'Socialised care futility' in the care of older people in hospital who call out repetitively: An ethnographic study

Interactions that support older inpatients with cognitive impairments to engage with falls prevention in hospitals: An ethnographic study

AIMS

To explore the nature of interactions that enable older inpatients with cognitive impairments to engage with hospital staff on falls prevention.

DESIGN

Ethnographic study.

METHODS

Ethnographic observations on orthopaedic and older person wards in English hospitals (251.25 h) and semi-structured qualitative interviews with 50 staff, 28 patients and three carers. Findings were analysed using a framework approach.

RESULTS

Interactions were often informal and personalised. Staff qualities that supported engagement in falls prevention included the ability to empathise and negotiate, taking patient perspectives into account. Although registered nurses had limited time for this, families/carers and other staff, including engagement workers, did so and passed information to nurses.

CONCLUSIONS

Some older inpatients with cognitive impairments engaged with staff on falls prevention. Engagement enabled them to express their needs and collaborate, to an extent, on falls prevention activities. To support this, we recommend wider adoption in hospitals of engagement workers and developing the relational skills that underpin engagement in training programmes for patient-facing staff.

IMPLICATIONS FOR PROFESSION AND PATIENT CARE

Interactions that support cognitively impaired inpatients to engage in falls prevention can involve not only nurses, but also families/carers and non-nursing staff, with potential to reduce pressures on busy nurses and improve patient safety.

REPORTING METHOD

The paper adheres to EQUATOR guidelines, Standards for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

Patient/public contributors were involved in study design, evaluation and data analysis. They co-authored this manuscript.

The impact of a hospital-based special care unit on behavioural and psychological symptoms in older people living with dementia

BACKGROUND

Hospital patients with behavioural and psychological symptoms of dementia (BPSD) are vulnerable to a range of adverse outcomes. Hospital-based Special Care Units (SCUs) are secure dementia-enabling environments providing specialised gerontological care. Due to a scarcity of research, their value remains unconfirmed.

OBJECTIVE

To compare hospital based SCU management of BPSD with standard care.

DESIGN

Single-case multiple baseline design.

SETTING AND PARTICIPANTS

One-hundred admissions to an 8-bed SCU over 2 years in a large Australian public hospital.

METHODS

Repeated measures of BPSD severity were undertaken prospectively by specialist dementia nurses for patients admitted to a general ward (standard care) and transferred to the SCU. Demographic and other clinical data, including diagnoses, medication use, and care-related outcomes were obtained from medical records retrospectively. Analysis used multilevel models to regress BPSD scores onto care-setting outcomes, adjusting for time and other factors.

RESULTS

When receiving standard care, patients' BPSD severity was 6.8 (95% CI 6.04-7.64) points higher for aggression, 15.6 (95% CI 13.90-17.42) points higher for the neuropsychiatric inventory, and 5.8 (95% CI 5.14-6.50) points higher for non-aggressive agitation compared to SCU. Patients receiving standard care also experienced increased odds for patient-to-nurse violence (OR 2.61, 95% CI 1.67-4.09), security callouts (OR 5.39 95% CI 3.40-8.52), physical restraint (OR 17.20, 95% CI 7.94-37.25) and antipsychotic administration (OR 3.41, 95% CI 1.60-7.24).

CONCLUSION

Clinically significant reductions in BPSD and psychotropic administration were associated with SCU care relative to standard ward care. These results suggest more robust investigation of hospital SCUs, and dementia-enabling design are warranted.

Is There a Role for Medication in Managing Delirium with Dementia?

People with dementia are more likely to develop delirium. We conducted a brief literature search and give a pragmatic overview of the key issues. Making rational and safe prescribing decisions is highly influenced by organisational culture and embedded staff practices. Comprehensive assessment for unmet physical, psychological, and social needs is an important intervention in itself. Taking a broad overview of possible pharmacological interventions should include stopping inappropriate medications and prescribing for key drivers of the underlying causes of delirium. Prescribing psychotropic medications may be indicated where there is significant distress or risk to the person with dementia and risk to those around them. It is vital to consider the dementia subtype and, where possible, involve family and friend carers in the decision-making process. Medications should be prescribed at the lowest possible dose for the least amount of time after carefully weighing risks versus benefits and documenting these. While these cases are challenging for staff and families, it can be rewarding to improve the quality of life and lessen distress for the person with dementia. There are also opportunities for informing family and friend carers, educating the wider multidisciplinary team, and promoting organisational change.

Family carer perspectives on the language of behaviour change in dementia: an online mixed methods survey

OBJECTIVE

following the #BanBPSD campaign there has been critical interest in common terminology used for 'changes in behaviour' associated with dementia. However, commentaries and emerging studies have not fully considered family carer perspectives. This study explores the views of family carers on terminology and language for this paradigm.

METHOD

a mixed methods online survey was conducted with family carers. Language preferences were scoped and examined with supporting open-ended questions that explored the reasons for choices.

RESULTS

about 229 family carers completed the survey. Terms such as Challenging Behaviour, Behaviour that Challenges and Behavioural and Psychological Symptoms of dementia were mostly disliked. The most preferred term was a new concept called 'Behavioural and Emotional Expressions of Need' that few people had previously heard of. Overall, carers preferred positively construed, easily understood, person-centred terms that attributed changes in behaviour to unmet need, which also acknowledged the carer's role in management.

CONCLUSIONS

given that carers are often the agents of change for this paradigm-where they may also be called on to act as proxy decision makers, it is important that professionals take time to explore their understandings and give due consideration to the language used when offering tailored interventions. These findings suggest that frequently used terms for changes in behaviour associated with dementia, such as Challenging Behaviour, BtC and BPSD, should be avoided.

Nurses' experiences in the management of delirium among older persons in acute care ward settings: A qualitative systematic review and meta-aggregation

BACKGROUND

Delirium is a multifactorial syndrome closely associated with negative hospitalisation outcomes. Given the global growth of the ageing population, delirium becomes increasingly prevalent among older persons. Nurses play a pivotal role in delirium management and receive direct impacts of delirious presentations. Yet, there is a dearth of literature reviewing nurses' experiences.

OBJECTIVE

To synthesise the best available evidence exploring nurses' experiences in managing delirium of older persons in acute care wards.

DESIGN

Systematic review of qualitative studies and meta-aggregation.

DATA SOURCES

Published and unpublished literature between January 2010 and December 2020 were identified from PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, PsycINFO and ProQuest.

REVIEW METHODS

A systematic search strategy was applied in October 2020, with an update in January 2021. Two reviewers independently screened the titles and abstracts and selected the eligible studies after reading the full texts. This review included studies focusing on licensed nurses providing care to patients aged 65 and above, having any type of delirium during their hospitalisation stays in acute care settings. Studies included are qualitative papers with research designs such as phenomenology, ethnography, qualitative descriptive and grounded theory. The eligible studies were appraised independently using The JBI Critical Appraisal Checklist for Qualitative Research. Data of included studies were extracted by two independent reviewers using a standardised form. Findings were synthesised by the meta-aggregative approach.

RESULTS

Thirty-one papers that considered nurses' (n = 464) experiences in managing older persons' delirium were included. A total of 375 findings were extracted, aggregated into 23 categories, and developed 5 synthesised findings: (i) delirium detection could be hindered when nurses possess a narrowed view of delirium, (ii) nurses navigate through complexity when providing multi-faceted care, (iii) nurses carry personal emotions, assumptions, and identities, (iv) various stakeholders have double-edged influences, and (v) nurses display preferences in their learning needs.

CONCLUSION

This review informed about nurses' perceptions of delirium, delirious older persons, and their nursing management which were specific to older persons and acute care settings. Nurses should practise self-awareness regarding their own knowledge and attitudes while performing delirium management in older adults. Meanwhile, healthcare professionals and policymakers should make a concerted effort in cultivating a better working environment. Future research of delirium care that specifically investigates with a geriatric perspective would better contribute to the improvement of evidence-based nursing practices for older persons.