Nurse-patient encounters in the hospital ward, from the perspectives of older persons: an analysis using the Authentic Consciousness Framework: Nurse-patient encounters in the hospital ward

Development of patient-centred care in acute hospital settings: A meta-narrative review

BACKGROUND

Patient-centred care is widely recognised as a core aspect of quality health care and has been integrated into policy internationally. There remains a disconnect between policy and practice, with organisations and researchers continuing to offer definitions and frameworks to suit the operational context. It is unclear if and how patient-centred care has been adopted in the acute care context.

AIM

To understand the development of patient-centred care in the context of acute hospital settings over the past decade.

METHODS

A literature review was conducted in accordance with RAMESES standards and principles for meta-narrative reviews. Five databases (Medline, CINAHL, SCOPUS, Cochrane Library, JBI) were searched for full-text articles published between 2012 and 2021 related to patient-centred care in the acute care setting, in the context of nursing, medicine and health policy. Literature reviews and discussion papers were excluded. Articles were selected based on their relevance to the research aim. Descriptive and thematic analysis and synthesis of data were undertaken via an interpretivist process to understand the development of the topic.

RESULTS

One hundred and twenty four articles were included that reported observational studies (n = 78), interventions (n = 34), tool development (n = 7), expert consensus (n = 2), quality improvement (n = 2), and reflection (n = 1). Most studies were conducted in developed countries and reported the perspective of patients (n = 33), nurses (n = 29), healthcare organisations (n = 7) or multiple perspectives (n = 50). Key words, key authors and organisations for patient-centred care were commonly recognised and provided a basis for the research. Fifty instruments measuring patient-centred care or its aspects were identified. Of the 34 interventions, most were implemented at the micro (clinical) level (n = 25) and appeared to improve care (n = 30). Four articles did not report outcomes. Analysis of the interventions identified three main types: i) staff-related, ii) patient and family-related, and iii) environment-related. Analysis of key findings identified five meta-narratives: i) facilitators of patient-centred care, ii) threats to patient-centred care, iii) outcomes of patient-centred care, iv) elements of patient-centred care, and v) expanding our understanding of patient-centred care.

CONCLUSIONS

Interest in patient centred care continues to grow, with reports shifting from conceptualising to operationalising patient-centred care. Interventions have been successfully implemented in acute care settings at the micro level, further research is needed to determine their sustainability and macro level implementation. Health services should consider staff, patient and organisational factors that can facilitate or threaten patient-centred care when planning interventions.

TWEETABLE ABSTRACT

Patient-centred care in acute care settings - we have arrived! Is it sustainable?

Older individuals' perceptions of a good death: A systematic literature review

The purpose of this literature review was to describe older individuals' perceptions of a good death. A systematic data search of CINAHL, Medline, PsycINFO, ASSIA, and Medic databases from 2010 to 2020, supplemented with a manual search, resulted in 16 studies that met the inclusion criteria. Study quality was assessed using the JBI critical appraisal criteria. Data were analyzed by inductive content analysis. The core elements of older individuals' perceptions of a good death were a dignified moment of death, factors that enhance the desire to live, an active agency in adapting to death, and equal interpersonal relationships.

Developing Assistive Bedside Furniture for Early Postoperative Mobilization in a Healthcare Setting With an Attentive Empathetic Design Approach

OBJECTIVES

This work endeavored to design and develop a tool to assist surgical patients with postoperative mobilization in a hospital.

BACKGROUND

Early postoperative mobilization after surgery can effectively help prevent complications, but it is difficult to achieve in practice.

METHOD

An attentive empathetic design approach was used to gain insights into the users' functional needs, characteristics, contexts, as well as their emotional needs, behaviors, and psychology. The insights led to a design that leveraged psychological heuristics and habit-building principles to effect necessary mindset and behavioral changes of the stakeholders. Over four iterations, design ideas were prototyped, tested, and improved with participation of 30 patients and 30 nurses.

RESULTS

Valuable insights were discovered. Most importantly, besides the medically critical need to avoid postoperative complications, the patients also had emotional needs for independence, confidence, and self-worthiness, while the nurses needed the patients' trust. Consequently, assistive bedside furniture prototypes were designed to enable the patients to move around safely by themselves. Feedback on the prototypes showed that the patients sat up more often, enjoyed doing more activities, became more confident and less fearful of moving around, and felt less burdening on the care providers. Moreover, the nurses appreciated that the prototypes reduced their patient-mobilization workload, facilitated patient empowerment, and improved their relationship with the patients.

CONCLUSIONS

An attentive empathetic design approach can comprehend complex challenges of and subsequently design an effective solution for healthcare contexts, in which the stakeholders' medical necessities intertwine with emotional, psychological, behavioral, and sociocultural needs.

The development and psychometric validation of the interpersonal geriatric care relationship (InteGer) tool

AIM

To develop and psychometrically test the Interpersonal Geriatric care relationship tool.

BACKGROUND

The quality of nursing care is highly influenced by the quality of the interpersonal care relationship, yet there are no tools available that capture the conceptual breadth of the interpersonal care relationship.

DESIGN

Instrument development and psychometric testing of the content and construct validity, factor structure and reliability.

METHODS

A four-phased validation procedure was conducted (January 2016-April 2019): defining the construct measured by the tool, tool development, content validation and psychometric evaluation.

RESULTS

The 30-item Interpersonal Geriatric care relationship tool was subjected to exploratory factor analysis. Four components (humanization, attentiveness, interest and accessibility) were extracted. The tool demonstrated discriminating power and good internal consistency. Cronbach's alphas for the components ranged between 0.69 and 0.84.

CONCLUSION

The Interpersonal Geriatric care relationship tool is a valuable measure that can be used by scientists, educators and healthcare professionals to benchmark the interpersonal care relationship culture in hospitals and optimize the quality of care.

Development and psychometric testing of the Gerontological Nursing Competence (GeroNursingCom) instrument

AIM

To develop and psychometrically test an instrument - GeroNursingCom - that measures gerontological nursing competence of nursing students.

DESIGN

An instrument development guided by COSMIN guidelines.

METHOD

The development and testing of the GeroNursingCom instrument proceeded according to four distinct phases: (a) establishing a theoretical background; (b) testing face and content validity; (c) examining structural validity; and (d) testing internal consistency. The items of instrument were based on a theoretical framework developed from a comprehensive literature review and focus group interviews with experts (N = 27) in spring 2018. Content validity was assessed by nine experts in gerontological nursing, while face validity was tested in a pilot study including 36 nursing students. Structural validity was examined with exploratory factor analysis with 267 nursing students from nine universities of applied sciences. The internal consistency was established with Cronbach's alpha. The data were collected in spring and autumn 2019. The data analysis was conducted with multivariate statistical methods.

RESULTS

The GeroNursingCom development and testing process yielded an instrument that includes 53 items across 11 factors: (a) appreciative encounters and interactions with older people; (b) medication for older people; (c) nutrition for older people; (d) safe living environment for older people; (e) supporting the functioning of older people; (f) end-of-life care; (g) developing one's competencies; (h) supporting an older person's mental well-being; (i) supporting an older person's sexuality; (j) guiding self-care among older people; and (k) responding to challenging situations. The instrument was able to explain 66.15% of the total observed variance, while Cronbach's alpha values for individual items varied from 0.75-0.89.

CONCLUSION

TheGeroNursingCom instrument can be used to measure gerontological nursing competence among nursing students to improve gerontological nursing education and/or geriatric care.

IMPACT

Graduating nursing students must develop versatile competencies to face the multiple needs of older patients and curriculums need to be further developed to ensure students are prepared for gerontological nursing.

The Effects of Clinical Experience on Early Career Psychiatrists' Beliefs and Attitudes Towards Older Psychiatric Patients

Although literature has documented widespread negative and stereotypical attitudes held by healthcare professionals towards the older adults, there is a current paucity of research about the perspective of psychiatrists. We aimed to identify the attitudes of Tunisian early career psychiatrists towards the older adults. This was a cross-sectional study conducted among 71 early career psychiatrists. Data were collected through anonymous online surveys. A series of 4 point Likert-type questions ("strongly agree", "somewhat agree", "somewhat disagree", "strongly disagree") asked participants about their beliefs about older patients, the characteristics of the psychiatric care of an older person and emotions related to caring for older patients. Psychiatrists agreed that the older patient: is frail and vulnerable in 64.8% of cases, does not trust his psychiatrist in 28% of cases, has problems of communication in 36.6% of the cases and shows hostile or aggressive behavior in 5.6% of the cases. A multivariate binary logistic regression analysis found that clinical experience would play an independent role in predicting the following beliefs and attitudes of early career psychiatrists towards older patients: the belief that the older patient often has perceptual disorders that he is fragile and vulnerable, that he often requires polypharmacy, and that his management exposes the psychiatrist to painful emotional experiences. Given the population aging, early career psychiatrists need to be equipped with skills to fulfil significant roles in responding to future health and support needs. Integrating clinical training in psychogeriatrics into the psychiatric curriculum is strongly recommended.

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.

How do clinicians practise the principles of beneficence when deciding to allow or deny family presence during resuscitation?

AIMS AND OBJECTIVES

To examine how clinicians practise the principles of beneficence when deciding to allow or deny family presence during resuscitation.

BACKGROUND

Family presence during resuscitation has important benefits for family and is supported by professional bodies and the public. Yet, many clinicians restrict family access to patients during resuscitation, and rationales for decision-making are unclear.

DESIGN

Secondary analysis of an existing qualitative data set using deductive category application of content analysis.

METHODS

We analysed 20 interview transcripts from 15 registered nurses, two doctors and three paramedics who had experienced family presence during resuscitation in an Australian hospital. The transcripts were analysed for incidents of beneficent decision-making when allowing or denying family presence during resuscitation.

RESULTS

Decision-making around family presence during resuscitation occurred in time poor environments and in the absence of local institutional guidelines. Clinicians appeared to be motivated by doing "what's best" for patients and families when allowing or denying family presence during resuscitation. However, their individual interpretations of "what's best" was subjective and did not always coincide with family preferences or with current evidence that promotes family presence during resuscitation as beneficial.

CONCLUSIONS

The decision to allow or deny family presence during resuscitation is complex, and often impacted by personal preferences and beliefs, setting norms and tensions between clinicians and consumers. As a result, many families are missing the chance to be with their loved ones at the end of life. The introduction of institutional guidelines and policies would help to establish what safe and effective practice consists of, reduce value-laden decision-making and guide beneficent decision-making.

RELEVANCE TO CLINICAL PRACTICE

These findings highlight current deficits in decision-making around FPDR and could prompt the introduction of clinical guidelines and policies and in turn promote the equitable provision of safe, effective family-centred care during resuscitation events.

Delivering dignified care: A realist synthesis of evidence that promotes effective listening to and learning from older people's feedback in acute care settings

AIMS AND OBJECTIVES

To explore effective mechanisms for listening to and learning from feedback from older people in the context of acute care.

BACKGROUND

Maintaining the dignity of older people in acute care has become an issue of international concern. In the United Kingdom, recommendations for care improvement have led to the formation of an implementation group, the "Listening and Learning Hospitals Pilot Project." This literature review forms phase 1 of the project.

DESIGN

Realist synthesis was used to explore and synthesise wide-ranging evidence.

METHODS

Using 12 databases, literature was scoped to propose four principles that underpin the context, mechanism and outcomes (CMO) of effective relation-based interventions with older people and their care partners in the acute care setting. A search was carried out in order to synthesise data to refute or support each principle. A total of 137 studies and 11 sources of grey literature were appraised and included. A final synthesis of evidence across all principles identified key mechanisms for effective relation-based interventions.

RESULTS

Eight essential mechanisms support effective care interventions.

CONCLUSIONS

This review adds depth and breadth to current nursing knowledge in this field through the process of realist synthesis. Acute care organisations need to make a commitment to supporting relational care at organisation and unit levels. Additionally, they need to value and support the well-being of the nurses delivering it so that interventions to improve care for older people can succeed.

RELEVANCE TO CLINICAL PRACTICE

Essential mechanisms synthesised from the review, together with other suggested interventions for improving dignified care of older people in acute care by listening to them and learning from their feedback, may contribute towards practice development in acute care.

Power and resistance within the hospital's hierarchical system: the experiences of chronically ill patients

AIMS AND OBJECTIVES

To explore experiences of chronically ill patients and registered nurses when they negotiate patient care in hospital settings. Specifically, we explored how social and institutional discourses shape power relations during the negotiation process.

BACKGROUND

The hospital system is embedded in a hierarchical structure where the voice of the healthcare provider as expert is often given more importance than the patient. This system has been criticised as being oppressive to patients who are perceived to be lower in the hierarchy. In this study, we illustrate how the hospital's hierarchical system is not always oppressing but can also create moments of empowerment for patients.

DESIGN

A feminist poststructuralist approach informed by the teaching of Foucault was used to explore power relations between nurses and patients when negotiating patient care in hospital settings.

METHODS

Eight individuals who suffered from chronic illness shared their stories about how they negotiated their care with nurses in hospital settings. The interviews were tape-recorded. Discourse analysis was used to analyse the data.

RESULTS AND CONCLUSIONS

Patients recounted various experiences when their voices were not heard because the current hospital system privileged the healthcare provider experts' advice over the patients' voice. The hierarchical structure of hospital supported these dynamics by privileging nurses as gatekeepers of service, by excluding the patients' input in the nursing notes and through a process of self-regulation. However, patients in this study were not passive recipients of care and used their agency creatively to resist these discourses.

RELEVANCE TO CLINICAL PRACTICE

Nurses need to be mindful of how the hospital's hierarchical system tends to place nurses in a position of power, and how their authoritative position may positively or adversely affect the negotiation of patient care.

Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review

Therapeutic interpersonal relationships are the primary component of all health care interactions that facilitate the development of positive clinician-patient experiences. Therapeutic interpersonal relationships have the capacity to transform and enrich the patients' experiences. Consequently, with an increasing necessity to focus on patient-centered care, it is imperative for health care professionals to therapeutically engage with patients to improve health-related outcomes. Studies were identified through an electronic search, using the PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases of peer-reviewed research, limited to the English language with search terms developed to reflect therapeutic interpersonal relationships between health care professionals and patients in the acute care setting. This study found that therapeutic listening, responding to patient emotions and unmet needs, and patient centeredness were key characteristics of strategies for improving therapeutic interpersonal relationships.

Participating in a world that is out of tune: shadowing an older hospital patient

Hospitalization significantly impacts the lives of older people, both physically and psychosocially. There is lack of observation studies that may provide an embodied understanding of older patients' experiences in its context. The aim of this single case study was to reach a deeper understanding of one older patient's lived experiences of hospitalization. The study followed a phenomenological embodied enquiry design and the qualitative observation method of shadowing was used. In April 2011, one older patient was shadowed for 7 days, 5-7 h per day. To facilitate understanding in the reader the experiences are first presented in a story and subsequently analyzed by means of the lifeworld framework. The findings show that hospitalization is experienced as ambiguous safety, disconnected time, the feeling of being partially involved, and the struggle to re-attune to the body.

Attitudes of Healthcare Workers towards Older People in a Rural Population: A Survey Using the Kogan Scale

With the global trend towards an increasingly ageing population, it is clear that nurses need to be equipped with the knowledge and skills to fulfil significant roles in responding to future health and support needs. This paper reports the results of a survey that aimed to identify and evaluate the attitudes of nurses, healthcare assistants, and nursing students towards older people. The survey was undertaken in a rural county in the Republic of Ireland. It is reassuring that in our study, we found that these healthcare workers hold positive attitudes towards older people. In addition, we found that study to a higher level at university appears to mitigate towards holding more positive attitudes, and this is an important finding in light of the shift towards nursing as an all-graduate profession.