A qualitative analysis of an advanced practice nurse-directed transitional care model intervention

[Advanced practice nurses in geriatric traumatology : A scoping review]

BACKGROUND

Older and very old persons have an increased risk of traumatic injuries as well as comorbidities and multimorbidities. The standardized workflow in hospitals can increase the occurrence of typical geriatric complications, such as challenging behavior and delirium, which can result in highly complex care situations. The application of advanced practice nurses (APN) is an international response to such challenges. In Germany, the scientifically based development of APN has so far lagged behind the international standard.

METHOD

For this scoping review, a systematic search in the databases PubMed and CINAHL and a supplementary hand search was conducted for the period 2010-2022.

RESULTS

Tasks and role profiles for the scope of practice of APN in geriatrics and traumatology already exist in the literature. There is a lack of scientifically proven tasks and role profiles for APN in geriatric traumatology in the literature.

DISCUSSION

Based on the current state of research it is not yet possible to derive specific tasks and role profiles for APN in geriatric traumatology. The transferability of tasks and profiles from geriatrics and traumatology seem to be possible. The development of tasks and role profiles for geriatric traumatology APN requires further research, especially to identify the specific needs of geriatric traumatology patients.

Transition of Care for Older Adults Undergoing General Surgery

The demand for surgical intervention and hospitalization is expected to increase with the growth of the older adult population. Despite advances in technology and minimally invasive surgical procedures, the needs of the older adult in the perioperative period are unique. Transitions of care from the decision to support surgery through surgical intervention, subsequent hospitalization, and postacute discharge must be supported to achieve optimal patient outcomes. The clinical nurse specialist is well suited to address care delivery and assure implementation of best practices across the continuum.

I want to be seen as myself: needs and perspectives of persons with dementia concerning collaboration and a possible future move to the nursing home in palliative dementia care

Introduction: Interprofessional collaboration (IPC) within and during movements between care settings is crucial for optimal palliative dementia care. The objective of this study was to explore the experiences of persons with dementia regarding collaboration with and between healthcare professionals (HCPs) and their perceptions of a possible future move to the nursing home (NH) in palliative dementia care. Method: We conducted a cross-sectional qualitative study and performed semi-structured interviews with a purposive sample of persons with dementia living at home (N = 18). Data analysis involved content analysis. Results: Our study demonstrated that even though most persons with dementia find it difficult to perceive the collaboration amongst HCPs, they could describe their perceived continuity of care (Theme 1. My perception of collaboration among HCPs). Their core needs in collaboration with HCPs were receiving information, support from informal caregivers, personal attention and tailored care (Theme 2. My needs in IPC). Regarding a possible future move to the NH, persons with dementia cope with their current decline, future decline and a possible future move to the NH (Theme 3. My coping strategies for a possible future move to the NH). They also prefer to choose the NH, and continue social life and activities in their future NH (Theme 4. My preferences when a NH becomes my possible future home). Conclusion: Persons with dementia are collaborative partners who could express their needs and preferences, if they are willing and able to communicate, in the collaboration with HCPs and a possible future move to the NH.

Mapping implementation strategies of evidence-based interventions for three preselected phenomena in people with dementia-a scoping review

BACKGROUND

Caring for people with dementia is complex, and there are various evidence-based interventions. However, a gap exists between the available interventions and how to implement them. The objectives of our review are to identify implementation strategies, implementation outcomes, and influencing factors for the implementation of evidence-based interventions that focus on three preselected phenomena in people with dementia: (A) behavior that challenges supporting a person with dementia in long-term care, (B) delirium in acute care, and (C) postacute care needs.

METHODS

We conducted a scoping review according to the description of the Joanna Briggs Institute. We searched MEDLINE, CINAHL, and PsycINFO. For the data analysis, we conducted deductive content analysis. For this analysis, we used the Expert Recommendations for Implementation Change (ERIC), implementation outcomes according to Proctor and colleagues, and the Consolidated Framework for Implementation Research (CFIR).

RESULTS

We identified 362 (A), 544 (B), and 714 records (C) on the three phenomena and included 7 (A), 3 (B), and 3 (C) studies. Among the studies, nine reported on the implementation strategies they used. Clusters with the most reported strategies were adapt and tailor to context and train and educate stakeholders. We identified one study that tested the effectiveness of the applied implementation strategy, while ten studies reported implementation outcomes (mostly fidelity). Regarding factors that influence implementation, all identified studies reported between 1 and 19 factors. The most reported factors were available resources and the adaptability of the intervention. To address dementia-specific influencing factors, we enhanced the CFIR construct of patient needs and resources to include family needs and resources.

CONCLUSIONS

We found a high degree of homogeneity across the different dementia phenomena, the evidence-based interventions, and the care settings in terms of the implementation strategies used, implementation outcomes measured, and influencing factors identified. However, it remains unclear to what extent implementation strategies themselves are evidence-based and which intervention strategy can be used by practitioners when either the implementation outcomes are not adjusted to the implementation strategy and/or the effects of implementation strategies are mostly unknown. Future research needs to focus on investigating the effectiveness of implementation strategies for evidence-based interventions for dementia care.

TRIAL REGISTRATION

The review protocol was prospectively published (Manietta et al., BMJ Open 11:e051611, 2021).

From FITT to FISTT: The task-skills fit before the introduction of assistive, digital health technologies

Objective

To enhance the predictive power of the Fit between Individuals, Task and Technology (FITT) framework in mobile, individual consumer settings by restructuring the individual-task fit to prominently emphasise the task-skills fit.

Design

A mixed study involving a quantitative survey of 679 potential patients (adopters) and a qualitative content analysis of ten semi-structured interviews with clinic assistants.

Setting

For the survey, three combined random samples of potential patients from Atteridgeville, Bapong and Garankuwa (South Africa). Ten Unjani clinic assistants were also interviewed about their tasks, skills, and related properties and attributes using a semi-structured interview guide.

Participants

Participants in the survey were potential patients over 18 years of age in the three sampled locations. In the qualitative study, interviewed participants were employed as clinic assistants in ten clinics within the Unjani Clinic Network.

Main outcome measures

in the quantitative study, the statistical significance of the relationships between smartphone experience and health motivation on the one hand and the adopter's perceived self-efficacy on the other. In the qualitative study, the extent to which task properties, context, and the adopters' levels of education and training affect their perceived self-efficacy.

Findings

There is a significant relationship between smartphone experience and perceived self-efficacy and a moderately significant relationship between health motivation and perceived self-efficacy. Furthermore, task properties, task context, and an adopter's level of education and training considerably influence their perceived self-efficacy on a given future assistive digital health technology (ADHT).

Conclusion

Extending the FITT to the FISTT framework to explicitly include the task-skills fit may improve the explanatory and predictive power of the traditional FITT framework in mobile individual consumer settings.

Unique Care Needs of People with Dementia and Their Caregivers during Transitions from Skilled Nursing Facilities to Home and Assisted Living: A Qualitative Study

OBJECTIVES

The purpose of the study was to describe unique care needs of people with dementia (PWD) and their caregivers during transitions from skilled nursing facilities (SNF) to home.

DESIGN

A qualitative study using focus groups, semistructured interviews, and descriptive qualitative analysis.

SETTING AND PARTICIPANTS

The study was set in one state, in 4 SNFs where staff had experience using a standardized transitional care protocol. The sample included 22 SNF staff, 4 home health nurses, 10 older adults with dementia, and their 10 family caregivers of whom 39 participated in focus groups and/or interviews.

METHODS

Data collection included 4 focus groups with SNF staff and semistructured interviews with home health nurses, SNF staff, PWD, and their family caregivers. Standardized focus group and interview guides were used to elicit participant perceptions of transitional care. We used the framework analytic approach to qualitative analysis. A steering committee participated in interpretation of findings.

RESULTS

Participants described 4 unique care needs: (1) PWD and caregivers may not be ready to fully engage in dementia care planning while in the SNF, (2) caregivers are not prepared to manage dementia symptoms at home, (3) SNF staff have difficulty connecting PWD and caregivers to community supports, and (4) caregivers receive little support to address their own needs.

CONCLUSIONS AND IMPLICATIONS

Based on findings, recommendations are offered for adapting transitional care to address the needs of PWD and their caregivers. Further research is needed (1) to confirm these findings in larger, more diverse samples and (2) to adapt and test interventions to support successful community discharge of PWD and their caregivers.

Health professionals' experience of implementing and delivering a 'Community Care' programme in metropolitan Melbourne: a qualitative reflexive thematic analysis

OBJECTIVES

To explore the experiences of health professionals involved in delivering a multidisciplinary Community Care programme that provides a transitional care coordination service for patients visiting a tertiary hospital service in Melbourne, Australia.

DESIGN

Reflexive thematic analysis was used to identify themes from descriptions of delivering the programme, including its perceived strengths and challenges.

PARTICIPANTS

12 healthcare professionals from four disciplines working in the Community Care programme were interviewed.

RESULTS

Four themes were identified: (1) 'increasingly complex', depicts the experience of delivering care to patients with increasingly complex health needs; (2) 'plugging unexpected gaps', describes meeting patient's healthcare needs; (3) 'disconnected', explains system-based issues which made participants feel disconnected from the wider health service; (4) 'a misunderstood programme', illustrates that a poor understanding of the programme within the health service is a barrier to patient enrolment which may have been exacerbated by a service name change.

CONCLUSIONS

The healthcare professionals involved in this study described the experience of providing care to patients as challenging, but felt they made a positive difference. By unravelling the patients' health problems in context of their surroundings, they were able to recognise the increasingly complex patients' health needs. The disconnection they faced to integrate within the wider healthcare system made their role at times difficult. This disconnection was partly contributed to by the fact that they felt the programme was misunderstood.

Spousal Caregiver Resilience in A Nutshell: A Directed Content Analysis in the Context of Dementia Caregiving in Vietnam

OBJECTIVES

This study aims to define resilience of spousal family caregivers for older adults living with dementia in the Vietnamese context.

METHODS

A directed content analysis was conducted on 22 interview transcripts, including nine follow-up interviews, of a sub-sample of 13 spousal caregivers, drawn from a larger study with family caregivers for relatives with dementia in a hospital in Vietnam. The study started with key categories from the theory of the unifying model of resilience in dementia caregiving to guide the analysis process, while new codes and categories were identified during this process.

FINDINGS

The study results show a revision and extension of this model by introducing a revised model with newly developed sub-categories under the five revised key categories of adversity, resilience processes, outcomes, internal resources, and external resources.

CONCLUSIONS

The results provide evidence for the development of resilience-based interventions and services for spousal caregivers in their contexts.

Evaluation of a nurse practitioner-led transitional care program: The effects on 30-day Medicare readmission rates and patient satisfaction scores

BACKGROUND

Data suggest that nurse practitioner (NP)-led transitional care models can reduce 30-day readmission rates. It remains unclear if transitional care has any impact on Press Ganey's Hospital Consumer Assessment of Health Provider and Systems (HCAHPS) patient satisfaction scores.

LOCAL PROBLEM

A transitional care encounter program (TCEP) was designed and implemented by an NP at an internal medicine private practice in response to an increase in Medicare 30-day readmission rates and lower HCAHPS results. A program evaluation was carried out to determine any impact on 30-day readmissions and HCAHPS.

METHODS

The evaluator used CDC's Framework for Program Evaluation in Public Health for program evaluation. Quantitative retrospective data collection of Medicare 30-day readmission rates was obtained and compared preimplementation/postimplementation. HCAHPS results were collected from the data analytics department at Methodist Health System and compared preimplementation/postimplementation.

INTERVENTIONS

All Medicare patients followed by the private practice discharged from hospital to home had a TCEP visit within 7 days of discharge. The NP extensively reviewed the hospital records, medication reconciliation, education about current medications, diagnoses, and treatment plan with the patient.

RESULTS

Readmission rates and HCAHPS are tracked by physician name at discharge. The TCEP resulted in a 2.1% reduction in Medicare 30-day readmission rate. Physician A pre-/post-HCAHPS score was 74% increased to 81.3%. Physician B pre-/post-HCAHPS score was 75.8% increased to 78.6%.

CONCLUSION

The TCEP model became an integral part of the clinic's daily operations. Transitional care has potential for decreasing Medicare 30-day readmission rate and improving HCAHPS.

Family caregivers for older persons with dementia offer recommendations to current caregivers: a qualitative investigation

BACKGROUND AND AIMS

Family members who care for older adults with dementia encounter significant difficulties across many domains. There is limited research in this area; thus, the aim here is to share the actual experiences of 30 family caregivers to other family caregivers and to show how these experiences can provide help and recommendations.

METHODS

This qualitative study of 30 family caregivers of family members aged 65 and older who died with dementia-related diagnoses used in-depth qualitative interviews conducted over a 12-month period for data collection and content analysis to understand the data. The study asked what they learned and what subsequent recommendations these caregivers had for other family caregivers taking care of an older person with dementia.

RESULTS

Four primary themes emerged from the content data analysis and included the following: (1) "do not do it alone"; (2) patience, love, and kindness; (3) "first of all, take care of yourself"; and (4) "get educated."

CONCLUSIONS

This study is unique in asking directly of family caregivers of older persons who died of dementia what they learned and what they want to share and recommend to ongoing and future family caregivers.

A myriad of factors influencing the implementation of transitional care innovations: a scoping review

Background

Care transitions of older persons between multiple care settings are frequently hampered by various issues such as discontinuous care delivery or poor information transfer among healthcare providers. Therefore, several innovations have been developed to optimize transitional care (TC). This review aims to identify which factors influence the implementation of TC innovations.

Methods

As part of TRANS-SENIOR, an international innovative training and research network focusing on enhancing or avoiding care transitions, a scoping review was conducted. The five stages of the Arksey and O’Malley framework were followed. PubMed/MEDLINE, EMBASE, and CINAHL were searched, and eligible studies published between years 2000 and 2020 were retrieved. Data were extracted from the included studies and mapped to the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) and Care Transitions Framework (CTF).

Results

Of 1537 studies identified, 21 were included. Twenty different TC innovations were covered and aimed at improving or preventing transitions between multiple care settings, the majority focused on transitions from hospital to home. Key components of the innovations encompassed transition nurses, teach-back methods, follow-up home visits, partnerships with community services, and transfer units. Twenty-five prominent implementation factors (seven barriers, seven facilitators, and eleven factors with equivalent hindering/facilitating influence) were shown to affect the implementation of TC innovations. Low organizational readiness for implementation and the overall implementation climate were topmost hindering factors. Similarly, failing to target the right population group was commonly reported as a major barrier. Moreover, the presence of skilled users but with restricted knowledge and mixed attitudes about the innovation impeded its implementation. Among the eminent enabling factors, a high-perceived advantage of the innovation by staff, along with encouraging transition roles, and a continuous monitoring process facilitated the implementation of several innovations. Other important factors were a high degree of organizational networks, engaging activities, and culture; these factors had an almost equivalent hindering/facilitating influence.

Conclusions

Addressing the right target population and instituting transition roles in care settings appear to be specific factors to consider during the implementation of TC innovations. Long-term care settings should simultaneously emphasize their organizational readiness for implementation and change, in order to improve transitional care through innovations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01087-2.

Positive Aspects of Family Caregiving for Older Adults at End-of-Life: A Qualitative Examination

Family caregivers of older adults with dementia have significant challenges across many domains. While this role has been found to be burdensome on the caregiver, increasingly, though, there are also significant positive aspects reported by caregivers (known as the positive aspects of caregiving-PAC). This participatory qualitative study of 30 United States caregivers of family members age 65 and older who died with a dementia-related diagnoses used in-depth qualitative interviews and directed content analysis to understand the data. The study addressed a gap in the research literature and asked about caregiver's positive experiences during their family members' last weeks of life and investigated what this meant for the caregiver. Three primary themes were identified: (1) The Importance and Impact of Family Traditions/Celebrations, (2) Use of Humor in Living and the Difficult Experiences at End-of-Life, and (3) "The Gift of Caregiving." These findings are explored and reviewed in light of other research looking at the positive aspects of caregiving for caregivers taking care of persons living with dementia, finding concurrence and some uniqueness across the results. Implications of the findings for families and social work professionals are reviewed.

Dying With Dementia: Caregiver Observations of Their Family Members' Physical Decline and Behavioral or Psychological Changes During Their Last Days

Family caregivers of older persons with dementia have significant challenges across many domains. These reported problems encountered over their caregiving time are for many reasons, but what makes the caretaking difficult is complicated by both the unknown nature of the dementia disease and the dying trajectory. While there are studies, primarily from health-care professionals, of this dying process and the last few weeks of life for older persons with dementia, much less is known directly from the family caregivers' perspectives and experiences. This qualitative study of 30 caregivers of family members aged 65 years and older who died with dementia-related diagnoses used in-depth qualitative interviews conducted over a 12-month period and directed content analysis to understand the data. The study asked what physical, behavioral, and psychological changes they observed and experienced during their family members' last weeks of life. Three primary themes were identified around behavioral and psychological changes: (a) they become different people, (b) did not recognize caregiver, and (c) wandering and getting lost; and two primary themes identified physical decline: (a) system started shutting down and (b) drastically diminished self-sufficiency. Implications for families and professionals are reviewed and discussed.

Predischarge Provider Visits as a Method of Improving Transitional Care Clinic Visit Rates

BACKGROUND

Transitional care interventions have been associated with reduced 30-day patient readmission, better quality of health care, and lower emergency department visits and health care costs.

LOCAL PROBLEM

Transition Services at a major quaternary care center was underutilized by patients who were referred to the program.

METHODS

A pre-/postimplementation evaluation design was used to evaluate a quality improvement intervention.

INTERVENTION

A face-to-face meeting between eligible patients and a Transition Services provider prior to patients being discharged from the hospital was evaluated as a process improvement intervention. The primary outcome was initial appointment attendance at the Transition Services clinic following hospital discharge.

RESULTS

There was no statistically significant difference (P = .59) in patients' initial appointment attendance at Transition Services between the preintervention (48.1%) and intervention phases (54.8%).

CONCLUSION

Provider engagement during hospitalization did not increase initial appointment attendance at Transition Services. Other strategies to improve Transition Services attendance rates are needed.

When Death With Dementia Is “A Memory Seared in My Brain”: Caregivers’ Recommendations to Health Care Professionals

The purpose of this study is to determine family caregivers’ recommendations for professional health care professionals on how to help prepare them for the death of an elder with dementia. Purposive criterion sampling was employed to identify 30 bereaved caregivers of family members aged 65 and older who died with a dementia-related diagnosis. In-depth, qualitative interviews were conducted over a 12-month period, and qualitative content analysis was used to analyze the data. Three primary themes emerged: (a) Educate Caregivers, (b) Lead Caregivers, and (c) Provide a Caring and Compassionate Presence. The results highlight the importance of various health care professionals’ roles in preparing family caregivers for a death. In doing so, both the dying and their caregivers may have a better end-of-life experience with improved bereavement outcomes.

Policy Flight Simulators: Accelerating Decisions to Adopt Evidence-Based Health Interventions

EXECUTIVE SUMMARY

In this study, the authors used simulation to explore factors that might influence hospitals' decisions to adopt evidence-based interventions. Specifically, they developed a simulation model to examine the extent to which hospitals would benefit economically from the transitional care model (TCM). The TCM is designed to transition high-risk older adults from hospitals back to communities using interventions focused on preventing readmissions.The authors used qualitative methods to identify and validate simulation facets. Four simulation experiments explored the economic impact of the TCM on more than 3,000 U.S. hospitals: (1) magnitude of readmission penalty, (2) application to specific diagnosis-related groups, (3) level of cost sharing between payer and provider, and (4) capitated versus fee-for-service payments. The simulator projected hospital-specific economic effects. The authors used Monte Carlo methods for the simulations, which were parameterized with public data sets from the Centers for Medicare & Medicaid Services (CMS) and TCM data from randomized controlled trials and comparative effectiveness studies.Under current conditions, the simulation indicated that only 10 of more than 3,000 Medicare-certified hospitals would benefit financially from the TCM. If current readmission penalties were doubled, the number of hospitals projected to benefit would increase to 300. Targeting selected diagnosis cohorts would also increase the number of hospitals to 300. If payers reimbursed providers for 100% of the TCM costs, 2,000 hospitals would benefit financially. Under a capitated payment model, 1,500 hospitals would benefit from the TCM.Current CMS penalties-or reasonable increases-have little economic effect on the TCM. In the current environment, two strategies are likely to facilitate adoption: (1) persuading payers to reimburse TCM costs and (2) focusing on hospitals with higher bed occupancies and higher revenue patients.

Barriers and Facilitators to Preparedness for Death: Experiences of Family Caregivers of Elders with Dementia

Less is known about how caregivers prepare (or not) for the death of a family member with dementia. This study's purpose was to explore how caregivers handle these dementia deaths, including identification of barriers and facilitators to preparing caregivers for the death of an elder family member dying with dementia. This qualitative, descriptive study employed a purposive sampling strategy in which the principal investigator interviewed 36 caregivers of family members age 65 and older who died from a dementia-related diagnosis. Directed content analysis was used to analyze the data. Four primary themes were identified as barriers: (1) hindrances to information; (2) barriers to hospice; (3) ineffective attempts to comfort; and (4) the nature of death with dementia. Six themes were identified as facilitators: (1) religious/spiritual beliefs; (2) caregiver initiative; (3) prior experience; (4) bearing witness to decline; (5) professionals alerting caregiver (of what to expect of impending death); and (6) culture and legacy of family caregiving. The results support an increased role of social work in addressing caregivers' awareness of impending death and helping prepare them for the death of an elder with dementia.

Understanding experiences of patients and family caregivers in the Mayo Clinic Care Transitions program: a qualitative study

Background

Care transitions programs are increasingly used to improve care and reduce re-admission of patients after hospitalization. To learn from the experience of patients who have participated in the Mayo Clinic Care Transitions (MCCT) program and to understand the patient experience, we sought perspectives of patients, caregivers, and providers who worked with participants of the MCCT program.

Methods

Investigators interviewed 17 patients and nine of their caregivers about their experience with the MCCT program. Eight health care providers described provider experiences with the MCCT program. Data from semistructured interviews were audio recorded, transcribed, and evaluated through content analysis. Inductive coding methods were used to elicit themes about patient experience with the MCCT program.

Results

Patients, caregivers, and providers emphasized that the MCCT program prevented hospitalizations and contributed to the health and quality of life of participants. All three stakeholder groups emphasized the value of the home visit and provision of the visit on a patient’s “home turf” as central to the program. Patients appreciated speaking to a provider without the stress and exertion of a trip to the clinic. Caregivers appreciated improved communication provided in the home visit and felt that home visits gave them peace of mind. Patients, caregivers, and providers also identified the need for improved phone triage and communication.

Conclusion

Patients, caregivers, and providers acknowledged the care transitions problem and emphasized the benefits of seeing patients on their home turf rather than in an office visit. This qualitative study of patient, caregiver, and provider experiences further validates the importance of the MCCT program.

Patient and family members' perceptions of family participation in care on acute care wards

BACKGROUND

Hospital leaders, policymakers and healthcare professionals are realising the benefits of delivering care that promotes family participation because it is known to enhance the quality of care, and improve patient satisfaction.

AIM

The aim of this study was to explore, from the perspective of patients and family members within an adult acute care ward: (a) their beliefs and attitudes towards family participation in patient care and (b) staff behaviours that support or hinder family participation in patient care.

DESIGN AND METHODS

A naturalistic approach with an exploratory sequential design was used in a medical assessment and planning unit of a regional referral hospital in Australia. Purposeful maximum variation sampling was used to recruit patients and family members who differed in age, ethnicity, relationship to patient and gender. Observer-as-participant observation data and semi-structured interviews were undertaken. Following separate inductive content analysis, data were triangulated.

RESULTS

Thirty-two patients and 26 family members were recruited. Thirty hours of observational data were gathered. Eighteen patients and 15 family members were interviewed. Analysis uncovered two contrasting categories: (a) disconnected communication and (b) family influence quality.

CONCLUSION

The findings of our study demonstrated that most patients and families perceived staff communication as disconnected and inadequate, which constrained them from engaging in care processes or decision-making. However, when family felt empowered and participated in patient care, the quality of health care was enhanced. Healthcare professionals can use these findings to make informed evidence-based changes to the way they practice and communicate to ensure family participation in patient care is optimised in the acute care setting.

Prática Avançada de Enfermagem: uma análise conceitual

Resumo Objetivo Analisar o conceito de Prática Avançada de Enfermagem e elucidar os elementos-chave: atributos, antecedentes e consequências. Métodos O referencial metodológico para o estudo foi o modelo de análise conceitual de Walker e Avant (2011), estruturado mediante uma revisão integrativa da literatura conduzida nos meses de maio e junho de 2017. A busca foi realizada nas bases de dados Scopus, PubMed, CINAHL, Web of Science, Science Direct, Cochrane e Lilacs, considerando estudos que trataram do termo e que foram publicados em português, inglês ou espanhol. Resultados A amostra foi composta por 33 estudos conduzidos em oito países entre os anos 2000 e 2016, sendo 56% publicado no quinquênio 2011-2016. Foram identificados oito atributos: Preparação educacional em nível de mestrado ou doutorado, e especialização em área clínica; Prática baseada em evidências; Habilidade de desenvolver raciocínio clínico e pensamento crítico; Alto nível de autonomia; Avaliação avançada e ampla; Liderança; Capacidades diagnóstica, gerencial e administrativa; Promoção do ensino às outras enfermeiras. Foram identificados os antecedentes e consequências e foi desenvolvida uma definição do conceito. Conclusão Diante da expansão da ideia de enfermagem avançada pelo mundo, particularmente na América Latina, recomendam-se outros estudos relacionados à Prática Avançada de Enfermagem. É necessária uma compreensão aprofundada das questões na prática de implementação no Brasil para ajudar a determinar o conceito futuro de PAE para o país. Este estudo contribui a essa compreensão ao definir o conceito de PAE com seus antecedentes, atributos e consequências.

Welcoming Death: Exploring Pre-Death Grief Experiences of Caregivers of Older Adults with Dementia

The death of an older adult with dementia often has an uncertain dying trajectory and has been referred to as "the long goodbye." Researchers have found both positive and negative outcomes of pre-death grief for caregivers of individuals with chronic illnesses. This qualitative study explored the end-of-life experiences for 36 bereaved family caregivers of older adults with dementia; focusing on understanding their experiences with pre-death grief. These caregivers shared experiences with the phenomenon of "welcoming death" and findings highlighted the primary reasons they anticipated, accepted, or wished for the death of their family member with dementia. With the overarching goal of improving bereavement outcomes and reducing feeling of guilt, inclusion of pre-death grief support services throughout the caregiving process are recommended.

Hospital-Community Partnerships to Aid Transitions for Older Adults: Applying the Care Transitions Framework

This study examined the implementation and hospitalwide scaling of a community-based transitional care program to reduce readmissions among adults 65 years or older. Our analysis was guided by the Care Transitions Framework and was based on semistructured interviews with program implementers to identify intervention successes, barriers, and outcomes beyond reducing readmissions. Such outcomes included the program's critical role in providing a safety net and transition to more advanced care, and redefining intervention success from more patient-centered perspectives.

Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers

AIMS AND OBJECTIVES

To collate, synthesise and discuss published evidence and expert professional opinion on enablers and barriers to the development and sustainability of specialist and advanced practice roles in nursing and midwifery.

BACKGROUND

Expanded practice is a response to population health needs, healthcare costs and practitioners' willingness to expand their scope of practice through enhanced responsibility, accountability and professional autonomy.

DESIGN

This discursive paper is based on a rapid review of literature on enablers and barriers to the development and sustainability of specialist and advanced practice roles and is part of a wider policy analysis.

METHODS

We analysed and synthesised of 36 research articles, reviews and discussion papers on enablers and barriers in the development and sustainability of expanded practice roles.

RESULTS

Several factors enable role expansion, including: role clarity; credentialing and endorsement; availability of education for expanded roles; individual practitioners' dispositions towards role expansion; support from peers, other professionals and the work organisation; and costs. Where limited or absent, these same factors can constrain role expansion.

CONCLUSIONS

Enabling nurses and midwives to practice to their full scope of education and expertise is a global challenge for disciplinary leadership, a national challenge for professional regulation and a local challenge for employers and individual clinicians. These challenges need to be addressed through multistakeholder coordinated efforts at these four levels.

RELEVANCE TO CLINICAL PRACTICE

This discursive paper synthesises empirical evidence and expert professional opinion on the factors that enable or hinder the development and sustainability of specialist and advanced practice roles. Providing a critical appraisal of current knowledge, it provides a reference source for disciplinary debate and policy development regarding the nursing and midwifery resource and informs clinicians of the myriad issues that can impact on their capacity to expand their scope of practice.

A qualitative study of older adults' and family caregivers' perspectives regarding their preoperative care transitions

AIMS AND OBJECTIVES

To explore how older patients with multiple chronic conditions and their family caregivers perceive their engagement and overall care experience throughout the preoperative phase of elective orthopaedic hip or knee joint replacement.

BACKGROUND

Patient engagement is a critical component of care necessary for improving patient outcomes. Little is known about how older adults with multiple chronic conditions and their family caregivers engage in preoperative care transitions and the subsequent impact of this experience on postoperative health outcomes.

DESIGN

Prospective qualitative descriptive design was used.

METHODS

Semi-structured telephone interviews with a convenience sample of older adults coping with multiple chronic conditions and their family caregivers. Interviews were conducted prior to surgery and, again 21 days postsurgery, were audio-recorded and transcribed for qualitative content analysis. The Quality Health Outcomes Model was used to categorise study findings.

RESULTS

Eleven patients and five family caregivers participated. Guided by the Quality Health Outcomes Model, four major themes were identified. (i) Older adults perceive that joint replacement is about quality of life. (ii) Standardised interventions often fail to address the unique needs of complex older adults. (iii) Family caregivers perceive they are the primary care coordinators. (iv) Postoperative outcomes and resource utilisation vary widely in complex older adults.

CONCLUSION

Findings suggest that current preoperative care interventions are often not designed to effectively engage complex older patients and their family caregivers. Coordinated patient-centred preoperative care that reflects the needs and goals of complex older patients and their family caregivers may positively influence perioperative care transitions and outcomes beyond this episode of care.

RELEVANCE TO CLINICAL PRACTICE

The current research documents the need for more in-depth knowledge about the relationship between older adults' and their family caregivers' engagement preoperatively and postoperative outcomes and resource utilisation.

Keeping one step ahead: A qualitative study among Norwegian health-care providers in hospitals involved in care coordination for patients with complex needs

Introduction

Various efforts aim to enhance continuity of care for patients with long-term health-care needs. Since 2012, Norwegian hospitals are mandated to appoint individual care coordinators for patients with complex needs to ensure continuity in the care pathway. New roles must meld with current practice. Implementation has been slow. This study investigates current care coordination across hospital contexts, from the perspective of health-care providers, a scarcely researched area.

Methods

A qualitative study using semi-structured individual, duo, and group interviews with 16 purposefully selected Norwegian health-care providers from different hospitals, departments, professions and with various roles. A thematic cross-case analysis using systematic text condensation was performed.

Results

Common for the interviewees’ care coordination experiences was to “keep one step ahead.” The scope of their coordination activities varied from diagnostics and treatment to orchestrating long-term, cross-sectional multidisciplinary care. This work was often performed without designated resources. The interviewees applied experience, knowledge, and sensitivity when defining the patients’ needs and searching for resources to orchestrate coordination work. They strived to balance the needs of patients with the resources available and adjusted the continuity ambitions on behalf of their patients to what they considered doable in the relevant contexts. However, many told of negotiating special solutions for selected patients with particularly complex needs.

Discussion

Care coordination for patients with complex needs emerged as diverse and context-sensitive. Acknowledgement of coordination activities that go beyond established workflow routines and clinical pathways, together with flexible leadership support and accessible infrastructural resources are needed.

Transitional Care in the Patient-Centered Medical Home: Lessons in Adaptation

Older adults with multiple chronic conditions (MCCs) typically have risk factors (e.g., functional deficits, social barriers) that complicate the management of their healthcare, often with devastating human and economic consequences. Finding new ways to provide patient-centered care to community-based older adults with MCCs is essential. Two current models of care, the Patient-Centered Medical Home (PCMH) and the Transitional Care Model (TCM), have demonstrated improvements in the outcomes of high-risk older adults at different points on the chronic illness trajectory. However, neither care management approach has optimally engaged vulnerable patients to address needs throughout both acute and more stable transitions in health. In this article, we summarize the development of the PCMH plus TCM (hereafter, PCMH + TCM), an innovative approach to care, and the experience of the providers involved in testing the feasibility of implementing the PCMH + TCM. Using content analyses to code open-ended survey responses from transitional care nurses and PCMH clinical leaders', two major themes, collaboration and communication, emerged as critical to the process of implementing the PCMH + TCM. Barriers and facilitators to implementing the PCMH + TCM are presented. Findings support that the TCM can be adapted and integrated into the PCMH with meticulous planning and implementation.

Toward a process-level view of distributed healthcare tasks: Medication management as a case study

We aim to highlight the importance of using a process-level view in analyzing distributed healthcare tasks through a case study analysis of medication management (MM). MM during older adults' hospital-to-skilled-home-healthcare (SHHC) transitions is a healthcare process with tasks distributed across people, organizations, and time. MM has typically been studied at the task level, but a process-level is needed to fully understand and improve MM during transitions. A process-level view allows for a broader investigation of how tasks are distributed throughout the work system through an investigation of interactions and the resultant emergent properties. We studied MM during older adults' hospital-to-SHHC transitions through interviews and observations with 60 older adults, their 33 caregivers, and 79 SHHC providers at 5 sites associated with 3 SHHC agencies. Study findings identified key cross-system characteristics not observable at the task-level: (1) identification of emergent properties (e.g., role ambiguity, loosely-coupled teams performing MM) and associated barriers; and (2) examination of barrier propagation across system boundaries. Findings highlight the importance of a process-level view of healthcare delivery occurring across system boundaries.

What Type of Transitional Care Effectively Reduced Mortality and Improved ADL of Stroke Patients? A Meta-Analysis

Stroke is a major cause of disability and mortality worldwide; yet; prior to this study; there had been no sufficient evidence to support the effectiveness of various transitional care interventions (TCI) on the disability and mortality of stroke survivors. This meta-analysis aimed to assess the effectiveness of TCI in reducing mortality and improving the activities of daily life (ADL) of stroke patients. PubMed; Web of Science; OVID; EMBASE; CINAHL; and Sino-Med were searched for articles published before November 2016. Thirty-one randomized controlled trials (RCTs) were identified in the study. This analysis showed that the total effect of TCI on reducing mortality was limited (Risk Ratio (RR) = 0.86; 95% Confidence Interval (CI): 0.75-0.98); that only home-visiting programs could reduce mortality rates (RR = 0.34; 95% CI: 0.17-0.67) compared with usual care; and that the best intervention was led by a multidisciplinary team (MT) ≤3 months (RR = 0.19; 95% CI: 0.05-0.71). In addition; home-visiting programs also produced ADL benefit (RR = 0.56; 95% CI: 0.31-0.81). Overall; there was a statistically significant difference in improving patients' independence between TCI and usual care (RR = 1.12; 95% CI: 1.02-1.23). However; none of the interventions was effective when they were differentiated in the analysis. It is the conclusion of this study that home-visiting programs; especially those led by MTs; should receive the greatest consideration by healthcare systems or providers for implementing TCI to stroke survivors.

Optimizing a Nurse-led Transitional Home Visit Program in Preparation for a Randomized Control Trial

Introduction:

The Hospital to Home Outcomes study began with the end goal of evaluating the effectiveness of a single, nurse-led transitional home visit (home visit) program, for acutely ill, pediatric patients, which had been piloted at our institution. As part of the overall study design, building on prior randomized control trials that utilized a run-in period prior to the trial, our study team designed an optimization period to test the home visit and study procedures under real-world conditions.

Methods:

For this optimization project, there were 3 process improvement goals: to improve the referral process to the home visit, to optimize the home visit content, and to define and operationalize measures of patient- and family-centered outcomes to be used in the subsequent randomized control trial. During the optimization period, a multidisciplinary study team met weekly to review family and stakeholder feedback about the iterative modifications made to the home visit process, content, and outcome measures.

Results:

Optimization home visits were completed with 301 families across a variety of discharge diagnoses. The outcomes planned for the clinical trial were tested and refined. Feedback from families and stakeholders indicated that the content changes made to the home visits resulted in increased family knowledge of warning signs to monitor postdischarge. Thirty-one percent of families reported that they altered the care of their child after the home visit.

Conclusion:

Through iterative testing, informed by multistakeholder feedback, we leveraged patient and family engagement to maximize the effectiveness and generalizability of the home visit intervention.

The role of the nurse and the preoperative assessment in patient transitions

Transitions in care in the perioperative environment are numerous and should be considered high-risk endeavors. The preoperative area is the first transition in care for a surgical patient and should be considered a critical dimension of care transition. The purposes of this study were to identify nursing's contributions to transitions in care in the perioperative environment and to identify the role of the preoperative assessment in this transition. Qualitative descriptive design was used. Focus groups were conducted with 24 nurses in a 975-bed medical center. The themes that arose in the focus groups were: (1) understanding patient vulnerabilities, (2) multidimensional communication, (3) managing patients' expectations, and (4) nursing's role in compensating for gaps. We conclude that the nurse's role in the preoperative assessment during the transition of preoperative care is that of advocate who identifies the patient's needs and risk factors that may be affected by the surgical experience. This study suggests that the nursing preoperative assessment can be useful in identifying and defining patients' risk factors not just for surgery, but for the entire perioperative care trajectory.

Managing Chronic Illness

Models of care coordination can significantly improve health outcomes for older adults with chronic illnesses if they can engage participants. The purpose of this study was to examine the impact of nursing contact on the rate of participants' voluntary disenrollment from a care coordination program. In this retrospective cohort study using administrative data for 1,524 participants in the Health Quality Partners Medicare Care Coordination Demonstration Program, the rate of voluntary disenrollment was approximately 11%. A lower risk of voluntary disenrollment was associated with a greater proportion of in-person (vs. telephonic) nursing contact (Hazard Ratio [HR] 0.137, confidence interval [CI] [0.050, 0.376]). A higher risk of voluntary disenrollment was associated with lower continuity of nurses who provided care (HR 1.964, CI [1.724, 2.238]). Findings suggest that in-person nursing contact and care continuity may enhance enrollment of chronically ill older adults and, ultimately, the overall health and well-being of this population.

Systematic review of planned care transitions for persons with dementia

A systematic review was conducted to identify, categorize and summarize available research on planned care transitions or relocations for persons with dementia (PWD) in order to help guide best practice. Articles were identified by keyword searches of electronic databases, and a soft search of references of relevant articles. The review found that planned care transitions in PWD are associated with an increase in undesirable outcomes, particularly immediately post-transition, and that caregivers are often underutilized in care planning and underprepared for care transitions. It is recommended that transitional care interventions for PWD make explicit efforts to enhance caregiver involvement, provide social and pragmatic support for PWD and their caregivers and offer assistance in managing behavioral and psychological symptoms of dementia.

A review of family carers' experiences of hospital discharge for people with dementia, and the rationale for involving service users in health research

In the UK, service user involvement is an important factor in health policy, and obtaining research funding. It may be helpful in expanding our knowledge in areas where research evidence is poor such as experiences of hospital discharge planning for the family carers of people with dementia.

Developing a rural transitional care community case management program using clinical nurse specialists

PURPOSE

This quality improvement project developed a community nursing case management program to decrease preventable readmissions to the hospital and emergency department by providing telephonic case management and, if needed, onsite assessment and treatment by a clinical nurse specialist (CNS) with prescriptive authority.

BACKGROUND

As more people reach Medicare age, the number of individuals with worsening chronic diseases with dramatically increases unless appropriate disease management programs are developed.

RATIONALE

Care transitions can result in breakdown in continuity of care, resulting in increased preventable readmissions, particularly for indigent patients. The CNS is uniquely educated to managing care transitions and coordination of community resources to prevent readmissions.

DESCRIPTION

After a thorough SWOT (strengths, weaknesses, opportunities, and threats) analysis, we developed and implemented a cost-avoidance model to prevent readmissions in our uninsured and underinsured patients.

OUTCOMES

The project CNS used a wide array of interventions to decrease readmissions. In the last 2 years, there have been a total of 22 less than 30-day readmissions to the emergency department or hospital in 13 patients, a significant decrease from readmissions in these patients prior to the program. Three of them required transfer to a larger hospital for a higher level of care.

CONCLUSION

Using advanced practice nurses in transitional care can prevent readmissions, resulting in cost avoidance. The coordination of community resources during transition from hospital to home is a job best suited to CNSs, because they are educated to work within organizations/systems.

IMPLICATIONS

The money we saved with this project more than justified the cost of hiring a CNS to lead it. More research is needed into this technology. Guidelines for this intervention need to be developed. Replicating our cost-avoidance transitional care model can help other facilities limit that loss.

TRACER: an 'eye-opener' to the patient experience across the transition of care in an internal medicine resident program

Background

A safe patient transition requires a complex set of physician skills within the interprofessional practice.

Objective

To evaluate a rotation which applies self-reflection and workplace learning in a TRAnsition of CarE Rotation (TRACER) for internal medicine (IM) residents. TRACER is a 2-week required IM resident rotation where trainees join a ward team as a quality officer and follow patients into postacute care.

Methods

In 2010, residents participated in semistructured, one-on-one interviews as part of ongoing program evaluation. They were asked what they had learned on TRACER, the year prior, and how they used those skills in their practice. Using transcripts, the authors reviewed and coded each transcript to develop themes.

Results

Five themes emerged from a qualitative, grounded theory analysis: seeing things from the other side, the ‘ah ha’ moment of fragmented care, team collaboration including understanding nursing scope of practice in different settings, patient understanding, and passing the learning on. TRACER gives residents a moment to breathe and open their eyes to the interprofessional practice setting and the patient's experience of care in transition.

Conclusions

Residents learn about transitions of care through self-reflection. This learning is sustained over time and is valued enough to teach to their junior colleagues.

How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery

Transition care is increasingly common for older people, yet little is known about the subjective experience of the transition care 'journey' from the perspective of clients themselves. This study examines how older people cope with frailty within the context of a dedicated transition care programme and discusses implications for improving service delivery. Qualitative in-depth interviews were carried out during 2011 in the homes of 20 older people who had recently been discharged from a transition care programme operating in Adelaide, South Australia (average age 80 years, 65% female). Thematic analysis identified three key themes: 'a new definition of recovery', 'complexities of control' and 'the disempowering system'. Despite describing many positive aspects of the programme, including meeting personal milestones and a renewed sense of independence, participants recognised that they were unlikely to regain their previous level of functioning. For some, this was exacerbated by lacking control over the transition care process while adapting to their new level of frailty. Overall, this research highlighted that benefits associated with transition care can be undermined by fragmentation in service delivery, loss of control and uncertainties around future support.

Using a Scorecard to Demonstrate Clinical Nurse Specialists’ Contributions

Clinical nurse specialists (CNSs) have the expertise to influence change at the patient, nurse, and system levels. They are clinical experts who understand the challenges of the current health care environment: decreasing costs, ensuring high-quality care, and achieving outcomes. Evidence has demonstrated CNSs’ influence on improving patient outcomes. Although CNSs often lead the work, they can be invisible when the outcomes are presented. A scorecard to display this work could be invaluable to the CNS role, as it would bring transparency to the evidence-based work done. This article describes the development of a CNS scorecard in a 627-bed tertiary hospital.

Rural geriatric glue: a nurse practitioner-led model of care for enhancing primary care for frail older adults within an ecosystem approach

OBJECTIVES

This article describes the implementation of the Care for Seniors model of care, an innovative approach to improving care coordination and integration, and provides preliminary evidence of effective use of specialist resources and acute care services.

DESIGN

Retrospective.

SETTING

Primary care; cross-sector.

PARTICIPANTS

Older adults living in a rural area in southwestern Ontario, Canada.

MEASUREMENTS

Number of new geriatrician referrals and follow-up visits before and after the launch of the Care for Seniors program, number of Nurse Practitioner visits in a primary care setting, in-home, retirement home and hospital, number of discharges home from hospital and length of hospital stay between.

RESULTS

In the 2 years before the launch of the program, the total number of visits to the geriatrician for individuals from this FHT was relatively low, 21 and 15, respectively for 2005-06 and 2006-07, increasing to 73 for the 2011-12 year. Although the absolute number of individuals supported by the NP-Geri has remained relatively the same, the numbers seen in the primary care office or in the senior's clinic has declined over time, and the number of home visits has increased, as have visits in the retirement homes. The percentage of individuals discharged home increased from 19% in 2008-09 to 31% in 2009-10 and 26% in 2011-12 and the average length of stay decreased over time.

CONCLUSIONS

This model of care represents a promising collaboration between primary care and specialist care for improving care to frail older adults living in rural communities, potentially improving timely access to health care and crisis intervention.

Studying nursing interventions in acutely ill, cognitively impaired older adults

OVERVIEW

Although it increases the risk of poor outcomes and raises the costs of care, cognitive impairment in hospitalized older adults is often neither accurately identified nor well managed. In conducting a two-phase, comparative-effectiveness clinical trial of the effects of three nursing interventions-augmented standard care, resource nurse care, and the transitional care model-on hospitalized older adults with cognitive deficits, a team of researchers encountered several challenges. For example, in assessing potential subjects for the study, they found that nearly half of those assessed had cognitive impairment, yet many family caregivers could not be identified or had no interest in participating in the study. One lesson the researchers learned was that research involving cognitively impaired older adults must actively engage clinicians, patients, and family caregivers, as well as address the complex process of managing postdischarge care.

Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults

AIM

This article reports the effects of three evidence-based interventions of varying intensity, each designed to improve outcomes of hospitalized cognitively impaired older adults.

MATERIALS & METHODS

In this comparative effectiveness study, 202 older adults with cognitive impairment (assessed within 24 h of index hospitalization) were enrolled at one of three hospitals within an academic health system. Each hospital was randomly assigned one of the following interventions: Augmented Standard Care (ASC; lower dose: n = 65), Resource Nurse Care (RNC; medium dose: n = 71) or the Transitional Care Model (TCM; higher dose: n = 66). Since randomization at the patient level was not feasible due to potential contamination, generalized boosted modeling that estimated multigroup propensity score weights was used to balance baseline patient characteristics between groups. Analyses compared the three groups on time with first rehospitalization or death, the number and days of all-cause rehospitalizations per patient and functional status through 6-month postindex hospitalization.

RESULTS

In total, 25% of the ASC group were rehospitalized or died by day 33 compared with day 58 for the RNC group versus day 83 for the TCM group. The largest differences between the three groups on time to rehospitalization or death were observed early in the Kaplan-Meier curve (at 30 days: ASC = 22% vs RNC = 19% vs TCM = 9%). The TCM group also demonstrated lower mean rehospitalization rates per patient compared with the RNC (p < 0.001) and ASC groups (p = 0.06) at 30 days. At 90-day postindex hospitalization, the TCM group continued to demonstrate lower mean rehospitalization rates per patient only when compared with the ASC group (p = 0.02). No significant group differences in functional status were observed.

CONCLUSION

Findings suggest that the TCM intervention, compared with interventions of lower intensity, has the potential to decrease costly resource use outcomes in the immediate postindex hospitalization period among cognitively impaired older adults.

An Analysis of Methodologies That Can Be Used to Validate if a Perioperative Surgical Home Improves the Patient-centeredness, Evidence-based Practice, Quality, Safety, and Value of Patient Care

Approximately 80 million inpatient and outpatient surgeries are performed annually in the United States. Widely variable and fragmented perioperative care exposes these surgical patients to lapses in expected standard of care, increases the chance for operational mistakes and accidents, results in unnecessary and potentially detrimental care, needlessly drives up costs, and adversely affects the patient healthcare experience. The American Society of Anesthesiologists and other stakeholders have proposed a more comprehensive model of perioperative care, the Perioperative Surgical Home (PSH), to improve current care of surgical patients and to meet the future demands of increased volume, quality standards, and patient-centered care. To justify implementation of this new healthcare delivery model to surgical colleagues, administrators, and patients and maintain the integrity of evidenced-based practice, the nascent PSH model must be rigorously evaluated. This special article proposes comparative effectiveness research aims or objectives and an optimal study design for the novel PSH model.

Case study: Transitional care for a patient with benign prostatic hyperplasia and recurrent urinary tract infections

Chronic urologic conditions, including benign prostatic hyperplasia, recurrent urinary tract infections, and urinary incontinence, are common in older adults. This article highlights the urologic and transitional care needs of an elderly, cognitively impaired male during and after an acute hospitalization. Collaboration between the patient, his family, the advanced practice nurse, primary care providers, and outpatient urology office are described. The importance of mutual goal setting and a focused plan for transitional care are discussed.

Care of the older adult in the emergency department: nurses views of the pressing issues

PURPOSE

The purpose of the study was to describe nurses' views of the issues to be addressed to improve care of the older adult in the emergency department (ED).

DESIGN AND METHODS

An exploratory content analysis examined the qualitative responses of 527 registered nurses from 49 U.S. hospitals who completed the Geriatric Institutional Profile.

RESULTS

5 central themes emerged from the analysis, representing a lack of older person hospital environment fit in the ED: (a) respect for the older adult and carers, (b) correct and best procedures and treatment, (c) time and staff to do things right, (d) transitions, and (e) a safe and enabling environment. The nurses offered solutions to address lack of fit, including modifications to the social climate, policies and procedures, care systems and processes, and physical design.

IMPLICATIONS

The nurses' descriptions of the pressing issues surrounding care of older adults in the ED provide useful information to consider when developing a senior-friendly ED. Results also illuminate solutions that can be taken to address issues. These solutions give direction for future intervention research.