Experience of general hospital care in older patients with cognitive impairment: are we measuring the most vulnerable patients' experience?

Exploring the experiences of people living with dementia in Dementia Friendly Communities (DFCs) in Northern Ireland: a realist evaluation protocol

BACKGROUND

The aim of this study is to 1) explore the experiences of people living with dementia interacting with DFCs and 2) identify factors that influence empower and support people living with dementia to live successfully in DFCs. The main elements of a DFC are related to people; communities; organisations and partnerships. There are over 200 organisations recognised as dementia-friendly in Northern Ireland (NI). This realist evaluation is to understand how DFCs work for people living with dementia, how positive outcomes are achieved, for whom and in what contexts do DFCs work best.

METHODS

A realist evaluation using case study methodology. The process evaluation includes a realist review of the literature, non-participant observation of people living with dementia in their local communities, semi-structured interviews to explore the facilitators and barriers to living well in DFCs and focus groups comprised of people living with dementia, family caregivers and people working in DFCs to support Context- Mechanisms and Outcomes (CMOs). This four-stage realist assessment cycle is used, including iterative rounds of theory development, data gathering, and theory testing. In the end, analysis will reveal context mechanisms that influence how dementia-friendly communities operate and present an initial theory of how people think, which, if adopted, may be able to alter current contexts so that "key" mechanisms are activated to generate desired outcomes.

DISCUSSION

To give confidence in moving from hypothetical constructions about how DFCs could function to explanations of possible or observable causal mechanisms, the realist evaluation of a complex intervention incorporates a variety of evidence and perspectives. Despite playing a significant role in a person with dementia's everyday life, it appears that little is known about how communities function to achieve intended results. Even though there has been a lot of work to pinpoint the fundamentals and crucial phases of building DFCs, it is still unclear how people living with dementia benefit the most from these communities. This study intends to advance our understanding of how outcomes are produced for people living with dementia by contributing to the underlying theory of DFCs as well as addressing the primary research objectives.

A non-randomised feasibility study of the Rehabilitation Potential Assessment Tool (RePAT) in frail older people in the acute healthcare setting

BACKGROUND

Rehabilitation potential involves predicting who will benefit from rehabilitation. Decisions about rehabilitation potential must take into account personal, clinical and contextual factors, a process which is complicated in the presence of acute ill-health and frailty. This study aimed to evaluate the feasibility and acceptability of the Rehabilitation Potential Assessment Tool (RePAT) - a 15 item holistic, person-centred assessment tool and training package - in the acute hospital setting.

METHODS

A non-randomised feasibility study with nested semi-structured interviews explored whether RePAT was feasible and acceptable. Feasibility was tested by recruiting physiotherapy and occupational therapy participants delivering the RePAT intervention to patients alongside usual clinical care. Acceptability was tested by conducting semi-structured interviews with staff, patient and carer participants. Staff and patient characteristics were analysed using descriptive statistics. Interview data were analysed thematically. Fidelity of completed RePAT items was assessed against a priori criteria on how closely they matched tool guidance by two researchers. Mean values of the two scores were calculated. RePAT content was analysed and supported with verbatim quotes.

RESULTS

Six staff participants were recruited and trained. They assessed 26 patient participants using RePAT. Mean (SD) patient age was 86.16 (±6.39) years. 32% were vulnerable or mildly frail, 42% moderately frail and 26% severely or very severely frail using the Clinical Frailty Scale. Mean (SD) time to complete RePAT was 32.7 (±9.6) minutes. RePAT fidelity was good where 13 out of 15 items achieved a priori fidelity. RePAT was acceptable and tolerated by staff and patients. Staff participants reported RePAT enabled them to consider rehabilitation decisions in a more structured and consistent way. Patients and carer participants, although unable to comment directly on RePAT, reported being satisfied with their rehabilitation assessments which were found to embrace a person-centred approach.

CONCLUSIONS

RePAT was found to be acceptable and feasible by staff, carers and patients. It allowed clinicians to make explicit their reasoning behind rehabilitation assessments and encouraged them to become more cognisant of factors which affected their clinical decision-making.

TRIAL REGISTRATION

ID ISRCTN31938453 . Registered 05/10/2021.

Use of the Quality of Interactions Schedule (QuIS) in assessing negative staff-patient interactions in acute care settings for older people: A content validation study

INTRODUCTION

The Quality of Interactions Schedule (QuIS) is an observational tool to assess the quality of staff-patient interactions in a healthcare context. QuIS is a promising measure for the evaluation of compassionate care, particularly where care is being delivered to patient populations, such as older people, who may be excluded from self-completion data collection methods. This study investigates the content validity of QuIS in identification of negative staff-patient interactions in acute care.

METHODS

Staff-patient interactions (n = 1598) on adult inpatient units with a high proportion of older patients in two UK National Health Service hospitals were observed and rated using QuIS. When rating interactions as negative quality, observers recorded brief field notes to explain the rating. Content analysis was used to develop categories of negative interaction type. These categories were compared with the QuIS negative interaction definitions.

RESULTS

Eighty-eight negative ratings were accompanied by a field note that could be used in the analysis. Five interaction categories were identified: Patient calls for help, call not acknowledged; Staff focused on task and appear to ignore/not hear patient; Patient-led interactions appear dismissed or ignored; Patient prevented from doing something without explanation; Staff interact with each other or talk to relatives, not including patient. There was clear association between the derived categories and QuIS guidance for negative ratings.

CONCLUSION

These findings support the validity of QuIS data in relation to measurement of interaction quality in acute care settings. Extending the research to a wider range of settings would be useful.

Association between Quality of Interactions Schedule ratings and care experiences of people with a dementia in general hospital settings: a validation study

INTRODUCTION

Establishing methods to evaluate interactions between hospital staff and patients with a dementia is vital to inform care delivery. This study aimed to assess the validity of Quality of Interactions Schedule (QuIS) ratings in relation to the care experiences of people with a dementia in a general hospital setting.

METHODS

Four hundred and ninety face-to-face interactions between staff and patients with a dementia (n = 107) on six medicine for older people wards in a UK National Health Service hospital were observed and rated using QuIS and the Psychological Well-Being in Cognitively Impaired Persons (PWB-CIP) tool. We also invited patient ratings for longer interactions (n = 217). Analyses explored associations between QuIS ratings, PWB-CIP ratings and patient ratings.

RESULTS

When QuIS was rated negative, the mean researcher-rated patient psychological well-being was lower (PWB = 7.9 out of maximum score of 10) than when QuIS was non-negative (PWB = 8.8, p = 0.036). Negative QuIS ratings were associated with negative ratings on seven out of ten individual PWB-CIP items. When QuIS was rated negative, the associated patient rating was 4% less likely to be 'happy'. The patient was also 4% more likely to rate the interaction as 'kind'. Patients struggled to participate in care ratings.

CONCLUSIONS

Some patients found responding to researcher questions difficult or not relevant, reflecting the need for development of more suitable methods in this field. Our findings of an association between lower quality QuIS-rated interactions and lower psychological well-being lend support to the use of QuIS with patient populations that include people with a dementia.

What does the patient have to say? Valuing the patient experience to improve the patient journey

Background

Patient-reported data—satisfaction, preferences, outcomes and experience—are increasingly studied to provide excellent patient-centred care. In particular, healthcare professionals need to understand whether and how patient experience data can more pertinently inform the design of service delivery from a patient-centred perspective when compared with other indicators. This study aims to explore whether timely patient-reported data could capture relevant issues to improve the hospital patient journey.

Methods

Between January and February 2019, a longitudinal survey was conducted in the orthopaedics department of a 250-bed Italian university hospital with patients admitted for surgery; the aim was to analyse the patient journey from the first outpatient visit to discharge. The same patients completed a paper-and-pencil questionnaire, which was created to collect timely preference, experience and main outcomes data, and the hospital patient satisfaction questionnaire. The first was completed at the time of admission to the hospital and at the end of hospitalisation, and the second questionnaire was completed at the end of hospitalisation.

Results

A total of 254 patients completed the three questionnaires. The results show the specific value of patient-reported data. Greater or less negative satisfaction may not reveal pathology-related needs, but patient experience data can detect important areas of improvement along the hospital journey. As clinical conditions and the context of care change rapidly within a single hospital stay for surgery, collecting data at two different moments of the patient journey enables researchers to capture areas of potential improvement in the patient journey that are linked to the context, clinical conditions and emotions experienced by the patient.

Conclusion

By contributing to the literature on how patient-reported data could be collected and used in hospital quality improvement, this study opens the debate about the use of real-time focused data. Further studies should explore how to use patient-reported data effectively (including what the patient reports are working well) and how to improve hospital processes by profiling patients’ needs and defining the appropriate methodologies to capture the experiences of vulnerable patients. These topics may offer new frontiers of research to achieve a patient-centred healthcare system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06341-3.

Comorbid vision and cognitive impairments in older adults hospitalized for acute myocardial infarction

Older patients presenting with acute myocardial infarction (AMI) often have comorbidities. Our objective was to examine how outcomes differ by cognitive and vision status in older AMI patients. We use data from a prospective cohort study conducted at 94 hospitals in the United States between January 2013 and October 2016 that enrolled men and women aged ≥75 years with AMI. Cognitive impairment (CI) was defined as telephone interview for cognitive status (TICS) score <27; vision impairment (VI) and activities of daily living (ADLs) were assessed by questionnaire. Of 2988 senior AMI patients, 260 (8.7%) had CI but no VI, 858 (28.7%) had VI but no CI, and 251 (8.4%) had both CI/VI. Patients in the VI/CI group were most likely to exhibit geriatric syndromes. More severe VI was associated with lower (worse) scores on the TICS (β −1.53, 95% confidence interval (CI) −1.87 to −1.18). In adjusted models, compared to participants with neither impairment, participants with VI/CI were more likely to die (hazard ratio 1.61, 95% CI 1.10–2.37) and experience ADL decline (odds ratio 2.11, 95% CI 1.39–3.21) at 180 days. Comorbid CIs and VIs were associated with high rates of death and worsening disability after discharge among seniors hospitalized for AMI. Future research should evaluate protocols to accommodate these impairments during AMI presentations and optimize decision-making and outcomes.

"Even Though I Have Dementia, I Prefer That They Are Personable": A Qualitative Focused Ethnography Study in a Danish General Hospital Setting

Patients with dementia often face challenges in hospital settings due to cognitive impairment. The aim of this study is to explore the encounter between patients with dementia and hospital staff, from the patient perspective. Focused ethnography guided the method for data collection and the analytical approach was abductive. The findings, based on 10 observations of patients with dementia and their encounter with hospital staff in a variety of hospital settings, reveal that staff often seem to not see the person beyond the dementia diagnosis. The findings also show, however, that significant moments are constantly negotiated during encounters between patients with dementia and hospital staff, moments which occasionally allow staff to see the patients to be seen as the person they are. A rethinking of the current dementia discourse is discussed, recommending attention to the two-way interaction between patients with dementia and hospital staff, and within this an awareness of a personable approach.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Hospital nurse staffing and staff-patient interactions: an observational study

Background

Existing evidence indicates that reducing nurse staffing and/or skill mix adversely affects care quality. Nursing shortages may lead managers to dilute nursing team skill mix, substituting assistant personnel for registered nurses (RNs). However, no previous studies have described the relationship between nurse staffing and staff–patient interactions.

Setting

Six wards at two English National Health Service hospitals.

Methods

We observed 238 hours of care (n=270 patients). Staff–patient interactions were rated using the Quality of Interactions Schedule. RN, healthcare assistant (HCA) and patient numbers were used to calculate patient-to-staff ratios. Multilevel regression models explored the association between staffing levels, skill mix and the chance of an interaction being rated as ‘negative’ quality, rate at which patients experienced interactions and total amount of time patients spent interacting with staff per observed hour.

Results

10% of the 3076 observed interactions were rated as negative. The odds of a negative interaction increased significantly as the number of patients per RN increased (p=0.035, OR of 2.82 for ≥8 patients/RN compared with >6 to <8 patients/RN). A similar pattern was observed for HCA staffing but the relationship was not significant (p=0.056). When RN staffing was low, the odds of a negative interaction increased with higher HCA staffing. Rate of interactions per patient hour, but not total amount of interaction time, was related to RN and HCA staffing levels.

Conclusion

Low RN staffing levels are associated with changes in quality and quantity of staff–patient interactions. When RN staffing is low, increases in assistant staff levels are not associated with improved quality of staff–patient interactions. Beneficial effects from adding assistant staff are likely to be dependent on having sufficient RNs to supervise, limiting the scope for substitution.

Where next for delirium research?

Clinicians who manage delirium must do so without key information required for evidence-based practice, not least lack of any clearly effective treatment for established delirium. Both the nature of delirium and the methods used to research it contribute to difficulties. Delirium is heterogeneous, with respect to motor subtype, aetiology, setting and the co-existence of dementia, and may be almost inevitable towards the end of life. Elements of assessment are subjective, so diagnosis can be uncertain or unreliable. Defining objectives of care and outcomes is sometimes unclear. Better identification and case definition, including seeking biomarkers, stratification by type, or aetiology, and application of more complex models of causation may help. This will likely require further observational epidemiology, imaging and laboratory-based research before further rounds of large-scale randomised controlled trials. Application of trial methodologies designed for drug treatments of better-defined conditions may have failed to take account of the complexities both of diagnosis and complex intervention in delirium. Both drug and complex intervention trials need sufficient preliminary work to ensure that the right dose, duration or intensity of treatment is delivered and a range of 'intermediate' and 'distal' outcome measures assessed. Re-purposing of established drugs may provide a source of investigational products. Greater use of alternative research methodologies (qualitative and realist), or adjuvants to trials (process evaluation), will help answer questions about focus, generalisability and why interventions succeed or fail. Delirium research will have to embrace both a 'back to basics' approach with increased breadth of methodologies to make progress.

Implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings: a pilot RCT and feasibility study

Background

Concerns about the degree of compassion in health care have become a focus for national and international attention. However, existing research on compassionate care interventions provides scant evidence of effectiveness or the contexts in which effectiveness is achievable.

Objectives

To assess the feasibility of implementing the Creating Learning Environments for Compassionate Care (CLECC) programme in acute hospital settings and to evaluate its impact on patient care.

Design

Pilot cluster randomised trial (CRT) and associated process and economic evaluations.

Setting

Six inpatient ward nursing teams (clusters) in two English NHS hospitals randomised to intervention (n = 4) or control (n = 2).

Participants

Patients (n = 639), staff (n = 211) and visitors (n = 188).

Intervention

CLECC is a workplace educational intervention focused on developing sustainable leadership and work team practices (dialogue, reflective learning, mutual support) theorised to support the delivery of compassionate care. The control setting involved no planned staff team-based educational activity.

Main outcome measures

Quality of Interaction Schedule (QuIS) for staff–patient interactions, patient-reported evaluations of emotional care in hospital (PEECH) and nurse-reported empathy (as assessed via the Jefferson Scale of Empathy).

Data sources

Structured observations of staff–patient interactions; patient, visitor and staff questionnaires and qualitative interviews; and qualitative observations of CLECC activities.

Results

The pilot CRT proceeded as planned and randomisation was acceptable to teams. There was evidence of potential contamination between wards in the same hospital. QuIS performed well, achieving a 93% recruitment rate, with 25% of the patient sample cognitively impaired. At follow-up there were more positive (78% vs. 74%) and fewer negative (8% vs. 11%) QuIS ratings for intervention wards than for control wards. In total, 63% of intervention ward patients achieved the lowest possible (i.e. more negative) scores on the PEECH connection subscale, compared with 79% of control group patients. These differences, although supported by the qualitative findings, are not statistically significant. No statistically significant differences in nursing empathy were observed, although response rates to staff questionnaire were low (36%). Process evaluation: the CLECC intervention is feasible to implement in practice with medical and surgical nursing teams in acute care hospitals. Strong evidence of good staff participation was found in some CLECC activities and staff reported benefits throughout its introductory period and beyond. Further impact and sustainability were limited by the focus on changing ward team behaviours rather than wider system restructuring. Economic evaluation: the costs associated with using CLECC were identified and it is recommend that an impact inventory be used in any future study.

Limitations

Findings are not generalisable outside hospital nursing teams, and this feasibility work is not powered to detect differences attributable to the CLECC intervention.

Conclusions

Use of the experimental methods is feasible. The use of structured observation of staff–patient interaction quality is a promising primary outcome that is inclusive of patient groups often excluded from research, but further validation is required. Further development of the CLECC intervention should focus on ensuring that it is adequately supported by resources, norms and relationships in the wider system by, for instance, improving the cognitive participation of senior nurse managers. Funding is being sought for a more definitive evaluation.

Trial registration

Current Controlled Trials ISRCTN16789770.

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 inHealth Services and Delivery Research; Vol. 6, No. 33. See the NIHR Journals Library website for further project information. The systematic review reported inChapter 2was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care Wessex, the University of Örebro and the Karolinska Institutet.

Translation, adaptation and psychometric validation of the Good Perioperative Nursing Care Scale (GPNCS) with surgical patients in perioperative care

AIM

To test the psychometric validity of the Good Perioperative Nursing Care Scale (GPNCS), a self-administered questionnaire, following translation and adaptation.

INTRODUCTION

Patients' satisfaction with and experience of nursing care in orthopaedic or perioperative settings are currently not routinely measured and few standardized patient-reported experience measurement tools exist for these settings.

MATERIALS AND METHODS

Cross-sectional survey. The 34-question, seven-factor questionnaire was translated, adapted, and face-validated; the translated version was then validated with a group of surgical patients in perioperative settings. The internal consistency of the translated version was validated and tested using confirmatory factor analysis combined with Cronbach's alpha.

RESULTS

In the orthopaedic department of a regional public hospital, 361 acute, traumatic and elective surgical patients were screened for eligibility; 215 were included. The full-scale model fit estimates were moderate. Factor loadings typically ranged from 0.65 to 0.97, except for the questions concerning Technical Skills (0.38-0.63) and Nursing Process (0.28). The Cronbach's alpha value for the total scale score was 0.92, with subfactors ranging from 0.72 to 0.87.

CONCLUSION

Providing evidence for quality, or lack thereof, the Danish version of the GPNCS is a valid tool for measuring surgical patients' experiences with perioperative nursing care. The electronic version proved practical.

RELEVANCE TO CLINICAL PRACTICE

The validated Danish version of the tool will help healthcare professionals to identify areas of nursing care that need improvement, facilitate international benchmarking of units and enable comparison of care quality, nationally and internationally.

Compassionate care intervention for hospital nursing teams caring for older people: a pilot cluster randomised controlled trial

OBJECTIVE

Compassionate care continues to be a focus for national and international attention, but the existing evidence base lacks the experimental methodology necessary to guide the selection of effective interventions for practice. This study aimed to evaluate the Creating Learning Environments for Compassionate Care (CLECC) intervention in improving compassionate care.

SETTING

Ward nursing teams (clusters) in two English National Health Service hospitals randomised to intervention (n=4) or control (n=2). Intervention wards comprised two medicines for older people (MOPs) wards and two medical/surgical wards. Control wards were both MOPs.

PARTICIPANTS

Data collected from 627 patients and 178 staff.

EXCLUSION CRITERIA

reverse barrier nursed, critically ill, palliative or non-English speaking. All other patients and all nursing staff and Health Care Assistant HCAs were invited to participant, agency and bank staff were excluded.

INTERVENTION

CLECC, a workplace intervention focused on developing sustainable leadership and work-team practices to support the delivery of compassionate care.

CONTROL

No educational activity.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary-Quality of Interaction Schedule (QuIS) for observed staff-patient interactions. Secondary-patient-reported evaluations of emotional care in hospital (PEECH); nurse-reported empathy (Jefferson Scale of Empathy).

RESULTS

Trial proceeded as per protocol, randomisation was acceptable. Some but not all blinding strategies were successful. QuIS observations achieved 93% recruitment rate with 25% of patient sample cognitively impaired. At follow-up there were more total positive (78% vs 74%) and less total negative (8% vs 11%) QuIS ratings for intervention wards versus control wards. Sixty-three per cent of intervention ward patients scored lowest (ie, more negative) scores on PEECH connection subscale, versus 79% of control. This was not a statistically significant difference. No statistically significant differences in nursing empathy were observed.

CONCLUSIONS

Use of experimental methods is feasible. The use of structured observation of staff-patient interaction quality is a promising outcome measure inclusive of hard to reach groups.

TRIAL REGISTRATION NUMBER

ISRCTN16789770.

Informal carers' perspectives on the delivery of acute hospital care for patients with dementia: a systematic review

Background

Providing high quality acute hospital care for patients with dementia is an increasing challenge as the prevalence of the disease rises. Informal carers of people with dementia are a critical resource for improving inpatient care, due to their insights into patients’ needs and preferences. We summarise informal carers’ perspectives of acute hospital care to inform best practice service delivery.

Methods

We conducted a systematic search of bibliographic databases and sought relevant grey literature. We used thematic synthesis analysis to assimilate results of the studies and describe components of care that influence perceived quality.

Results

Twenty papers met the inclusion criteria. Findings identified four overarching components of care that influenced carer experience and their perceptions of care quality: ‘Patient care’, ‘Staff interactions’, ‘Carer’s situation’ and ‘Hospital environment’. Need for improvement was identified in staff training, provision of help with personal care needs, and dignified treatment of patients. Carers need to be informed, involved and supported during hospital admission in order to promote the most positive experience.

Conclusion

This review identifies common perspectives of informal carers of people with dementia in the acute hospital setting and highlights important areas to address to improve the experience of an admission for both carer and patient.

Notes from the hospital bedside: reflections on researcher roles and responsibilities at the end of life in dementia

Purpose

The purpose of this paper is to explore some of the ethical and practical dilemmas faced by an experienced researcher in undertaking research with a person with dementia (whom we have called Amy). Amy died shortly after a period of observation had ended and the family subsequently consented to the data being shared.

Design/methodology/approach

This individual case study presentation was nested within a larger study conducted in England and Scotland between 2013 and 2014. The overall aim of the main study was to investigate how healthcare professionals and informal carers recognised, assessed and managed pain in patients living with dementia in a range of acute settings.

Findings

The presented case study of Amy raises three critical reflection points: (i) Researcher providing care, i.e. the place and positioning of compassion in research observation; (ii) What do the stories mean? i.e. the reframing of Amy's words, gestures and behaviours as (end of) life review, potentially highlights unresolved personal conflicts and reflections on loss; and (iii) Communication is embodied, i.e. the need to move beyond the recording of words to represent lived experience and into more multi-sensory methods of data capture.

Originality/value

Researcher guidance and training about end of life observations in dementia is presently absent in the literature and this case study stimulates debate in a much overlooked area, including the role of ethics committees.

"Little things matter!" Exploring the perspectives of patients with dementia about the hospital environment

BACKGROUND

Recognising demographic changes and importance of the environment in influencing the care experience of patients with dementia, there is a need for developing the knowledge base to improve hospital environments. Involving patients in the development of the hospital environment can be a way to create more responsive services. To date, few studies have involved the direct voice of patients with dementia about their experiences of the hospital environment.

DESIGN AND METHOD

Using an action research approach, we worked with patients with dementia and a team of interdisciplinary staff on a medical unit to improve dementia care. The insights provided by patients with dementia in the early phase shaped actions undertaken at the later stage to develop person-centred care within a medical ward. We used methods including go-along interviews, video recording and participant observation to enable rich data generation.

AIM

This study explores the perspectives of patients with dementia about the hospital environment.

RESULTS

The participants indicated that a supportive hospital environment would need to be a place of enabling independence, a place of safety, a place of supporting social interactions and a place of respect.

CONCLUSIONS

Patient participants persuasively articulated the supportive and unsupportive elements in the environment that affected their well-being and care experiences. They provided useful insights and pointed out practical solutions for improvement. Action research offers patients not only opportunities to voice their opinion, but also possibilities to contribute to hospital service development.

IMPLICATIONS FOR PRACTICE

This is the first study that demonstrates the possibility of using go-along interviews and videoing with patients with dementia staying in a hospital for environmental redesign. Researchers, hospital leaders and designers should further explore strategies to best support the involvement of patients with dementia in design and redesign of hospital environments.

Reliability, feasibility, and validity of the quality of interactions schedule (QuIS) in acute hospital care: an observational study

BACKGROUND

Research into relational care in hospitals will be facilitated by a focus on staff-patient interactions. The Quality of Interactions Schedule (QuIS) uses independent observers to measure the number of staff-patient interactions within a healthcare context, and to rate these interactions as 'positive social'; 'positive care'; 'neutral'; 'negative protective'; or 'negative restrictive'. QuIS was developed as a research instrument in long term care settings and has since been used for quality improvement in acute care. Prior to this study, its use had not been standardised, and reliability and validity in acute care had not been established.

METHODS

In 2014 and 2015 a three - phase study was undertaken to develop and test protocols for the use of QuIS across three acute wards within one NHS trust in England. The phases were: (1) A pilot of 16 h observation which developed implementation strategies for QuIS in this context; (2) training two observers and undertaking 16 h of paired observation to inform the development of training protocols; (3) training four nurses and two lay volunteers according to a finalised protocol followed by 36 h of paired observations to test inter-rater agreement. Additionally, patients were asked to rate interactions and to complete a shortened version of the Patient Evaluation of Emotional Care during Hospitalisation (PEECH) questionnaire.

RESULTS

Protocols were developed for the use of QuIS in acute care. Patients experienced an average of 6.7 interactions/patient/h (n = 447 interactions). There was close agreement between observers in relation to the number of interactions observed (Intraclass correlation coefficient (ICC) = 0.97) and moderate to substantial agreement on the quality of interactions (absolute agreement 73%, kappa 0.53 to 0.62 depending on weighting scheme). There was 79% agreement (weighted kappa 0.40: P < 0.001; indicating fair agreement) between patients and observers over whether interactions were positive, negative or neutral.

CONCLUSIONS

Observers using clear QuIS protocols can achieve levels of agreement that are acceptable for the use of QuIS as a research instrument. There is fair agreement between observers and patients' rating of interactions. Further research is needed to explore the relationship between QuIS measures and reported patient experience.

Reconciling conceptualisations of the body and person-centred care of the older person with cognitive impairment in the acute care setting

In this article, we sought reconciliation between the "body-as-representation" and the "body-as-experience," that is, how the body is represented in discourse and how the body of older people with cognitive impairment is experienced. We identified four contemporary "technologies" and gave examples of these to show how they influence how older people with cognitive impairment are often represented in acute care settings. We argued that these technologies may be mediated further by discourses of ageism and ableism which can potentiate either the repressive or productive tendencies of these technologies resulting in either positive or negative care experiences for the older person and/or their carer, including nurses. We then provided examples from research of embodied experiences of older people with dementia and of how nurses and other professionals utilized their inter-bodily experiences to inform acts of caring. The specificity and individuality of these experiences were more conducive to positive care experiences. We conclude the article by proposing that the act of caring is one way nurses seek to reconcile the "body-as-representation" with the "body-as-experience" to mitigate the repressive effects of negative ageism and ableism. The act of caring, we argue, is the essence of caring enacted through the provision of person-centred care which evokes nurses to respond appropriately to the older person's "otherness," their "variation of being" while enabling them to enact a continuation of themselves and their own version of normality.

Quantity and quality of interaction between staff and older patients in UK hospital wards: A descriptive study

Background

The quality of staff-patient interactions underpins the overall quality of patient experience and can affect other important outcomes. However no studies have been identified that comprehensively explore both the quality and quantity of interactions in general hospital settings.

Aims & objectives

To quantify and characterise the quality of staff-patient interactions and to identify factors associated with negative interaction ratings.

Setting

Data were gathered at two acute English NHS hospitals between March and April 2015. Six wards for adult patients participated including medicine for older people (n = 4), urology (n = 1) and orthopaedics (n = 1).

Methods

Eligible patients on participating wards were randomly selected for observation. Staff-patient interactions were observed using the Quality of Interactions Schedule. 120 h of care were observed with each 2 h observation session determined from a balanced random schedule (Monday-Friday, 08:00-22:00 h). Multilevel logistic regression models were used to determine factors associated with negative interactions.

Results

1554 interactions involving 133 patients were observed. The median length of interaction was 36 s with a mean of 6 interactions per patient per hour. Seventy three percent of interactions were categorized as positive, 17% neutral and 10% negative. Forty percent of patients had at least one negative interaction (95% confidence interval 32% to 49%). Interactions initiated by the patient (adjusted Odds Ratio [OR] 5.30), one way communication (adjusted OR 10.70), involving two or more staff (adjusted OR 5.86 for 2 staff, 6.46 for 3+ staff), having a higher total number of interactions (adjusted OR 1.09 per unit increase), and specific types of interaction content were associated with increased odds of negative interaction (p < 0.05). In the full multivariable model there was no significant association with staff characteristics, skill mix or staffing levels. Patient agitation at the outset of interaction was associated with increased odds of negative interaction in a reduced model. There was no significant association with gender, age or cognitive impairment. There was substantially more variation at ward level (variance component 1.76) and observation session level (3.49) than at patient level (0.09).

Conclusion

These findings present a unique insight into the quality and quantity of staff-patient interactions in acute care. While a high proportion of interactions were positive, findings indicate that there is scope for improvement. Future research should focus on further exploring factors associated with negative interactions, such as workload and ward culture.

The CareWell in Hospital questionnaire: a measure of frail elderly inpatient experiences with individualized and integrated hospital care

Given our aging society with an increasing number of frail elderly patients, we must provide integrated care tailored to their complex needs regarding health and well-being. The aim of this study was to develop and validate a questionnaire designed to assess how frail hospitalized elderly patients experience several important aspects of individualized and integrated care. An 8-item questionnaire was developed using input from a panel representing the target group and administered to patients age ≥70 years from surgical, medical, and geriatric departments to measure data characteristics, internal consistency, test-retest reliability, construct validity, and responsiveness. A total of 470 questionnaires were returned, including 78 for test-retest reliability. Data were missing from 1.7% to 7.0% within the individual questions. The percentage of questions answered with "don't know" ranged 3.8% to 21.9%. Cronbach's α for internal consistency was 0.70. Test-retest intraclass correlation was 0.75. Achievement of goals during the hospital stay was significantly correlated with the questionnaire score. Scores did not differ significantly between departments or between the before and after measurements related to an innovative intervention study in healthcare delivery. The CareWell in Hospital questionnaire has good content validity, internal consistency, and test-retest reliability and warrants further research to explore responsiveness.