humanistic and clinical caring as equally important. Comfort care was considered important for nurses and patients. Both groups considered relational caring items as the least important.

CONCLUSION

Results show that patients and nurses value clinical aspects of care, which is the visible aspect of care. The Caring Nurse Patient Inventory-23 is a reliable instrument to measure the nurses' and patients' perception of caring behaviours in rehabilitation.

Speaking Up for Fundamental Care: the ILC Aalborg Statement

OBJECTIVE

The International Learning Collaborative (ILC) is an organisation dedicated to understanding why fundamental care, the care required by all patients regardless of clinical condition, fails to be provided in healthcare systems globally. At its 11th annual meeting in 2019, nursing leaders from 11 countries, together with patient representatives, confirmed that patients' fundamental care needs are still being ignored and nurses are still afraid to 'speak up' when these care failures occur. While the ILC's efforts over the past decade have led to increased recognition of the importance of fundamental care, it is not enough. To generate practical, sustainable solutions, we need to substantially rethink fundamental care and its contribution to patient outcomes and experiences, staff well-being, safety and quality, and the economic viability of healthcare systems.

KEY ARGUMENTS

We present five propositions for radically transforming fundamental care delivery:Value: fundamental care must be foundational to all caring activities, systems and institutionsTalk: fundamental care must be explicitly articulated in all caring activities, systems and institutions.Do: fundamental care must be explicitly actioned and evaluated in all caring activities, systems and institutions.Own: fundamental care must be owned by each individual who delivers care, works in a system that is responsible for care or works in an institution whose mission is to deliver care.

RESEARCH

fundamental care must undergo systematic and high-quality investigations to generate the evidence needed to inform care practices and shape health systems and education curricula.

CONCLUSION

For radical transformation within health systems globally, we must move beyond nursing and ensure all members of the healthcare team-educators, students, consumers, clinicians, leaders, researchers, policy-makers and politicians-value, talk, do, own and research fundamental care. It is only through coordinated, collaborative effort that we will, and must, achieve real change.

The Quality of Interactions Schedule (QuIS) and person-centred care: Concurrent validity in acute hospital settings

BACKGROUND

There is a lack of consensus on how the practices of health care workers may be assessed and measured in relation to compassion. The Quality of Interactions Schedule (QuIS) is a promising measure that uses independent observers to assess the quality of social interactions between staff and patients in a healthcare context. Further understanding of the relationship between QuIS and constructs such as person-centred care would be helpful to guide its future use in health research.

OBJECTIVE

This study aimed to assess the validity of QuIS in relation to person-centred care measured using the CARES® Observational Tool (COT™).

METHODS

168 nursing staff-patient care interactions on adult inpatient units in two acute care UK National Health Service hospitals were observed and rated using QuIS and COT™. Analyses explored the relationship between summary and individual item COT™ scores and the likelihood of a negative (lower quality) QuIS rating.

RESULTS

As the degree of person-centred care improved, QuIS negative ratings generally decreased and positive social ratings increased. QuIS-rated negative interactions were associated with an absence of some behaviours, in particular staff approaching patients from the front (relative risk (RR) 3.7), introducing themselves (RR 3.1), smiling and making eye contact (RR 3.4), and involving patients in their care (RR 3.7).

CONCLUSION

These findings provide further information about the validity of QuIS measurements in healthcare contexts, and the extent to which it can be used to reflect the quality of relational care even for people who are unable to self-report.

Making health care responsive to the needs of older people

This commentary highlights the importance of health system responsiveness to older people living with complex health needs. Age-related changes and associated morbidity can present barriers to identifying an individual's health needs, expectations, values and preferences, and so sufficient time, skill and resource is required to inform the development of a tailored plan for each individual. A focus on responsiveness moves thinking beyond the responsibilities of the individual clinician in the single encounter, and allows us to identify elements of the wider system that may constrain how well the clinician is able to respond. Setting the goal of responsive health care requires us to assess the suitability of wider health system features and processes for meeting the diverse needs of individual people throughout their journey, and the extent to which the system can adapt dynamically as needs change. Standardised approaches to care prescribed across organisations (such as time-based targets or routinised approaches to inpatient nursing care) are likely to result in low responsiveness as individual complexity grows, disadvantaging patients with needs that do not fit the prescribed approach. Responsiveness is high when individual practitioners and clinical teams have the resources, decentralised authority, flexibility and autonomy to provide the care required. Building a more responsive health system requires a greater understanding of how these conditions can be achieved.

A Protocol-Driven, Bedside Digital Conversational Agent to Support Nurse Teams and Mitigate Risks of Hospitalization in Older Adults: Case Control Pre-Post Study

BACKGROUND

Hospitalized older adults often experience isolation and disorientation while receiving care, placing them at risk for many inpatient complications, including loneliness, depression, delirium, and falls. Embodied conversational agents (ECAs) are technological entities that can interact with people through spoken conversation. Some ECAs are also relational agents, which build and maintain socioemotional relationships with people across multiple interactions. This study utilized a novel form of relational ECA, provided by Care Coach (care.coach, inc): an animated animal avatar on a tablet device, monitored and controlled by live health advocates. The ECA implemented algorithm-based clinical protocols for hospitalized older adults, such as reorienting patients to mitigate delirium risk, eliciting toileting needs to prevent falls, and engaging patients in social interaction to facilitate social engagement. Previous pilot studies of the Care Coach avatar have demonstrated the ECA's usability and efficacy in home-dwelling older adults. Further study among hospitalized older adults in a larger experimental trial is needed to demonstrate its effectiveness.

OBJECTIVE

The aim of the study was to examine the effect of a human-in-the-loop, protocol-driven relational ECA on loneliness, depression, delirium, and falls among diverse hospitalized older adults.

METHODS

This was a clinical trial of 95 adults over the age of 65 years, hospitalized at an inner-city community hospital. Intervention participants received an avatar for the duration of their hospital stay; participants on a control unit received a daily 15-min visit from a nursing student. Measures of loneliness (3-item University of California, Los Angeles Loneliness Scale), depression (15-item Geriatric Depression Scale), and delirium (confusion assessment method) were administered upon study enrollment and before discharge.

RESULTS

Participants who received the avatar during hospitalization had lower frequency of delirium at discharge (P<.001), reported fewer symptoms of loneliness (P=.01), and experienced fewer falls than control participants. There were no significant differences in self-reported depressive symptoms.

CONCLUSIONS

The study findings validate the use of human-in-the-loop, relational ECAs among diverse hospitalized older adults.

Patients' perception of quality of nursing care; a tertiary center experience from Ethiopia

Background

Nursing care closely influences patients' satisfaction with the overall quality of care, and the importance of measuring patient satisfaction with nursing care cannot be emphasized enough. Data are however scarce regarding patients' perception of quality of nursing care in Ethiopia. We performed this study to assess patient's perception of the quality of nursing care in a tertiary center in Ethiopia.

Methods

Data were collected prospectively using Quality of Nursing Care Questionnaires-patient of Safford & Schlotfeldt. A total of 340 patients were included using systematic random sampling and data were analyzed using SPSS for windows version- 20.

Result

The nursing care performance was highest for nurse-physician relation (mean = 3.95) and low for education and home care preparation and physical care (mean score of 2.79 and 2.89 respectively). The emotional care and nurse administration mean score were 3.5 and 3.83 respectively. The overall nursing quality was neither satisfying nor dissatisfying (mean of 3.39). While only 36% of the respondents were satisfied with the nursing care, patient education has the strongest (AOR of 7.4) association with satisfaction.

Conclusion

Patients perceived low quality of physical care, education and preparation for home care but better nurse-physician relation and nursing administration. However the overall quality measure was neither satisfying nor dissatisfying. This calls for an action from the health care administrators, educators and other stakeholders to improve the patient perception of quality nursing care.