Perceptions about nursing care. Comparing elders' and nurses' priorities

Core elements of the interpersonal care relationship between nurses and older patients without cognitive impairment during their stay at the hospital: A mixed-methods systematic review

BACKGROUND

The fundamental importance of establishing an interpersonal care relationship for quality nursing care has been highlighted. However specific elements of the interpersonal care relationship of importance to older patients in the hospital have not been identified.

OBJECTIVES

The aim of this review was to explore and synthesise research findings regarding the elements of the interpersonal care relationship concept from the perspectives of older patients.

DESIGN

A systematic mixed-methods review.

DATA SOURCES

An extensive search was conducted up until October 2018 for articles without any publication date time limit in PubMed, Web of Science, Cochrane Database of Systematic Reviews and CINAHL.

REVIEW METHODS

Primary studies were included if they concerned patients aged 65 years or older and their perspectives on the elements of the interpersonal care relationship with nurses. Inclusion was limited to patients without cognitive impairment who were admitted to an acute hospital setting. The methodological quality of each study was assessed using the Critical Appraisal Skills Programme for qualitative studies, the Quality Assessment Tool for Quantitative Studies and the Mixed-Methods Appraisal Tool. Thematic analysis was used to structure the results of the included studies.

RESULTS

Of the 7596 studies found, 24 were included in this review. Twenty articles had a qualitative, three a quantitative and one a mixed methods design. Older patients consider dignity and respect as core values that need to be met in the interpersonal care relationship. Five core elements of the interpersonal care relationship were identified to meet these core values: elements related to caring behaviour and attitude, person-centred care, patient participation, communication and situational aspects. These core elements were structured according to three categories, identified in the literature, that determine the quality of the interpersonal care relationship: nurse-, older-patient-related elements and situational aspects.

CONCLUSIONS

The elements identified in this review can guide efforts to define the interpersonal care relationship between older patients and nurses. Nurses should be supported and motivated by education and practice to adapt their behaviour, attitudes and communication to meet older patients' expectations. Hospital management can also encourage nurses to communicate well. Investment in the current organisation of care is needed to improve nurses' work overload and presence. Further research is needed to clarify the underlying processes influencing the experience of the interpersonal care relationship from the perspectives of older patients, nurses, informal caregivers and hospital management.

The meaning of patient-nurse interaction for older women in healthcare settings: A Qualitative Descriptive Study

AIMS AND OBJECTIVES

The purpose of this study was to explore the meaning of patient-nurse interaction for older women receiving care in healthcare settings.

BACKGROUND

Older women are often overlooked or misunderstood by the nurses caring for them. Some research exists on nurses' perception of their interaction with patients, yet few studies have described the meaning of such interaction from the patients' perspective.

METHODS

This was a pilot study using qualitative description as a methodology. Data were filtered through a lens of critical feminist theory to interpret interactions taking place in healthcare settings that are often characterised by paternalism. Seven women between the ages of 66 and 81 were interviewed using a semi-structured guide.

RESULTS

Participants had a distinctive perspective on the experience of caring. Their expressions include stories of being cared for themselves by nurses as well as historical recalls of being the one-caring for family members. In these combined stories, the contrast between the nurses who held caring in primacy and those who were distinctly uncaring sheds light on the importance of cultivating a moral ideal of caring and respect for personhood.

CONCLUSION

A population of older women who potentially face disabling conditions must rely on direct, meaningful, interaction with nurses to successfully navigate the healthcare system. The findings suggest that these women did not have consistent access to such interaction.

IMPLICATIONS FOR PRACTICE

The gathering and interpretation of new narratives about patient-nurse interaction for older women could lead to a deeper understanding of power and civility as it impacts a caring relationship. Further research using a theoretical lens of critical feminism has implications for improving healthcare delivery for older women worldwide.

Outcomes of acutely ill older hospitalized patients following implementation of tailored models of care: A repeated measures (pre- and post-intervention) design

BACKGROUND

There is a lack of research investigating models of nursing care for older hospitalised patients that address the nursing needs of this group.

OBJECTIVES

The objective of this study is to evaluate the efficacy of models of care for acutely older patients tailored to two contexts: an aged care specific ward and a medical ward.

DESIGN

This is a repeated measures design. Efficacy of the models was evaluated in terms of: patient and nurses' satisfaction with care provided; increased activities of daily living; reduced unplanned hospital readmissions; and medication knowledge.

SETTINGS

An aged care specific ward and a medical ward in two Sydney teaching hospitals.

PARTICIPANTS

There were two groups of patients aged 65 years or older who were admitted to hospital for an acute illness: those admitted prior to model implementation (n=232) and those admitted during model implementation (n=116). Patients with moderate or severe dementia were excluded. The two groups of nurses were the pre-model group (n=90) who were working on the medical and aged care wards for the study prior to model implementation, and the post-model group (n=22), who were the nurses working on the wards during model implementation.

METHODS

Action research was used to develop the models of care in two wards: one for an aged care specific ward and another for a general medical ward where older patients were admitted. The models developed were based on empirical data gathered in an earlier phase of this study.

RESULTS

The models were successful in both wards in terms of increasing satisfaction levels in patients and nurses (p<0.001), increasing functional independence as measured by activities of daily living (p<0.01), and increasing medication knowledge (p<0.001).

CONCLUSIONS

Findings indicate that models of care developed by nurses using an evidence-based action research strategy can enhance both satisfaction and health outcomes in older patients.

Evaluation of a model of nursing care for older patients using participatory action research in an acute medical ward

AIMS AND OBJECTIVES

The main aim of this study was to improve the quality of nursing care for older acutely ill hospitalized medical patients through developing, implementing and evaluating a new model of care using a participatory action research process.

BACKGROUND

One of the challenges of nursing today is to meet the health-care needs of the growing older population. It is important to consider what quality of nursing care means to older patients if nurses are to address gaps between their own perceptions and those of older patients themselves and to consider conceptual models of care appropriate for older patients care in order to improve the quality of care provided.

DESIGN

This study is a mixed method triangulated study, involving the use of both quantitative and qualitative methods through participatory action research methodology to establish an evidence-base for an evolving model of care.

METHODS

The model was tested on 60 acutely ill patients aged at least 65 years. The medical ward nurses selected a key reference group including the researcher to facilitate the participatory action research process to develop, implement and evaluate a new model of care based on Orem's self-care model incorporating the Nurses Improving Care to Health System Elders Faculty (Am J Nurs 1994; 94:21) medication protocol to improve the nursing care provided for acutely ill older patients.

RESULTS

The participatory action research process resulted in improved heath-care outcomes for the patients, such as significant improvements in activities of daily living capabilities between admission to discharge, significant improvements in knowledge levels regarding their medication regimes, as well as increased satisfaction with nursing care activities as perceived by older patients and nursing staff. The implementation of educational sessions during the model of care improved the older patient's functional activities and knowledge levels of their medication regime prior to discharge. In addition, by repeatedly explaining procedures, nurses became more involved with their individual patient's care, developing a patient-centred care relationship based on Orem's self-care model.

CONCLUSIONS

This study demonstrates the efficacy of a new model of nursing care in improving the quality of nursing care for older patients in the acute medical ward setting.

RELEVANCE TO CLINICAL PRACTICE

This study is significant because of its evidence-base and demonstrates how the participatory action research process empowered nurses to make sustainable changes to their practice. The nurses in the study wanted to affect change. The planned change was not dictated by management, but was driven by the clinical nursing staff at the 'grass roots' level. Therefore, being involved in the decision-making process provided an incentive to actively implement change.

Managing personal integrity: the process of hospitalization for elders

BACKGROUND

Although, in the United States of America (USA), 40% of people aged 75 years old and older are hospitalized each year, the literature does not provide insight into their perspectives on hospitalization.

AIM

The study was designed to illuminate the experience and behaviours of hospitalized elders, discover the meaning of that experience for them, and develop a substantive theory that could explain the social processes in which elders engaged while hospitalized.

METHOD

Interviews and participant observation data were used to develop a grounded theory. Participants had to be at least 75 years old, speak English, have been admitted to the hospital for medical (non-surgical) reasons, and be able to give informed consent. The elder, a family member, and a registered nurse caring for the elder were interviewed. Two-hour periods of observation were conducted throughout the elder's hospital stay. Computer-assisted data analysis included open, axial and theoretical coding. Techniques to improve the trustworthiness of the research included persistent observation, participant checking, a peer research support group and an audit conducted by an expert gerontology nurse researcher.

FINDINGS

Hospitalization was characterized as a process beginning when an alteration in health is identified and continuing through to the process of adjusting to returning home. Personal integrity was found to be a dynamic, intrinsic quality of the self, composed of health, dignity and autonomy. During hospitalization, elders used strategies to manage their personal integrity. At first, elders focused on strategies relating to health and then moved on to dignity and, finally, autonomy.

CONCLUSION

Hospitalized elders choose how they will interact with health care providers and the actions they will take to manage their health, dignity and autonomy. The findings have implications for developing nursing care and for further research.

Nursing needs of acutely ill older people

BACKGROUND

Investigating older acutely ill hospitalized patients' nursing needs and quality of care is paramount, given the growing pressure on nurses to provide increasingly intensive levels of care to a growing older population while at the same time working with reduced staffing levels.

AIMS

The aims of this study were to determine: (1) important aspects of nursing care as perceived by older patients, their family member/carer who observed care during hospitalization, and nurses; (2) satisfaction levels of patients, family/carers and nurses on nursing care received; and (3) mismatches between nursing care priorities and satisfaction with nursing care.

METHODS

Two hundred and thirty-two acutely ill patients aged over 65 years, 99 carers/family members and 90 nurses completed the Caregiving Activities Survey, which measures importance of and satisfaction with various aspects of nursing care. Qualitative data, which qualified responses to survey items, were also obtained from participants.

RESULTS

Patients, carers and nurses perceived that carrying out doctors' orders was the most important aspect of nursing care, followed by physical care, psychosocial care and discharge planning. Nurses and carers rated physical care, psychosocial care and discharge planning more highly than patients. Physical care was rated highly by patients in terms of importance, but rated moderately in terms of satisfaction. Carers' and patients' ratings of satisfaction with physical care were lower than nurses' ratings of opportunities to provide it. The importance of discharge planning was rated highly by nurses but all groups were only moderately satisfied with this aspect of care.

STUDY LIMITATIONS

The findings do not apply to acutely ill older patients with confusion, mental illness or more than early stage dementia.

CONCLUSIONS

Patients, nurses and family/carers were generally in agreement about the relative importance of particular aspects of nursing care. Nurses may need to communicate more effectively with older patients and their family carers about the particular roles they will play during the patient's hospital episode, the expectations they have of patients in the process of healing and recovery, and the reasons for the actions they take in aiding this process. The findings are useful in making nurses more aware of the expectations and needs of older hospital patients and their carers. They provide evidence for developing both new models of nursing care for this patient group, and nursing education programmes.

Nursing Needs of Hospitalized Older Adults Consumer and Nurse Perceptions

The proportion of older adults is increasing in Australia, and the proportion of older adults requiring medical care is expected to increase in the future. At the same time, budget restrictions are a reality for Australia's health system. Increasing need and decreasing resources suggest the need to focus on the quality aspect of treatment and care for older adults. Little research has been conducted in the area of perceived nursing needs of elderly patients during hospitalization. This is an important area of research because it is increasingly recognized that elderly patients have specialized needs and are the major consumers of health care. Even less research has compared patient and carer perceptions with those of nursing staff. This article is a literature review and an investigation of the quality of care elderly patients receive, and of patient and nurse perceptions of the importance of various nursing activities. Quality of care is reviewed in terms of perceptions of nursing care priorities and elderly patients' satisfaction with the quality of nursing care they receive. Research examining nurses' perceptions related to why they are unable to consistently provide quality nursing care to all elderly patients is also reviewed. By identifying the nursing needs of elderly patients and educating nursing staff about these needs, professional practice can be guided and improvements in quality of care, patient satisfaction, and patient outcomes may occur.

The influence of demographic variables and ward type on elderly patients' perceptions of needs and satisfaction during acute hospitalization

This article reports on a study designed to determine whether demographic characteristics of patients such as age, gender and cultural background were associated with different perceptions of the importance of and satisfaction with various aspects of nursing care. In addition, patients, their family/carer and nurses from wards specializing in aged care were compared with general medical wards to determine if there were differences in these perceptions. Results demonstrated that patients who were older (aged > 80 years), female and from aged care wards perceived that physical aspects of nursing care were more important than did patients who were younger (aged 65-80 years), male and from medical wards. Older patients and those from aged care wards were more satisfied with physical care. Nurses need to be aware of these differences and focus on physical aspects of care to ensure patient satisfaction better health outcomes.

Do nurses exercise power in basic care situations?

Power is a matter of authority and control. It can be wielded either consciously or unconsciously, and it can be either overt or latent. Using a structured questionnaire, this study set out to describe nurses' opinions about the exercise of power in basic care situations in both acute and long-term care. The questionnaire was organized into four categories in which items concerned: power in obligatory daily activities; power in activities necessitated by obligatory activities; power in voluntary activities; and power in activities that take into account the patient's characteristics. The samples consisted of 228 nurses from five medical and surgical wards of district hospitals, and 233 nurses from five geriatric units of a community health centre and from one nursing home in Finland. The final response rate was 65% (acute care 76%; long-term care 55%). Data analysis was based on statistical methods. The results showed that, in the nurses' own opinion, negative power is exercised only in certain situations and in the patient's best interest, when for instance there are concerns that something may happen to the patient.

Older patients' first 72 hours in hospital

The aim of this study was to determine what kind of care older patients receive in hospital during the first 72 h after admission. This was examined through four categories: patient's arrival on the hospital ward; patient's daily schedule on the ward; information and guidance; and interaction during the hospital stay. The focus was on five patients aged over 70 who had been admitted for prescribed examinations and care, including starting insulin medication, colonoscopy and a computed tomography scan of the colon. The data were collected by means of non-participant observation; interpretation was based on the method of content analysis. The results showed that the patients' arrival on the ward consisted of routine procedures and periods of waiting. The patients' daily schedule was determined by the ward's routines. They had very little control or influence over their own care, and limited privacy. Interaction between the patient and personnel was minimal, and lasted for only short periods of time. Patients were important sources of information for one another. There was also good cooperation among patients, helping one another to cope with minor everyday problems. It is concluded that nursing staff on the ward were preoccupied by their own routines and largely failed to take into account the views of their patients.

Pain in nursing home residents. Comparison of residents' self-report and nursing assistants' perceptions. Incongruencies exist in resident and caregiver reports of pain; therefore, pain management education is needed to prevent suffering

Physical pain is a significant problem for many older adults, and as many as 83% of nursing home residents reportedly have pain. Unrelieved pain has consequences for elderly individuals' physical and mental health, rehabilitation, and quality of life. Evidence suggests, however, that pain is underdetected and poorly managed among older adults. This may be due, in part, to lack of congruence between patients' and caregivers' perceptions of pain. Thus, the purpose of this study was to investigate: the prevalence, location, and intensity of residents' self-rated and nursing assistants' (NA) rated pain; the congruence between residents' and NAs' ratings of pain; and resident-based and NA-based correlates of congruent and incongruent pain ratings. Participants in this study were 45 nursing home resident-NA dyads. The results indicated 49% of residents stated they experienced pain in the past week, but NAs reported that 36% of residents experienced pain during the same time interval. There was no significant association between residents' self-ratings and NAs' ratings of pain. Of the 45 paired ratings, residents and NAs were congruent in 37.7% of cases and incongruent in 62.2% of cases. Incongruent ratings included both underdetection (37.8%) and overreporting (24.4%) by the NAs. Only residents' self-rated affect (e.g., depression, well-being) was significantly associated with whether their pain was congruently assessed, underdetected, or overreported. Depression was highest in those for whom pain was not perceived by the NAs and well-being was highest in those residents who denied pain but for whom NAs reported pain. Caregiver characteristics (e.g., age, education, work experience) were not significantly associated with pain congruence outcomes. These findings illustrate the complexities of assessing pain in older adults, and the need to include nursing assistants (NAs) in educational programs focusing on managing pain in elderly nursing home residents.