In-hospital medical complication in older people after spine surgery: a scoping review

OBJECTIVE

Worldwide, older people are suffering from lumbar degenerative disease at an annual rate of 266 million. Although spine surgeries restore mobility, reduce pain and resolve neurological damage, these procedures can place older persons at high-risk for medical complications due to multiple comorbid conditions that are often present in this population. However, the prevalence of complications occurring in older people prior to discharge is unknown. Postoperative medical complications lead to increased healthcare costs as well as pain and potential harm for the patient. Hence, this scoping review aimed to provide an overview of the current knowledge state regarding in-hospital medical postoperative complications in older people (≥65 years) after elective spine surgery.

METHOD

A scoping review was conducted following Arksey and O'Malley's framework. Four databases (PubMed, Cochrane, Scopus and CINAHL) were systematically searched. Inclusion criteria were medical complication(s) after elective spine surgery prior to discharge, age ≥65 years and English language. Co-occurrence analysis was used to examine how often each complication was examined in the literature and how often the complications co-occur.

RESULTS

Twenty-six studies met inclusion criteria. The most frequently examined postoperative medical complications after spine surgery are delirium and urinary tract infection, followed by gastrointestinal and pulmonary embolus. Despite the list of in-hospital medical complications, definitions or criteria for measurement of any identified complication were sparse and inconsistent. There is a lack of definition or instruments to comprehensively assess medical complications incurred by older people following spine surgery, including characteristics, classification methodology and temporality. To date, no research has been conducted on how older people experience or perceive a medical complication after elective spine surgery.

CONCLUSION

The findings highlight the importance to develop comprehensive instruments to assess co-occurrence of postoperative medical complications and design interventions to mitigate the negative impacts of medical complications incurred by older people after spine surgery.

Awakening Canadians to ageism: a study protocol

Background

Making fun of growing older is considered socially acceptable, yet ageist humour reinforces negative stereotypes that growing old is linked with physical and mental deterioration, dependence, and less social value. Such stereotypes and discrimination affect the wellbeing of older people, the largest demographic of Canadians. While ageism extends throughout professions and social institutions, we expect nurses—the largest and most trusted group of healthcare professionals—to provide non-ageist care to older people. Unfortunately, nurses working with older people often embrace ageist beliefs and nursing education programs do not address sufficient anti-ageism content despite gerontological nursing standards and competencies.

Methods

To raise awareness of ageism in Canada, this quasi-experimental study will be supported by partnerships between older Canadians, advocacy organizations, and academic gerontological experts which will serve as an advisory group. The study, guided by social learning theory, will unfold in two parts. In Phase 1, we will use student nurses as a test case to determine if negative stereotypes and ageist perceptions can be addressed through three innovative e-learning activities. The activities employ gamification, videos, and simulations to: (1) provide accurate general information about older people, (2) model management of responsive behaviours in older people with cognitive impairment, and (3) dispel negative stereotypes about older people as dependent and incontinent. In Phase 2, the test case findings will be shared with the advisory group to develop a range of knowledge mobilization strategies to dispel ageism among healthcare professionals and the public. We will implement key short term strategies.

Discussion

Findings will generate knowledge on the effectiveness of the e-learning activities in improving student nurses’ perceptions about older people. The e-learning learning activities will help student nurses acquire much-needed gerontological knowledge and skills. The strength of this project is in its plan to engage a wide array of stakeholders who will mobilize the phase I findings and advocate for positive perspectives and accurate knowledge about aging—older Canadians, partner organizations (Canadian Gerontological Nurses Association, CanAge, AgeWell), and gerontological experts.

Nurse and Health Care Aide Knowledge of Urinary Continence Promotion and Management In Hospitalized Older People

PURPOSE

The aims of this study were to determine if there was a change in medical unit nursing staffs' knowledge about lower urinary tract symptoms following an education presentation and whether the education session met their learning needs.

DESIGN

Single-group, before-after study.

SUBJECTS AND SETTING

The study sample comprised 21 licensed nurses and 16 health care aides from 3 medical units in a tertiary care hospital in western Canada.

METHODS

Participants completed pre- and post-true/false questionnaires developed for the project to assess lower urinary tract symptom knowledge, and a questionnaire to determine whether the education session met staff learning needs.

RESULTS

Knowledge was moderate on the pretest in both groups, with licensed nurses showing a significant improvement after the education intervention. Health care aides did not have a significant change in knowledge; they persisted in their belief that incontinence is a normal change of aging.

CONCLUSIONS

Health care aides need targeted education and enhanced care processes to shift their knowledge and thinking about continence.

Older Persons and Nursing Staff's Perspectives on Continence Care in Rehabilitation: A Qualitative Study

PURPOSE

The aim of the study was to understand continence care in geriatric rehabilitation from the perspectives of older persons and nursing staff.

DESIGN

This is a qualitative descriptive study.

METHODS

Ten patients and 10 nursing staff participated in semistructured interviews. Observations of care were recorded in field notes. Content analysis was used to develop themes of patient and nursing staff perspectives.

FINDINGS

Three themes were developed: Perceptions of Assessment, Continence Management, and Rehab: The Repair Shop. Patients had limited insight into continence assessment and management by nursing staff. For older persons, incontinence was embarrassing and created dependence; independence in toileting meant gaining control. Staff viewed continence as an important part of rehabilitation nursing but focused on containment and regular toileting, with patients seeing absorbent pads as commonly suggested.

CONCLUSIONS

Continence care approaches that engage older persons during rehabilitation are needed.

CLINICAL RELEVANCE

Restoration of continence through patient-centered care is core to older person rehabilitation.

Effects of a Person Centered Dementia Training Program in Greek Hospital Staff-Implementation and Evaluation

People with Dementia (PwD) are frequently admitted in general hospitals. However, health care professionals have lack of dementia knowledge, negative attitudes toward dementia, and lack of confidence in caring those patients. The aim of this study is to develop, implement and evaluate a dementia staff training program in Greek general hospitals. It was a repeated-measures research design. Fourteen (14) two-day workshops were conducted, consisting of six targeted and interactive modules. Staff members (N = 242) attended the program and were assessed according to (1) individual performance: questionnaires about attitudes towards dementia, confidence in care, knowledge about dementia and anxiety before, immediately after the training and three months later, (2) an overall training evaluation immediately after the training and (3) an evaluation of training implementation three months later. Positive attitudes towards dementia, improvement of confidence in care and decrease of feeling of anxiety as a trait, were sustained over time. Knowledge about dementia also increased after the training and sustained, with, however, a slight decrease over time. A well applied training program seems to provide the basis of a better care in PwD during hospitalization. However, changes in the organizational level and a transformation of care culture are necessary for training sustainability over time.

Nursing faculty and students' perspectives of how students learn to work with older people

BACKGROUND

Despite efforts to incorporate information about older people in pre-licensure nursing programs, there are inconsistent results from studies examining student nurses' perceptions towards the aging population. There is research suggesting that healthcare settings and nursing practice is perpetuating negative perspectives towards older people.

OBJECTIVE

To gain an understanding of how social contexts are influencing student nurses' experiences when learning to work with older people.

DESIGN

Descriptive case study guided by the theoretical framework of social learning theory.

SETTING

A university in Western Canada that offers a pre-licensure nursing program.

PARTICIPANTS

28 student nurses and 13 faculty in the nursing program.

METHODS

Participant interviews and focus groups were conducted with nursing faculty and students.

RESULTS

Key findings from this study are that students' previous experiences with older people, through family or work experiences, and their first clinical experience in long- term care negatively influenced their perceptions about working with older people. Clinical nurses and faculty influenced students' perceptions about nursing practice with older people, sometimes in subtle ways, underscoring that students are learning from what they see and hear in practice. Students were ill-prepared for the complexity of the aging population, particularly those with cognitive impairment.

CONCLUSIONS

Learning activities that engage students in active learning, such as simulation, providing students with a positive lexicon of how to describe older patients, and more overt attention to the perspectives students and faculty bring to the learning environment need to be carefully explored. Meaningful learning experiences with older people in multiple contexts are needed to thoughtfully plan how to disrupt negative perceptions that might emerge through the nursing education program.

Exploring acute care nurses' decision-making in psychotropic PRN use in hospitalised people with dementia

AIMS AND OBJECTIVES

To understand how acute care nurses make decisions about administering "as-needed" (PRN) psychotropic medications to hospitalised people with dementia (PWD).

BACKGROUND

Behavioural and psychological symptoms of dementia occur in approximately 75% of PWD admitted to acute care. Despite this, few studies provide insight into the use and prevalence of psychotropic use in acute care.

DESIGN

A qualitative descriptive design was used to explore acute care nurses' decision-making about PRN psychotropic medication administration to PWD.

METHODS

Semi-structured interviews were conducted with eight nurses from three acute care medical units in a large tertiary hospital in Western Canada. Conventional content analysis was used to develop three themes that reflect nurses' decision-making related to administering PRNs to hospitalised PWD. COREQ guidelines were followed.

RESULTS

Three themes of legitimising control, making the patient fit and future telling were developed. Legitimising control involved medicating undesirable behaviours to promote the nurses' perceptions of safety. Making the patient fit involved maintaining routine and order. Future telling involved pre-emptively medicating to prevent undesirable behaviours from escalating. Nurses provided little to no mention of assessing for physical causes contributing to behaviours. PRNs were seen as a reasonable alternative to physical restraints and were frequently used. Additionally, organisational and unit routines greatly influenced nurses' decision-making.

CONCLUSIONS

These findings provide an initial understanding of how nurses make decisions to administer PRN medications to hospitalised older people and may inform prescribing practices. There were novel findings about the lack of assessment prior to PRN administration, and the nurses' collective response in decision-making. More research is needed to better understand the complexities of nurses' decision-making, to assist in the development of interventions for nursing practice.

Nurses' perceptions of their role in functional focused care in hospitalised older people: An integrated review

AIM

The aim of this integrative review was to identify nurses' perspectives of their role in influencing the functional status of hospitalised older people.

METHODS

An integrative review using Whittemore and Knafls' method was conducted using EBSCOhost CINAHL, Ovid MEDLINE(R), EBSCOhost, Social Gerontology, Cochrane Database of Systematic Reviews and ProQuest Dissertations & Theses data bases. Only studies with nurses' perspectives, or beliefs about their role in function-focused care were included. Content analysis was used to develop the themes nurses' role in function-focused care and barriers to functional care.

RESULTS

The review found 12 relevant articles. Nurses believed that they were responsible for function-focused care, yet functional care tasks were often missed. Organisational contexts created many barriers to providing function-focused care for patients. Nurses felt powerless to address these overarching problems in their organisations.

CONCLUSION

Nurses understand the importance of functional care yet often fail to carry out functional care interventions. Lack of organisational support creates a workplace that is short on staff, time and equipment and does not prioritise functional care needs. Nurse leaders and healthcare organisations need to reprioritise function-focused care for the good of patients, families and healthcare budgets.

How nurses' use of language creates meaning about healthcare users and nursing practice

Nursing practice occurs in the context of conversations with healthcare users, other healthcare professionals, and healthcare institutions. This discussion paper draws on symbolic interactionism and Fairclough's method of critical discourse analysis to examine language that nurses use to describe the people in their care and their practice. We discuss how nurses' use of language constructs meaning about healthcare users and their own work. Through language, nurses are articulating what they believe about healthcare users and nursing practice. We argue that the language nurses use can contribute to viewing their practice as tasks on bodies that must be accomplished efficiently and objectively within the biomedical model, rather than relational and person-centered. Moreover, the language nurses use can perpetuate a sense of powerlessness within healthcare systems yet paradoxically they are in a position of power over healthcare users. Nurses' compliance with the efficiency and biomedical model results in a lack of emphasis on the full breadth of nursing work, which could be enacted in relational rather than power-laden practices. We conclude by positing that careful use of language among nurses in all settings is essential, if we are to begin to articulate what nursing is to ourselves and to others.

Student Nurses’ Perceptions About Older People

Educating nursing students about the ageing population is situated within negative societal, heath care and nursing perceptions. A cross-sectional design using Burbank’s perceptions towards older people scale was used to survey students in a pre-licensure nursing program in western Canada. Findings revealed that students’ perceptions about older people were lower in the third year of the nursing program and after four clinical experiences. We suggest that students’ first experiences in long-term care settings, in which they learn to provide basic care to older people, be balanced with experiences of older people in a variety of settings. Such experiences would allow students to develop the knowledge and skill needed to work with an ageing population with complex healthcare needs. More research is needed to better understand students’ experiences and perceptions about where in the program more learning strategies about how to best work with older people would be helpful.

Perspectives about Interprofessional Collaboration and Patient-Centred Care

Interprofessional collaboration is understood to improve efficiencies and quality of care but is associated with challenges such as professionals' differing routines, knowledge, and identities, as well as professional hierarchies and time constraints. Given these challenges, there is limited understanding of how professionals collaborate effectively in providing patient-centred care. This study, with a convergence triangulation mixed-methods study design, explored interprofessional staffs' perceptions of interprofessional collaboration and patient-centred care when working with hospitalized older adults. Thirty-six staff responded to a survey which included the Patient-Centred Care measure and the Modified Index of Interdisciplinary Collaboration; we also interviewed 14 nursing staff. Although all scores suggested a high value was placed on interprofessional collaboration, scores were low related to activities that facilitated team processes. We identified three themes from the data: knowing the patient/family, functional needs, and communication processes. Staff identified daily rounds with interprofessional teams as supportive of interprofessional collaboration and patient-centred-care.

The feasibility of implementing education on older person care to practice on medical units: Nurses' perceptions and the influence of practice context

AIM

As part of a larger primary study on evidence-informed practice with hospitalised older people, we aimed to (a) examine nursing staffs' perceptions of the interactive geriatric educational intervention and to explore how perceptions of their work context may influence their ability to enact the evidence-informed assessment and care approaches discussed during the educational sessions and (b) compare differences in perceptions of context between RNs, LPNs and HCAs.

METHOD

A survey-based evaluation that used both closed and open-ended questions was conducted as part of an interactive educational intervention on cognitive impairment and managing responsive behaviours. Data were gathered on participants' perceptions of the education intervention and organisational context.

RESULTS

Findings from this study suggest when education is tailored to nurses' articulated educational needs, it is well received; however, barriers to implementation exist. Assessment of the context by using a standardised survey tool to get the nursing staffs' perceptions of organisational context revealed strengths in leadership support and day-to-day interactions with other nurses and healthcare professionals, but potential barriers related to lack of facilitation to transfer new knowledge into practice existed.

CONCLUSION

Providing evidence-based education related to care of older patients and evaluating nursing staffs' perceptions of the education and their context has laid the groundwork for a long-term relationship with the managers and nursing staff on the participating medical units. Further investigation about how best to incorporate the facilitator role into the medical units to support evidence-based practices with older patients is warranted.  IMPLICATIONS FOR PRACTICE: While nurses are receptive to new knowledge, the unpredictable workload of acute care creates challenges to implementing this new knowledge. Assessment of contextual factors that influence evidence-informed practice facilitates planning for implementation of new knowledge and support practice change.

Nursing practice with hospitalised older people: Safety and harm

BACKGROUND

Nursing teams work with hospitalised older people in institutions, which prioritise a biomedical model of care. This model does not fit the needs of older people because it emphasises efficacy and a narrow definition of patient safety, but does not prioritise functional needs. Nursing care is provided around the clock within the context of fiscal restraints as well as negative societal and nursing perspectives about ageing and old people. Yet, nursing perceptions of managing safety and potential harms to older patients within these hospital institutions are not well understood.

METHODS

An integrative review was conducted to examine nursing perspectives of safety and harm related to hospitalised older people.

RESULTS

The majority of included papers focused on restraint use. Findings reveal that nurses are using restraints and limiting mobility as strategies to manage their key priority of keeping older patients safe, reflecting a narrow conceptualisation of safety. Policy, administrative support and individual nurse characteristics influence restraint use. Safety policies that nurses interpret as preventing falls can encourage the use of restraints and limiting mobility, both of which result in functional losses to older people.

CONCLUSIONS

This complex issue requires attention from clinical nurses, leaders, policy makers and researchers to shift the focus of care to preservation and restoration of function for older people in hospital as a safety priority.

IMPLICATIONS FOR PRACTICE

Clinical leaders and nursing teams should engage in developing processes of care that incorporate maintaining and restoring older people's function.

The Components of Nursing Competence in Caring for Older People in Iranian Hospitals: A Qualitative Study

Background:

There is limited research on gerontological nursing competence in hospitals. However, there is no comprehensive and integrated description of the gerontological nursing competence requirements in hospitals. The purpose of this study was to explain the components of nursing competence in caring for older people in Iranian hospitals.

Materials and Methods:

This is a qualitative descriptive-exploratory study. The data were collected through a semi-structured interview with nurses, nurse managers, and clinical educators in teaching hospitals and nursing schools affiliated to Arak, Isfahan, and Tehran Universities of Medical Sciences in Iran from September 2015 to July 2016. Participants included 25 people who were selected by purposive and snowball sampling method. Sampling continued until data saturation. Data were analyzed using conventional content analysis method.

Results:

Data analysis generated three main categories including (1) Patient and family centered care; (2) Process-oriented care; and (3) Self-care and continuing professional development.

Conclusions:

Nurses should have competencies such as participation and empowerment of the patient and family; ease of comfort in the elderly; comprehensive geriatric assessment; development, implementation and evaluation of care plan; development of knowledge and clinical proficiency; and coaching so that they can work effectively during the care of the elderly. The results of this study can be used by nursing educators, nursing students, and nurses to develop their individual and professional skills in the field of gerontological nursing.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Actions of the fall prevention protocol: mapping with the classification of nursing interventions

Objective:

to analyze the correspondence between the actions contained in the fall prevention protocol of the Ministry of Health and the Nursing Interventions Classification (NIC) by a cross-mapping.

Method:

this is a descriptive study carried out in four stages: protocol survey, identification of NIC interventions related to nursing diagnosis, the risk of falls, cross-mapping, and validation of the mapping from the Delphi technique.

Results:

there were 51 actions identified in the protocol and 42 interventions in the NIC. Two rounds of mapping evaluation were carried out by the experts. There were 47 protocol actions corresponding to 25 NIC interventions. The NIC interventions that presented the highest correspondence with protocol actions were: fall prevention, environmental-safety control, and risk identification. Regarding the classification of similarity and comprehensiveness of the 47 actions of the protocol mapped, 44.7% were considered more detailed and specific than the NIC, 29.8% less specific than the NIC and 25.5% were classified as similar in significance to the NIC.

Conclusion:

most of the actions contained in the protocol are more specific and detailed, however, the NIC contemplates a greater diversity of interventions and may base a review of the protocol to increase actions related to falls prevention..