The challenges of improving discharge planning in Sweden and the UK: different but the same

• ? Discharge of older people from hospital has been an area of concern for over 20 years.
• ? The present emphasis on rapid throughput of patients in acute care settings is likely to exacerbate existing problems.
• ? Improving current practice will mean addressing a number of complex issues to do with communication between agencies and professions.
• ? Despite different welfare systems, many of the challenges of discharge planning are shared in different countries.
• ? This paper describes attempts to involve patients and carers in discharge planning in Sweden and the UK and identifies a number of areas which require attention if the ideals of patient and carer empowerment are to be achieved.

     

Discharging older people from hospital to care homes: implications for nursing

This paper summarizes a research study which explored the experiences of older people being discharged from hospital to nursing and residential homes in the North East of England. While there has been considerable research which has looked at the discharge of patients from hospital to their own homes, little literature could be found which addressed discharge to care homes. While this may reflect an assumption that this form of discharge is less problematic, it is arguable that this is only the case for staff - there is a body of literature on re-location which suggests that the move to a care home is a major life event for older people. Taking a qualitative approach, this study interviewed 20 older people and 17 of their family members after discharge from hospital to a care home. We found that few people had been offered opportunities to discuss their move with nurses, and that older people tended to adopt a stoical attitude. In focus groups, interviews and written responses from 23 members of staff in the hospital and in care homes, we found that there was a lack of clarity over whose role it was to initiate such discussions. The paper concludes with some discussion of the implications for nursing practice of changing care interfaces.     

A client-centered approach in home care for older persons – an integrative review

Objective To describe and synthesize client-centered care and service in home care for older persons.Methods The study was an integrative review using the guidelines for literature reviews by the Joanna Briggs Institute. The research process followed the Whittemore and Knafl framework and PRISMA toolkit in the selection of eligible articles. The CINAHL, Medline, Scopus, Web of Science and Social Sciences abstracts were searched for articles published between January 2007 and May 2020 according to previously designed search strategies. In total, 24 articles were deemed relevant for an analysis using a thematic analysis.Results The analysis resulted in four themes with sub-themes which revealed that client-centered care and service in home care consist of: 1) Clients’ involvement in their own care; self-care, decision-making, satisfactory daily life, 2) Family members’ and care partners’ participation in care; family members’ and care partners’ commitment to care, family members’ and care partners’ competence in care, 3) Communication and co-operation; communication models, empowerment, partnership, and 4) Evidence-based service competence; delivery and organization of services, implementation of services, versatile clinical skills, quality outcomes and personnel wellbeing.Conclusions According to the results, achieving client-centered care and service in home care requires the realization of all of the above aspects. The practice of nursing must better identify all dimensions of client-centered care and take these into account in the delivery of home care services.

KEY POINTS

• Client-centeredness is a fundamental value and the basis of nursing and care in home care provided for older persons
• This paper:
• deepens and structures the concept of client-centered care in the context of home care.
• assists professionals to understand the factors behind client-centered care within the home care environment.
• provides deeper understanding of the roles of the older person, family members, and the service system in developing client-centered services in home care for older persons.

     

Impact of environmental factors in home rehabilitation – a qualitative study from the perspective of older persons using the International Classification of Functioning,Disability and Health to describe facilitators and barriers

Purpose: The aim of this study was to explore older people’s experience of environmental factors that impact on their activity and participation in home rehabilitation. Method: Older people aged between 68 and 93 years and receiving home rehabilitation were interviewed. A qualitative content analysis was performed on the interview text using the predetermined structure of the International Classification of Functioning, Disability and Health (ICF) environmental domain. The text was linked to the closest ICF category. Results: The results identified environmental facilitators and barriers that influenced activity and participation among older people receiving home rehabilitation. Approaches that provided a facilitative environment were access to assistive products and technologies, alterations to the physical environment, social support and relationships, and adjusted health and social care services. Conclusions: A qualitative study using ICF-listed environmental factors contributed a holistic view of facilitators and barriers in home rehabilitation for older people. Awareness of the importance of the impact of the social environment on activities and participation could improve home rehabilitation services for older people. The study represents an important step towards a holistic approach using the ICF, which aims to enable all health care professionals to describe, plan and evaluate rehabilitation services together with older people across the health and social care sectors.

Implications for Rehabilitation

• Environmental factors can be considered as obstacles or facilitators depending on each unique individual’s need.

• In a relatively small sample, this study shows the importance of the impact of the social environment on activities and participation among older people receiving home rehabilitation.

• Using ICF “linking rules” to link environmental factors as facilitators or barriers reported by older people can identify potentially important areas in home rehabilitation service described in the ICF categories. This can facilitate to improve rehabilitation service for older people.

• Reveals health care professionals as one central environmental factor for older people’s rehabilitation.

     

Evaluation of a new night nursing service for elderly people suffering from dementia

• ? A new night hospital nursing service was developed for older people with dementia.
• ? A case study approach to evaluation was adopted using a structure-process-outcome quality assurance cycle.
• ? The effects and attendance of patients are reported and discussed.
• ? Discussion relating to care provision for the future is presented.
• ? The effects on carers of patients' attendance are briefly discussed.

     

Listening to the voices of older patients: an existential-phenomenological approach to quality assurance

• ? The motivation behind this study was a desire to gain access to the experiences of elderly people receiving nursing care in hospital. Previous experience with quantitative approaches to quality assurance had led to dissatisfaction with their neglect of the patient perspective or reliance on patient satisfaction questionnaires.
• ? An existential-phenomenological approach was used in an attempt to reconstruct patients' experiences as reported in their own words.
• ? Themes which emerged from the data and are reported here focus on ‘routine geriatric care’, ‘care deprivation’, ‘depersonalization’, and ‘geriatric segregation’.
• ? The findings are discussed against the background of literature about nursing care of elderly people. It is suggested that in the setting studied, limitations posed by past management deficiencies, under-staffing and poor physical environment contributed to the situation reported. Trained nurses felt they worked hard to give the best care they could but, with a high ratio of untrained staff and lack of continuing education, they were aware that their levels of achievement were far from ideal.
• ? The study demonstrates that, with an appropriate methodology, it is possible to gain access to how patients' experience their care and in this sense the attempt to ‘listen to the voices of patients’ was successful and gives pointers to developing more patient-sensitive quality-assurance processes.

     

Inappropriate prescribing for older people admitted to an intermediate-care nursing home unit and hospital wards

Objective

To identify inappropriate prescribing among older patients on admission to and discharge from an intermediate-care nursing home unit and hospital wards, and to compare changes during stay within and between these groups.

Design

Observational study.

Setting and subjects

Altogether 400 community-dwelling people aged ≥ 70 years, on consecutive emergency admittance to hospital wards of internal medicine and orthopaedic surgery, were randomized to an intermediate-care nursing home unit or hospital wards; 290 (157 at the intermediate-care nursing home unit and 133 in hospital wards) were eligible for this sub-study.

Main outcome measures

Prevalence on admission and discharge of potentially inappropriate medications (Norwegian general practice [NORGEP] criteria) and drug–drug interactions; changes during stay.

Results

The mean (SD) age was 84.7 (6.2) years; 71% were women. From admission to discharge, the mean numbers of drugs prescribed per person increased from 6.0 (3.3) to 9.3 (3.8), p < 0.01. The prevalence of potentially inappropriate medications increased from 24% to 35%, p < 0.01; concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-inflammatory drugs (NSAIDs) increased significantly. Serious drug–drug interactions were scarce both on admission and discharge (0.7%).

Conclusions

Inappropriate prescribing was prevalent among older people acutely admitted to hospital, and the prevalence was not reduced during stay at an intermediate-care nursing home unit specially designed for these patients.Key Words: Acute illness, drug–drug interactions, elderly, general practice, hospital, intermediate care unit, NORGEP screening tool, Norway, potentially inappropriate medicationsOlder people are at increased risk of adverse drug events. Screening tools may identify potentially inappropriate medications. Treatment in intermediate care units may possibly provide an opportunity for reducing inappropriate prescribing.

• Inappropriate prescribing was prevalent among community-dwelling older people on emergency admittance to hospitals in Bergen, Norway.
• Concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-inflammatory drugs (NSAIDs) increased significantly during stay.
• Serious drug–drug interactions were scarce on admission and discharge.

     

Staff perspectives on the role of the nurse in rehabilitation wards for elderly people

• ? The increasing demand for cost-effective and efficient health care may create a demand for more demonstrably effective hospital-based rehabilitation services, with the explicit goal of enabling patients to return home after short admissions; thus rehabilitation is centre stage.
• ? This paper reports the findings from a study of the rehabilitation of elderly people in hospital; in particular it focuses on an aspect of the process of care: namely staff perceptions of rehabilitation work, with particular emphasis on the role of the nurse.
• ? A conversational style of interviewing was used with 56 staff respondents from two rehabilitation wards for elderly people.
• ? Findings suggest that therapists are often seen as experts, and nursing is viewed as separate from rehabilitation, and hence nurses are an under-utilized resource in this field.
• ? It is suggested that there is a need to examine further the reality of multidisciplinary teamwork in rehabilitation, particularly with respect to maximizing the potential contribution of nurses, with the end goal of improving patient outcomes.

     

Experiences of elderly patients concerning discharge from hospital

Summary

• ? Problems surrounding the discharge of patients from hospital have been well-documented in the research literature and highlighted in recent Audit Commission reports.
• ? The need for effective discharge planning and post-discharge support is increasing as lengths of stay in hospital continue to fall.
• ? Elderly patients are in particular need of well-planned discharge.
• ? This paper reports the findings of an exploratory study in which elderly patients were interviewed before and after discharge from hospital.
• ? Three main problem areas which were identified are discussed:

• — lack of preparation for discharge;
• — difficulties in managing at home after discharge;
• — limited provision of health and social services in the post-discharge period.

• ? It is suggested that nurses are in a key position to improve discharge planning and procedures for patients (particularly the elderly) returning home from hospital.

     

The therapeutic use of music in a care of the elderly setting: a literature review

• ? This paper reviews recent literature concerning the use of music and music therapy in health care.
• ? Focusing particularly on the elderly, the use of music in relation to patients with dementia and Parkinsonism is examined.
• ? Brief reference is also made to the use of music in pain control.
• ? Although in this case, literature is not specific to care of the elderly settings, the results are still relevant to gerontological nursing.
• ? Projects which achieved positive results in controlling pain perception could be transferable to a care of the elderly scenario, where chronic pain is often part of daily life.

     

An attempt to give nursing home residents a voice in the quality improvement process: the challenge of frailty

• ? Advanced frailty and confusion of many nursing home residents present a particular conundrum to researchers committed to resident participation. While the research is set in Australia, the challenge of frailty is common to researchers working with compromised older persons.
• ? This study was conducted in an Australian 32 bed nursing home. As researchers we took on the roles of facilitators and negotiators within a quality improvement process using the approach of fourth generation evaluation.
• ? The overall aim of the project was to provide all stakeholders, including residents and their significant others, with a voice in the negotiations and decisions that impact on their lives.
• ? The focus of this paper is our attempt to gain the perspective of residents and significant others.

     

Including patient preferences in nurses' assessment of older patients

• ? The refinement of a patient assessment tool for older patients, Lorensen's Self-Care Capability Scale, is described where a systematic elicitation of patient preferences is included in the assessment.
• ? This study tests a decision analytic approach as a strategy for formalizing subjective judgement, which makes it possible to include patients' own values and preferences in planning patient care.
• ? Applying this technique to patient assessment contributes to explicitly tailoring nursing care decisions to desired outcomes as preferred by individual patients.
• ? A shared approach to decision making between nurse and patient ensures a mutual understanding about goals, priorities and patient values through discussion and negotiation.
• ? This pilot study supported the merit of including patient preferences systematically in the assessment of older patients.
• ? The method provides an important decision aid for nurses in planning nursing care in accordance with patients' own values and preferences for care.

     

What are nurses doing to patients? A review of theories of nursing past and present

• ? This paper looks critically at the nature of nursing theory from three perspectives.
• ? Firstly, it examines the current state of nursing theory with a particular focus on Patricia Benner's work. This examination concludes that nursing theory is currently beset by the problems of scientific and moral relativism and philosophical incoherence because it has abandoned a traditional realist approach to the care of patients.
• ? Secondly, the roots of this contemporary nursing position are analysed and the conclusion is reached that nursing theorists are implicitly presuming this traditional ‘common sense’ view of nursing, although their own philosophical assumptions do not support it and indeed are removing the ground from beneath it.
• ? The traditional theory underpinning the quality of the nurse's care, and hence the ethos of nursing, is rearticulated.
• ? In conclusion it is suggested that nursing needs to debate the modernist views that are now holding sway in nursing and rediscover a theory for the care of patients that holds together the personal, the pastoral, the scientific and the technological aspects of patient care.

     

Shiftwork and quality of care

Summary

• ? This article reviews the literature on shiftwork in nursing and relates this to quality of care issues.
• ? The implications of a fully rotational shift system are discussed.
• ? The biological effects of working shifts are reviewed, but there appear to be other factors, such as social circumstances and autonomy, which moderate these effects.
• ? It is suggested that tasks, formal and informal structures, and staff needs vary widely between nursing shifts, and that this should be taken into account when quality initiatives are introduced.
• ? It is concluded that claims that increasing the number of nurses who work fully rotating shifts results in an improved quality of care for patients are premature, as quality issues in nursing have not been addressed on a 24-hour basis.

     

Nutrition: a hard nut to crack. An exploration of the knowledge,attitudes and activities of qualified nurses in relation to nutritional nursing care

• ? Provision of adequate nutrition is recognized as essential, yet malnutrition continues to be reported in patients admitted to hospital.
• ? The effects of malnutrition in hospital patients have been well documented; however, most work relating to nutritional management has been produced by members of Nutrition Support Teams, nurse specialists and interested clinicians, whilst the majority of hospitals are still without such specialist posts.
• ? This study used two data collection methods to gain information about the attitudes, nutritional knowledge base and nutrition-related nursing care in a large trust hospital in the South of England.
• ? A survey of care plans for documentation of nutrition-related nursing activities, carried out on the day of discharge for all patients from five wards over a period of a fortnight (totalling 141 sets of documentation), was followed by a questionnaire to all qualified nurses on these and a further four wards (110 nurses).
• ? Results demonstrated that nurses generally felt that nutritional assessment was primarily their responsibility.
• ? Whilst there was evidence of knowledgeable and proactive nursing care, it also appeared that there were fairly widespread deficiencies in the knowledge, communication and co-ordination required to ensure consistent good practice.

     

Caring: fitting the concept to nursing practice

• ? This paper explores the concept of caring when used to define the nature of nursing.
• ? It is suggested that explorations of caring in nursing fail to acknowledge the real world of work in nursing, which is influenced by personal career choice and the organization of the health-care systems in which nurses work.
• ? In some situations nurses delegate the caring role to others thus giving ‘care by proxy’, a factor that is not clearly acknowledged in the literature on caring.
• ? It is suggested that if caring in nursing practice was denned as ‘formalized caring’ it would offer a framework for the analysis of caring more conducive to the reality of nursing practice today.

     

Admission to care: facilitating role transition amongst family carers

• ? Admission to care after a period of family care-giving has been the focus of much recent research.
• ? Rather than being seen as an end in itself, admission is part of a process.
• ? This article concentrates on ‘reaching the end’ of family care-giving and the ‘new beginning’ of entering residential care.
• ? A cross-national study conducted in the USA and the UK is discussed, and similarities and differences in the two cultures are highlighted.
• ? Decisions to enter a nursing home were often taken hurriedly and with lack of information in both countries.
• ? Issues of quality of care and emotional responses by former carers were also important in both settings.

     

A service evaluation of stoma care nurses' practice

• ? Stoma care nurses aim to meet the physical, psychological, social and spiritual needs of patients.
• ? Development of stoma care nursing services has varied, as it has been the responsibility of each nurse, resulting in differences in the mode of delivery.
• ? This qualitative and quantitative study involved stoma care nurses from six areas in Essex, to assess patient perception of the service they received.
• ? Overall, the satisfaction level was high despite differences in delivery of care, especially timing and frequency of visits at home.