Falling behind: a substantive theory of care for older people with cognitive impairment in acute settings

A narrative review of staff views about dementia care in hospital through the lens of a systems framework

Background

Significant numbers of people with dementia are admitted into acute settings. They are likely to face poor health outcomes during hospitalisation. There is the need to fully understand the care provided to people with dementia through novel methods such as a systems approach (i.e. human interactions, policy, environment and equipment).

Aim

The aim of this literature review is to explore hospital practitioners' views on dementia care and to analyse findings using a systems approach.

Methods

We conducted a narrative review of primary studies that examined dementia care in acute settings. We analysed a total of 33 papers using Thomas and Harden's thematic synthesis guidelines.

Results

Thirty-three papers met the inclusion criteria for the review. The findings were as follows: (1) staff-patient relationships (e.g. coping with difficult behaviour), (2) staff-family relationships (e.g. the benefits of involving families in patient care), (3) staff-staff relationships (e.g. building a robust multidisciplinary team), (4) staff-patient care decisions (e.g. decisions directly related to the patient), (5) the environment (e.g. difficulty in adjusting to the hospital environment), (6) policies (e.g. hospital bureaucratic processes) and (7) equipment (e.g. pain assessment tools).

Conclusion

The paper revealed multidimensional challenges in the provision of dementia care within hospitals. We conclude that training programmes, hospital policies and processes aimed at improving outcomes for patients with dementia should adopt a systems approach which focuses on the relational, environmental, procedural and instrumental aspects of the hospital system.

Nursing Care Management of Responsive Behaviors for Persons Living With Dementia in Acute Care Settings: An Integrative Review

The current integrative review was performed to understand how acute care nurses manage responsive behaviors among persons living with dementia (PLWD) in acute care settings. Eight studies were included, and three themes were developed: Person-Centered Approach, Non-Person-Centered Approach, and Facilitators and Barriers to Care Approaches. Nurses expressed difficulties in caring for hospitalized PLWD due to lack of knowledge of dementia care, pressure to work more efficiently, and prioritization of acute medical concerns. Nurses frequently used nonpharmacological approaches that required less time spent with patients. Results suggest that nurses in acute care settings require further education regarding dementia and person-centered care approaches for PLWD. Nursing management can support nurses' learning needs through education and policies to improve patient outcomes. [Journal of Gerontological Nursing, 49(2), 19-25.].

Nurse competence provides more individuality in the care of older hospitalized people

AIM

The aim of the study was to assess Registered Nurses' perceptions of general nurse competence, patient-centred care competence, and individuality in the care of older patients and to explore their associations.

DESIGN

A descriptive correlative survey.

METHODS

Data were collected using questionnaires at one Finnish university hospital during winter 2016-2017 amongst Registered Nurses (n = 223) and analyzedd statistically using descriptive and inferential statistics (ANOVA, Pearson's correlations coefficients) and path analysis.

RESULTS

Registered Nurses assessed their general competence, patient-centred care competenc,e and individuality in the care of older patients at a good level. The Path model confirmed general nurse competence was a predictor of patient-centred care competence, which in turn was a predictor of individuality in the nursing care of older patients. The novelty lies in empirical confirmation of the association between nurse competence and individuality in the care. Increasing competence may enhance individuality in the care of older people and enable interventions to support care outcomes.

Disjunctures in practice: ethnographic observations of orthopaedic ward practices in the care of older adults with hip fracture and presumed cognitive impairment

Organisational priorities for health care focus on efficiency as the health and care needs of populations increase. But evidence suggests that excessive planning can be counterproductive, leading to resistance from staff and patients, particularly those living with cognitive impairment. The current paper adds to this debate reporting an Institutional Ethnography of staff delivering care for older patients with cognitive impairment on acute orthopaedic wards in three National Health Service hospitals in the United Kingdom. A key problematic identified in this study is the point of disjuncture seen between the actualities of staff experience and intentions of protocols and policies. We identified three forms of disjuncture typified as: ‘disruptions’, where sequenced care was interrupted by patient events; ‘discontinuities’, where divisions in professional culture, space or time interrupted sequenced tasks; and ‘dispersions’, where displaced objects or people interrupted sequenced care flow. Arguably disruption is an integral characteristic of care work; it follows that to enable staff to flourish, organisations need to confer staff the autonomy to address systemic disruptions rather than attempt to eradicate them. Ultimately, organisational representations of ‘good practice’ as readily joined up, impose a care standard ‘stereotype’ that obscures rather than clarifies the interactional problems encountered by staff.

COVID-19 related visiting ban in nursing homes as a source of concern for residents’ family members: a cross sectional study

Background

Visiting a close relative who resides in a nursing home is an opportunity for family members to extend their caring roles and find reassurance that the older person’s life is continuing as well as possible. At the same time, visits allow family members to observe the quality of formal care in the facility. In Finland, the COVID-19 pandemic led to the imposition of visiting bans in nursing homes in March 2020, thereby preventing customary interaction between residents and their family members. The aim of this study is to investigate family members’ experiences of the visiting ban and its effects on their concern over the wellbeing of close relatives living in nursing homes.

Methods

A cross-sectional study was conducted to explore family members’ self-reported concerns and the factors associated with those concerns. In the context of this unpredictable pandemic, this was considered an appropriate approach, as information at the very beginning of the visiting ban was sought, and causal relations were not investigated. The data consist of a quantitative survey (n = 366) conducted among family members in May–June 2020. Binary logistic regression analyses were performed to explore the association between the independent variables and reported concern.

Results

The results showed that increased concern was extremely common (79%). The factors associated with this notable increase were adequacy of contact and information, observations of changes in the wellbeing of the relative in question, and doubts over the appropriateness of the visiting restriction.

Conclusions

In light of the findings, care providers should improve their information provision to residents’ family members and find new ways of allowing visits to nursing homes in the future in all circumstances.

New horizons for caring for people with dementia in hospital: the DEMENTIA CARE pointers for service change

Approximately two-thirds of hospital admissions are older adults and almost half of these are likely to have some form of dementia. People with dementia are not only at an increased risk of adverse outcomes once admitted, but the unfamiliar environment and routinised practices of the wards and acute care can be particularly challenging for them, heightening their confusion, agitation and distress further impacting the ability to optimise their care. It is well established that a person-centred care approach helps alleviate some of the unfamiliar stress but how to embed this in the acute-care setting remains a challenge. In this article, we highlight the challenges that have been recognised in this area and put forward a set of evidence-based 'pointers for service change' to help organisations in the delivery of person-centred care. The DEMENTIA CARE pointers cover areas of: dementia awareness and understanding, education and training, modelling of person-centred care by clinical leaders, adapting the environment, teamwork (not being alone), taking the time to 'get to know', information sharing, access to necessary resources, communication, involving family (ask family), raising the profile of dementia care, and engaging volunteers. The pointers extend previous guidance, by recognising the importance of ward cultures that prioritise dementia care and institutional support that actively seeks to raise the profile of dementia care. The pointers provide a range of simple to more complex actions or areas for hospitals to help implement person-centred care approaches; however, embedding them within the organisational cultures of hospitals is the next challenge.

Making clinical care decisions with people living with dementia in hospital: An integrative literature review

BACKGROUND

As our population ages, the percentage of hospitalised patients diagnosed with dementia is expected to rise. However, there is emerging evidence that people living with dementia may experience discrimination and exclusion from decisions about their clinical care. Although dementia affects cognition, many patients living with dementia want to participate in decision-making processes relating to their clinical care in hospital.

OBJECTIVE

Identify the processes associated with making decisions about clinical care with people living with dementia in hospital.

DESIGN

An integrative literature review.

DATA SOURCES

Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus, EMBASE (Ovid), MEDLINE (PubMED), PsycINFO and HeinOnline.

REVIEW METHOD

One author conducted the initial screening of titles, and two authors screened in subsequent rounds for abstracts and full text. The process of making clinical decisions was the outcome of interest. Articles about people with cognitive impairment that did not include dementia, or decisions such as discharge planning or end of life care were excluded. An inductive synthesis of the findings was undertaken.

RESULTS

Nine articles were identified for review and included expert opinion or hypothetical discussion (n=5), cross-sectional survey research (n=3), and qualitative research (n=1). Three themes were identified: capacity for decision-making is conceptualised as 'all or nothing'; there are no universal principles for including people living with dementia in decision-making in acute care settings; and autonomy is recognised but superseded by beneficence.

CONCLUSIONS

Contemporary hospital practice is focused on determining capacity for decisions, with an all or nothing attitude to capacity, effectively excluding many people living with dementia from participation in decisions. While there is limited evidence to guide clinicians in this complex and situated process of making clinical decisions, emerging models of supported decision-making require further evaluation in the hospital setting.

Validating the Hebrew version of the Person-Centered Care of Older People with Cognitive Impairment in Acute Care scale

AIM

To validate the Hebrew version of the Person-Centered Care of Older People with Cognitive Impairment in the Acute Care scale.

BACKGROUND

The Person-Centered Care of Older People with Cognitive Impairment in Acute Care scale is a reliable and valid measure to assess the extent to which person-centred care among people with dementia is adopted in the acute care setting.

METHODS

A cross-sectional study using a self-reporting structured questionnaire was conducted with 678 professionals (69% nurses, 26% physicians, 5% other health care professionals) in five hospitals across Israel.

RESULTS

Similar to other languages, best results were obtained using 14 of the 15 items included in the original scale. Confirmatory factor analysis indicated the appropriateness of a three-factor structure for the Hebrew version of the scale. Cronbach's alpha scores for these factors were moderate to good.

CONCLUSIONS

The Hebrew version of the scale is a reliable and valid tool for assessing hospital professionals' perceptions of person-centred care.

IMPLICATIONS FOR NURSING MANAGEMENT

A new language validated version of the scale will allow nurse managers to learn from multiple countries' experience while conducting international comparisons. Such developments will improve and expand the implementation of the person-centred care among people with dementia in hospital settings.

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.

Patient-centredness in acute stroke care - a qualitative study from the perspectives of patients, relatives and staff

BACKGROUND AND PURPOSE

Although patient-centredness is considered a key component of high-quality neurological care, it is unclear to what extent it can or should be implemented during the acute phase. Using acute stroke as an example, the aim was to identify critical junctures for patient-centredness along the acute care pathway from the perspectives of patients, relatives and staff.

METHODS

A qualitative multi-method study was conducted including 27 non-participant observations and 37 semi-structured interviews with patients, relatives and staff. Junctures were defined as critical when mentioned (as problematic) in two or three information sources (i.e. observations, staff interviews, or patient and relative interviews), as potentially critical when mentioned in one, and as uncritical when not mentioned.

RESULTS

Post-procedure communication after thrombectomy, patients' stay at the stroke unit and decision-making around transfer, discharge and rehabilitation were identified as critical junctures for patient-centredness. Arrival at the emergency department and the (thrombectomy) treatment itself were identified as uncritical junctures, whilst history-taking and treatment preparation, the treatment decision and patients' stay at the intensive care unit were identified as potentially critical junctures.

CONCLUSIONS

In acute stroke care, patients, relatives and staff prioritize fast over patient-centred decision-making in the most time-critical phases, especially before and during treatment. This is reversed after the procedure, when difficulties arise implementing a patient-centred approach in clinical practice. To improve patient-centredness where it is most needed, clear guidelines and accessible resources are recommended. Future research should investigate whether insights from acute phases of stroke care are applicable to other neurological conditions as well.

The experiences of hospital staff who provide care for people living with dementia: A systematic review and synthesis of qualitative studies

AIMS AND OBJECTIVES

To systematically review and synthesise qualitative data from studies exploring the experiences of hospital staff who care for people living with dementia (Plwd).

BACKGROUND

In hospital, the number of Plwd continues to rise; however, their experiences of care remain problematic. Negative experiences of care are likely to contribute to poorer mental and physical health outcomes for Plwd while in hospital and after discharge. Experiences of the hospital staff who care for Plwd can also be poor or unrewarding. It is important to understand the experiences of staff in order to improve staff well-being and ultimately the experience of care for Plwd while in hospital.

DESIGN

Systematic review and evidence synthesis of qualitative research.

DATA SOURCES

We searched 16 electronic databases in March 2018 and completed forward and backward citation chasing.

METHODS

Eligible studies explored the experiences of paid and unpaid staff providing care in hospital for Plwd. Study selection was undertaken independently by two reviewers, and quality appraisal was conducted. We prioritised included studies according to richness of text, methodological rigour and conceptual contribution. We adopted approaches of meta-ethnography to analyse study findings, creating a conceptual model to represent the line of argument.

FINDINGS

Forty-five studies reported in 58 papers met the inclusion criteria, and of these, we prioritised 19 studies reported in 24 papers. The line of argument was that Institutions can improve staff experiences of care for Plwd by fostering person-centred care (PCC). PCC aligned with staff perceptions of 'good care'; however, staff often felt prevented from providing PCC because of care cultures that prioritised tasks, routines and physical health. Staff experienced conflict over the care they wanted to give versus the care they were able to give, and this caused moral distress. When staff were able to provide PCC, this increased experiences of job satisfaction and emotional well-being.

CONCLUSIONS

Person-centred care not only has the potential to improve the experience of care for Plwd and their carers, but can also improve the experiences of hospital staff caring for Plwd. However, without institutional-level changes, hospital staff are often unable to provide PCC even when they have the experience and knowledge to do so.

IMPLICATIONS FOR PRACTICE

Institutional-level areas for change include the following: training; performance indicators and ward cultures that prioritise psychological needs alongside physical needs; adequate staffing levels; inclusive approaches to carers; physical environments that promote familiarisation, social interaction and occupation; systems of documentation about individual needs of Plwd; and cultures of sharing knowledge across hierarchies.

Facilitators for person-centred care of inpatients with dementia: A meta-synthesis of registered nurses’ experiences

Person-centred care is widely advocated when caring for people with dementia. When a person with dementia is admitted for hospital care, hospital wards are obliged to not only address the cause for admission but also provide dementia-specific care during the hospital stay. Research has shown that the delivery of person-centred care to people with dementia is often inadequate or absent in the hospital setting. Moreover, whilst registered nurses often wish to improve the in-hospital care of patients with dementia, there is evidence of experienced barriers. This study aimed to describe registered nurses’ experiences of facilitators for the delivery of person-centred care to inpatients with dementia. By way of systematic searches in the databases PubMed, CINAHL and PsycINFO, qualitative studies (n = 19) reporting registered nurses experience of caring for inpatients with dementia were identified. Relevant content was analysed using a method of thematic synthesis. Three main categories and nine subcategories were presented, internal facilitators (experience and knowledge; values and beliefs; professional identity; empathy), external facilitators (physical environment; organisational culture and structure) and facilitating actions (forming a holistic picture; establishing trust; adjusting routines and interventions). While facilitators did exist in the hospital setting, the findings indicate that care received by inpatients with dementia is dependent on individual registered nurses knowledge, personal aptitude and ability to compensate for structural flaws. In order to minimise arbitrary outcomes of care for patients with dementia, consistent organisational support in the form of educational interventions and allocation of resources is crucial.

Nurses' Experiences in Caring for Older Adults With Responsive Behaviors of Dementia in Acute Care

Introduction: Approximately 56,000 individuals with dementia were admitted to Canadian hospitals in 2016, and 75% of them experience responsive behaviors. Responsive behaviors are words or actions used to express one's needs (e.g., wandering, yelling, hitting, and restlessness). Health-care professionals perceive these behaviors to be a challenging aspect in providing care for persons with dementia.

Aims: This study explores the perceptions of nurses about (a) caring for older adults with dementia experiencing responsive behaviors in acute medical settings and (b) recommendations to improve dementia care.

Methods: Thorne's interpretive description approach was used. In-person, semistructured interviews were conducted with 10 nurses and 5 allied health professionals from acute medical settings in an urban hospital in Ontario. Interviews were conducted with allied health professionals to understand their perspectives regarding care delivery for persons with responsive behaviors of dementia. Data were analyzed using Braun and Clarke's experiential thematic analysis.

Findings: Themes related to caring for individuals with responsive behaviors included (a) delivering care is a complex experience, (b) using pharmacological strategies and low investment nonpharmacological strategies to support older adults with responsive behaviors, (c) acute medical settings conflicted with principles of dementia care due to a focus on acute care priorities and limited time, and (d) strong interprofessional collaboration and good continuity of care were facilitators for care.

Conclusions: Findings provide guidance for improved support for nurses who provide care for individuals experiencing responsive behaviors in acute medical settings such as increasing staffing and providing educational reinforcements (e.g., annual review of dementia care education and in-services).

Involvement of Hospitalized Persons With Dementia in Everyday Decisions: A Dyadic Study

Background and Objectives

To examine the involvement of persons with dementia (PWDs) in everyday decision making from the perspectives of hospitalized PWDs and their family caregivers, and to identify determinants thereof.

Research Design and Methods

Using multilevel modeling, we examined cross-sectional data collected prospectively from 42 family care dyads regarding the care values of the PWD.

Results

Both members of the dyad rated the PWD, on average, as being "somewhat involved". There was a significant amount of variability around the average perceptions of PWD involvement in decision making for both PWDs (χ2 = 351.02, p < .001) and family caregivers (χ2 = 327.01, p < .001). Both PWDs and family caregivers were significantly more likely to perceive greater PWD involvement in decision making when the family caregiver reported the PWD as valuing autonomy. Additionally, PWDs were significantly more likely to report greater involvement when they had greater cognitive function. Finally, family caregivers perceived significantly greater involvement of the patient in decision making when they reported less strain in the relationship. Together, autonomy, relationship strain, cognitive function, and care-related strain accounted for 38% and 46% of the variability in PWDs' and family caregivers' perceptions, respectively, of the PWD's decision-making involvement.

Discussion and Implications

Although research indicates that decision-making abilities decline with advancing dementia, these results imply that working with families to support PWDs in their value of autonomy and mitigate strain in the dyad's relationship may help prolong PWDs' decision-making involvement.

The Person, Interactions and Environment Programme to improve care of people with dementia in hospital: a multisite study

Background

Improving the care of people with dementia on acute hospital wards is a policy priority. Person-centred care is a marker of care quality; delivering such care is a goal of service improvement.

Objectives

The Person, Interactions and Environment (PIE) Programme comprises an observation tool and a systematic approach to implement and embed a person-centred approach in routine care for hospitalised patients with dementia. The study aims were to evaluate PIE as a method to improve the care of older people with dementia on acute hospital wards, and develop insight into what person-centred care might look like in practice in this setting.

Methods

We performed a longitudinal comparative case study design in 10 purposively selected wards in five trusts in three English regions, alongside an embedded process evaluation. Data were collected from multiple sources: staff, patients, relatives, organisational aggregate information and documents. Mixed methods were employed: ethnographic observation; interviews and questionnaires; patient case studies (patient observation and conversations ‘in the moment’, interviews with relatives and case records); and patient and ward aggregate data. Data were synthesised to create individual case studies of PIE implementation and outcomes in context of ward structure, organisation, patient profile and process of care delivery. A cross-case comparison facilitated a descriptive and explanatory account of PIE implementation in context, the pattern of variation, what shaped it and the consequences flowing from it. Quantitative data were analysed using simple descriptive statistics. A qualitative data analysis employed grounded theory methods.

Results

The study furthered the understanding of the dimensions of care quality for older people with dementia on acute hospital wards and the environmental, organisational and cultural factors that shaped delivery. Only two wards fully implemented PIE, sustaining and embedding change over 18 months. The remaining wards either did not install PIE (‘non-implementers’) or were ‘partial implementers’. The interaction between micro-level contextual factors [aspects of leadership (drivers, facilitators, team, networks), fit with strategic initiatives and salience with valued goals] and meso- and macro-level organisational factors were the main barriers to PIE adoption. Evidence suggests that the programme, where implemented, directly affected improvements in ward practice, with a positive impact on the experiences of patients and caregivers, although the heterogeneity of need and severity of impairment meant that some of the more visible changes did not affect everyone equally.

Limitations

Although PIE has the potential to improve the care of people with dementia when implemented, findings are indicative only: data on clinical outcomes were not systematically collected, and PIE was not adopted on most study wards.

Research implications

Further research is required to identify more precisely the skill mix and resources necessary to provide person-focused care to hospitalised people with dementia, across the spectrum of need, including those with moderate and severe impairment. Implementing innovations to change practices in complex organisations requires a more in-depth understanding of the contextual factors that have an impact on the capacity of organisations to absorb and embed new practices.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Incongruent perceptions of the care values of hospitalized persons with dementia: a pilot study of patient-family caregiver dyads

OBJECTIVE

Many difficult decisions are made in the inpatient hospital setting regarding the daily care of persons with dementia (PWDs). Incongruent perceptions of the PWD's care values limit the family caregiver's ability to make surrogate decisions. The objectives of this pilot study were to describe and identify determinants of incongruent perceptions in the hospital setting.

METHODS

Using multilevel modeling (MLM), we examined cross-sectional data collected from 42 PWD-family caregiver dyads.

RESULTS

There was a significant amount of incongruence, on average, for all four subscales representing the PWD's care values: autonomy = -0.33 (p < .001); burden = -.49 (p < .001); safety/quality of care = -.26 (p < .001); and social interactions = -.21 (p = .004). Family caregivers (CG) rated the importance of care values to the PWD as lower than the PWD rated the importance. Determinants of greater incongruence included higher relationship strain and fewer positive dyadic interactions.

CONCLUSION

Our findings reveal significant levels of incongruence in perceptions of the PWD's values among dementia care dyads in the hospital setting. Our analysis suggests a potential impact of relationship variables on incongruence. Further research is needed around this overlooked interpersonal context for supporting the dementia care dyad in the hospital setting.

Delirium in older hospitalized patients-signs and actions: a retrospective patient record review

Background

Delirium is common in older hospitalized patients, and is associated with negative consequences for the patients, next of kin, healthcare professionals and healthcare costs. It is important to understand its clinical features, as almost 40% of all cases in hospitals may be preventable. Yet, delirium in hospitalized patients is often unrecognized and untreated. Few studies describe thoroughly how delirium manifests itself in older hospitalized patients and what actions healthcare professionals take in relation to these signs. Therefore, the aim of this study was to describe signs of delirium in older hospitalized patients and action taken by healthcare professionals, as reported in patient records.

Methods

Patient records from patients aged ≥65 (n = 286) were retrospectively reviewed for signs of delirium, which was found in 78 patient records (27%). Additionally, these records were reviewed for action taken by healthcare professionals in relation to the patients’ signs of delirium. The identified text was analyzed with qualitative content analysis in two steps.

Results

Healthcare professionals responded only in part to older hospitalized patients’ needs of care in relation to their signs of delirium. The patients displayed various signs of delirium that led to a reduced ability to participate in their own care and to keep themselves free from harm. Healthcare professionals met these signs with a variation of actions and the care was adapted, deficient and beyond the usual care. A systematic and holistic perspective in the care of older hospitalized patients with signs of delirium was missing.

Conclusion

Improved knowledge about delirium in hospitals is needed in order to reduce human suffering, healthcare utilization and costs. It is important to enable older hospitalized patients with signs of delirium to participate in their own care and to protect them from harm. Delirium has to be seen as a preventable adverse event in all hospitals units. To improve the prevention and management of older hospitalized patients with signs of delirium, person-centered care and patient safety may be important issues.

Reconciling conceptualizations of ethical conduct and person-centred care of older people with cognitive impairment in acute care settings

Key commentators on person-centred care have described it as a "new ethic of care" which they link inextricably to notions of individual autonomy, action, change and improvement. Two key points are addressed in this article. The first is that few discussions about ethics and person-centred are underscored by any particular ethical theory. The second point is that despite the espoused benefits of person-centred care, delivery within the acute care setting remains largely aspirational. Choices nurses make about their practice tend to comply more often with prevailing norms than those championed by person-centred care. We draw on elements of work by moral philosopher Løgstrup and Foucault to provide insight into nurses' ethical conduct and ask why nurses would want to act otherwise, when what they think and do is viewed as normal, or think and act otherwise if doing so is seen within the organization as transgressive? To address these more specific questions, we discuss them in relation to the following constructs: the ethical demand, sovereign expressions of life and parrhêsia. We conclude by arguing that a ethical theoretical framework enables nurses to increase their perceptibility and appreciation of the ethical demand particularly those emanating from incommensurability between organizational norms and the norms invoked by person-centred care. We argue that nurses' responses to the ethical demand by way of parrhêsia can be an important feature of intra-organizational reflexivity and its transformation towards the delivery care that is more person-centred, particularly for older people with cognitive impairment. We conclude the article by highlighting the implications of this for nursing education and research.

The liminality of the patient with dementia in hospital

AIMS AND OBJECTIVES

The aim was to explore the experiences of people with dementia in subacute geriatric rehabilitation hospitals to critically evaluate the care received by such patients.

BACKGROUND

Globally, the number of people with dementia is growing and is expected to impact progressively more on health systems. People with dementia can become deconditioned and deteriorate in cognitive function while in hospital. The unfamiliar environment and people can cause the person to become disorientated, which then leads to behavioural symptoms which complicate care.

DESIGN

Critical ethnography.

METHODS

Methods included observation with field notes and 30 audio-recorded conversational interviews with patients with dementia in an Australian subacute care setting. Data were collected in May-December 2014, transcribed verbatim and analysed using thematic analysis.

RESULTS

The central theme identified that patients with dementia described a liminal experience and felt like outsiders in the hospital environment. This was supported by the subthemes of not understanding why they were being kept in hospital, feeling lost in the space, bored, anxious about discharge plans and lacking intersubjective relationships. Many felt imprisoned by the locked wards. There was little evidence of nursing care delivered in an empathetic person-centred way. Nurses were busy and engaged with the patients only superficially.

CONCLUSIONS

People with dementia can have a liminal experience and feel like outsiders in this environment, which does not cater for the specific needs of this patient group. It should be acknowledged that people with dementia require additional resources. A caring nurse-patient relationship is fundamental to the patient experience. Nurses require further support and education about dementia in order to deliver quality care to this patient group.

RELEVANCE TO CLINICAL PRACTICE

These findings will influence nurse leaders to advocate for improved resources for nurses to provide appropriate care for patients with dementia in subacute geriatric hospitals. The clinical practice of nurses needs to be supported with education, pyschological and material support to improve the therapeutic environment for patients with cognitive impairment resulting from dementia.

Workplace continuing education for nurses caring for hospitalised older people

AIMS AND OBJECTIVES

To develop, implement and evaluate a workplace continuing education programme about nursing care of hospitalised older people.

BACKGROUND

The healthcare system cannot rely solely upon nurses' prelicensure education to prepare them to meet the evolving needs of hospitalised older patients. Over the past decade, there has been a dramatic rise in the proportion of older people in hospitals, yet many nurses do not have specialised knowledge about the unique care needs of this population.

DESIGN

A multimethod pre-to post-design was employed.

METHODS

Between September 2013 and April 2014, data were collected via surveys, focus groups and interviews. Thirty-two Registered Nurses initially enrolled in the programme of which 22 completed all data points. Three managers also participated in interviews. One-way repeated-measures ANOVAs were conducted to evaluate the effect of the programme and change over time. Qualitative data were analysed using thematic analysis.

RESULTS

Survey results indicated improvements in perceptions about nursing care of older people but no changes in knowledge. Themes generated from the qualitative data focused on participants' experiences of taking part in the programme and included: (i) relevance of content and delivery mode, (ii) value of participating in the programme and (iii) continuing education in the context of acute care.

CONCLUSIONS

This study illustrated the potential role of workplace continuing education in improving care for hospitalised older people, particularly the potential to change nurses' perceptions about this population. Nurses prefer learning opportunities that are varied in delivery of educational elder-focused content and accessible at work. Organisational leaders need to consider strategies that minimise potential barriers to workplace continuing education.

IMPLICATIONS FOR PRACTICE

Workplace continuing education can play a key role in improving quality of care for hospitalized older adults and ought to be a priority for employers planning education for nurses.

Optimising care for patients with cognitive impairment and dementia following hip fracture

The global shift in demographics towards aging populations is leading to a commensurate increase in age-related disease and frailty. It is essential to optimise health services to meet current needs and prepare for anticipated future demands. This paper explores issues impacting on people living with cognitive impairment and/or dementia who experience a hip fracture and are cared for in acute settings. This is important given the high mortality and morbidity associated with this population. Given the current insufficiency of clear evidence on optimum rehabilitation of this patient group, this paper explored three key themes namely: recognition of cognitive impairment, response by way of training and education of staff to optimise care for this patient group and review of the importance of outcomes measures. Whilst there is currently insufficient evidence to draw conclusions about the optimal ways of caring for patients living with dementia following hip fracture, this paper concludes that future research should improve understanding of healthcare staff education to improve the outcomes for this important group of patients.

The experience of people with dementia and nurses in hospital: an integrative review

AIMS AND OBJECTIVES

To identify and examine existing research exploring how people with dementia and nurses view acute hospital care.

BACKGROUND

Admission to hospital can be traumatic for a person with dementia due to an inability to cope with unfamiliar environments, faces and routines. Adverse behavioural and health outcomes can result. Dementia adds complexity to patient care. Inability to deliver appropriate care is a source of stress and frustration for nurses.

METHODS

Integrative review of the literature 2005-2015 reporting the experience of people with dementia and nurses caring for them in an acute hospital setting (n = 24).

RESULTS

Hospitals focus on acute medical care; consequently people with dementia are considered low priority and a disruption to normal routine. Risk management often takes priority over patient dignity. People with dementia are stigmatised. Families have significant roles to play in the care of a person with dementia in hospital but are often excluded. Nurses struggle to complete even basic patient care, and focus on tasks often at the expense of specific patient needs. Support for nurses is lacking. The job satisfaction of nurses caring for people with dementia is poor.

CONCLUSIONS

Nurses require improved education and support to care for patients with dementia. Hospitals must focus on genuine caring concurrently with rapid discharge requirements, risk mitigation and fiscal restraint. More research is needed to inform the development of appropriate care for people with dementia in hospitals.

RELEVANCE TO CLINICAL PRACTICE

Nurses must understand the complex needs of people with dementia in hospital. Nurse education about dementia, practical support, strong clinical leadership and role-modelling is needed. Empathy for patients regardless of diagnosis must remain a core attribute of nurses. Current hospital culture requires wider system review to mitigate against stigmatisation of patients with dementia.

Reconciling conceptualizations of relationships and person-centred care for older people with cognitive impairment in acute care settings

Relationships are central to enacting person-centred care of the older person with cognitive impairment. A fuller understanding of relationships and the role they play facilitating wellness and preserving personhood is critical if we are to unleash the productive potential of nursing research and person-centred care. In this article, we target the acute care setting because much of the work about relationships and older people with cognitive impairment has tended to focus on relationships in long-term care. The acute care setting is characterized by archetypal constraints which differentiate it from long-term care, in terms of acuity and haste, task-orientated work patterns and influence from "the rule of medicine," all of which can privilege particular types of relating. In this article, we drew on existing conceptualizations of relationships from theory and practice by tapping in to the intellectual resources provided by nurse researchers, the philosophy of Martin Buber and ANT scholars. This involved recounting two examples of dyadic and networked relationships which were re-interpreted using two complementary theoretical approaches to provide deeper and more comprehensive conceptualizations of these relationships. By re-presenting key tenets from the work of key scholars on the topic relationships, we hope to hasten socialization of these ideas into nursing into the acute care setting. First, by enabling nurses to reflect on how they might work toward cultivating relationships that are more salutogenic and consistent with the preservation of personhood. Second, by stimulating two distinct but related lines of research enquiry which focus on dyadic and networked relationships with the older person with cognitive impairment in the acute care setting. We also hope to reconcile the schism that has emerged in the literature between preferred approaches to care of the older person with cognitive impairment, that is person-centred care versus relationship-centred care by arguing that these are complementary rather than mutually exclusive and can be brought together in one theoretical framework acknowledging personhood as relational in essence.

The experience of caring for patients with dementia within a general hospital setting: a meta-synthesis of the qualitative literature

OBJECTIVES

The optimal care of people with dementia in general hospitals has become a policy and practice imperative over recent years. However, despite this emphasis, the everyday experience of staff caring for this patient group is poorly understood. This review aimed to synthesise the findings from recent qualitative studies in this topic published prior to January 2014 to develop knowledge and provide a framework to help inform future training needs.

METHOD

A systematic search of the literature was conducted across five academic databases and inclusion/exclusion criteria applied to the retrieved papers. A meta-ethnographic approach was utilised to synthesise the resulting 14 qualitative papers.

RESULTS

Five key themes were constructed from the findings: overcoming uncertainty in care; constraints of the environmental and wider organisational context; inequality of care; recognising the benefits of person-centred care; and identifying the need for training. These themes explore the opportunities and challenges associated with caring for this group of patients, as well as suggestions to improve staff experiences and patient care.

CONCLUSION

The synthesis highlighted a lack of knowledge and understanding of dementia within general hospital staff, particularly with regard to communication with patients and managing behaviours that are considered challenging. This limited understanding, coupled with organisational constraints on a busy hospital ward, contributed to low staff confidence, negative attitudes towards patients with dementia and an inability to provide person-centred care. The benefits of dementia training for both ward staff and hospital management and peer discussion/support for ward staff are discussed.

Factors influencing nurses' readiness to care for hospitalised older people

AIMS AND OBJECTIVES

To gain a better understanding of nurses' perspectives on factors that influence their readiness to provide appropriate care for hospitalised older people.

BACKGROUND

Hospitals have consistently been criticised for failing to address the unique, complex needs of older people. Research suggests that multiple issues have led to this situation, including a lack of educational preparation for nurses, limited attention to environmental factors, and an absence of organisational preparedness that ensures hospitals are adapted to meet the needs of older people.

DESIGN

An exploratory, qualitative approach was used.

METHODS

Forty-one Registered Nurses participated (24 point-of-care nurses; 17 organisational leaders). Six focus groups and one individual interview were conducted. Thematic data analysis was employed to generate the main study findings.

RESULTS

An overarching theme of 'Poor Fit' emerged. While participants identified the shifting needs of patients towards more complex and relational care, the broader organisational and societal contexts were, largely, unchanging. This resulted in nurses recognising the factors needed to be ready to care for older patients and their families, but working in hospitals that were not suited to these needs.

CONCLUSIONS

The findings identify factors at the point-of-care, the organisational level, and in broader societal attitudes that shape nurses' readiness to care for hospitalised older people. However, many of these factors are modifiable and care for older people could be improved through quality improvement initiatives and nursing leadership. This study offers insight into ways to re-imagine nursing care that can be responsive to older people's complex needs in hospitals.

IMPLICATIONS FOR PRACTICE

With a growing contingent of hospitalised older people, it is imperative that nurses, who comprise the largest workforce in this setting, be included in the planning and delivery of healthcare services to ensure readiness to meet the needs of this population.

Characteristics and Needs of Psychiatric Patients With Prolonged Hospital Stay

OBJECTIVE

To describe the characteristics and needs prior to, on admission, during the first month in hospital, at the thirtieth day of hospitalization and posthospital discharge of psychiatric patients occupying acute beds.

METHODS

This prospective observational study was conducted in 2 tertiary care hospitals. Adult patients hospitalized on a psychiatric unit for 30 days were identified. Data was collected from their medical charts and interviews with their health care team. The categorization of acute and nonacute status at day 30 was based on the health care professional's evaluation. Descriptive and univariate analyses were performed.

RESULTS

A total of 262 patients were identified (mean age 45 years), 66% lived at home and 11% were homeless. More than one-half were cognitively impaired and a few had special medical needs. Ninety-seven per cent had been admitted from the emergency department. At day 30, 81% of patients required acute care, while 19% (95% CI 15% to 24%) occupied an acute care bed, despite the resolution of their acute condition. The main reason preventing discharge of nonacute patients was the difficulty or inability to find appropriate resources that met patients' needs. As for patients who required acute care, the most common psychiatric issues were delusions or hallucinations (34%), inability to take medications independently (23.6%), and inadequate control of aggression or impulsivity (16.5%).

CONCLUSIONS

Prevention of the discharge of nonacute patients is largely due to the difficulty in finding appropriate resources that meet patients' needs. Improved access to community and subacute care resources could potentially facilitate the hospital discharge of psychiatric nonacute patients.

The experience of family carers of people with dementia who are hospitalised

Hospital admission of a person with dementia can have a significant impact on the family carer, who temporarily relinquishes caring to health professionals. A descriptive qualitative design using in-depth interviews with a conversational approach was used to elicit data. Adjusting to the change in the carer's role can be challenging and result in feelings of helplessness, loneliness, loss of control and being undervalued. Family support can assist with the transition but family conflict increases anxiety. Good communication between clinicians and the carer is vital. The carer should be included in decision-making as the 'expert' in the care of the person with dementia. This article discusses findings of a larger study specifically related to the emotional support required for the carers of people with dementia, who are admitted to hospital. The carer and the patient must be considered as a dyad in relation to discharge planning.

Measuring levels of person-centeredness in acute care of older people with cognitive impairment: evaluation of the POPAC scale

BACKGROUND

Person-centeredness is increasingly advocated in the literature as a gold-standard, best practice concept in health services for older people. This concept describes care that incorporates individual and multidimensional needs, personal biography, subjectivity and interpersonal relationships. However, acute in-patient hospital services have a long-standing biomedical tradition that may contrast with person-centred care. Since few tools exist that enable measurements of the extent to which acute in-patient hospital services are perceived as being person-centred, this study aimed to translate the English version of the Person-centred care of older people with cognitive impairment in acute care scale (POPAC) to Swedish, and evaluate its psychometric properties in a sample of acute hospital staff.

METHODS

The 15-item POPAC was translated, back-translated and culturally adjusted, and distributed to a cross-sectional sample of Swedish acute care staff (n = 293). Item performance was evaluated through assessment of item means, internal consistency by Cronbach's alpha on total and on subscale levels; temporal stability was assessed through Pearson's product correlation and intra-class correlation between test and retest scores. Confirmatory factor analysis was used to explore model fit.

RESULTS

The results indicate that the Swedish version POPAC provides a tentatively construct-valid and reliable contribution to measuring the extent to which acute in-patient hospital services have processes and procedures that can facilitate person-centred care of older patients with cognitive impairment. However, some questions remain regarding the dimensionality of POPAC.

CONCLUSIONS

POPAC provides a valuable contribution to the quest of improving acute care for older patients with cognitive impairment by enabling measures and subsequent accumulation of internationally comparable data for research and practice development purposes. POPAC can be used to highlight strengths and areas for improvements in care practice for older patients, and to illuminate aspects that risk being overlooked in busy acute hospital settings.