Critical thinking: what does it mean in the care of elderly hospitalized patients?

In today's complex healthcare environment, it is more important than ever that nurses possess critical thinking skills to provide optimal care for their patients. This article offers a definition of critical thinking for nurses and describes the importance of critical thinking in the care of our growing elderly patient population. Examples related to geriatric nursing care, including acute care, dementia care, and end-of-life care, are provided to reinforce the importance of critical thinking and its benefits to our elderly patient population.     

New graduate nurses and dementia care in acute care: A qualitative study

With the increasing older adult population, new graduate nurses will be providing care for patients with dementia more frequently. The purpose of this qualitative study was to explore the experiences of new graduate nurses when providing care for patients with dementia in acute care environments. We conducted semi-structured interviews with eleven new graduate nurses in Ontario, Canada. Three themes emerged from the thematic analysis: (1) building of vision and values; (2) clashing of vision and values; and (3) making do with what you have. Barriers to providing dementia care in acute care were similar to barriers experienced by non- new graduate nurses reported in the literature, such as challenges with responsive behaviours, maintaining safety and providing psychosocial care. Facilitators identified were supportive colleagues and early exposure to dementia care.     

The negative attitudes of nurses towards older patients in the acute hospital setting: a qualitative descriptive study

AIM: This paper reports the findings of a sub-sample of interviews from a larger study designed to explore the attitudes of health care workers towards older people in that acute care setting.The discussion in this paper focuses only on interviews with nurses and their negative attitudes towards older people in their care. BACKGROUND: As Australia's ageing population continues to grow exponentially, their demand for hospital care also increases. Many nurses in the acute care setting have had little, if any, specialist education in the care of older people and therefore do not understand the extent of their needs. Coupled with the lack of specialist knowledge is the low status of older person care in this setting. Many nurses prefer to care for younger patients with acute illnesses that are curable (Nay 1993 in Nay & Garratt 2004: 61). As with the population at large, health care professionals hold negative views about old age and this is reflected in their attitudes. METHOD: The findings presented in this paper focus on data analysed from in depth interviews with nurses. As a prompt to discussions, nurses were presented with scenarios that exemplified both positive and negative attitudes to care. However, much of what was discussed in interviews focused on negative attitudes. Interviews with medical and allied health staff will be reported in a separate paper. RESULTS: The analysis of data with nurses reveals two themes and subthemes. 'Marginalisation and oppression of the older person' shows the ways in which nurses perceive older people are relegated to a lower status in the acute care setting, how this is 'contagious' and how 'lack of time' for care for older people is problematic and has become their 'catchcry'.'Stereotyping the older person' depicts some of the ways in which this evolves, for example, through 'Chinese Whispers' (UsingEnglish.com 2006), but has become part of the ageist culture.     

Situated clinical reasoning: distinguishing acute confusion from dementia in hospitalized older adults

In this study a dimensional analysis approach was used to explore the clinical reasoning of nurses who care for hospitalized older adults to identify factors that might explain their failure to detect acute confusion and to distinguish it from dementia in this patient population. Data analysis yielded a grounded theory of situated clinical reasoning, which proposes that the ability of nurses to identify acute confusion varies widely. This variation can be attributed to the differences in nurses' philosophical perspectives on aging. According to this theory, three distinct perspectives are unwittingly embraced by nurses who care for older patients. These perspectives influence how nurses characterize aging and the aged and condition the ways in which they judge and ultimately deal with older adults in clinical situations.     

Nurse staffing, bed numbers and the cost of acute psychiatric inpatient care in England

The aim of this analysis was to describe the composition, variability and factors associated with nurse staffing costs in acute psychiatric inpatient care. Numbers of acute inpatient beds in England have fallen, creating an occupancy crisis. Numbers of acute inpatient nursing staff are linked to quality of care. Variance in staffing and beds has considerable resource implications, but little is known about how these costs are structured. The sample comprised survey data from 136 wards in 26 NHS Trusts, matched with nationally available data on service levels, population and outcomes. The cost of providing acute inpatient care varied fivefold between different Trusts. This variation comprised of numbers of beds/population, numbers of nurses/beds and the proportion of nurses qualified. These variations were not fully accounted for by differing levels of social deprivation. Although service provision levels in London were higher, wide variation in costs existed in every region. Associations between nursing cost per bed and performance indicators were found. As investment in acute inpatient care varies widely, we need to know much more about the relationship of inputs to outputs, so that empirically based standard service levels can be defined.     

From cure to palliation: staff communication, documentation, and transfer of patient

In the transition from curative treatment to palliative care of a general end-of-life patient population, the internal communication of the acute care staff seems to be less than optimal. The communication had reference to the dialogue within the staff both before and after the decision to concentrate on palliative care, and possible transfer of the patient. This survey of Swedish nurses and physicians showed that most of 780 respondents wanted more internal communication, and a more individualized procedure of decision-making. All staff should be informed about the decision made but full agreement was not seen as realistic. The largest difference of opinion between nurses and physicians concerned the involvement of nurses in the decision-making about the transition. A uniform documentation of the decision to transfer care focus was the ideal. Approximately every fourth patient in acute care is transferred to receive palliative care. Only approximately half of the respondents had any training in palliative care and the majority wanted more training. There seems to be a need for more palliative care training, perhaps somewhat different for each specialty. Furthermore, a common language to enable nurses and physicians to communicate more easily may improve the transition process.     

Medication management by graduate nurses: before, during and following medication administration

The purpose of the present study was to explore graduate nurses' perceptions of their medication management activities in the acute care context. A qualitative research design with a semistructured interview schedule was used to elicit information from participants. The sampling population consisted of graduate nurses involved in direct patient care in medical and surgical wards of a Melbourne metropolitan teaching hospital, completing a graduate nurse program. Twelve graduate nurses participated in the interviews. Two major themes emerged: (i). monitoring medications and (ii). interventions for patient care. The findings indicate that graduate nurses are required to address several facets of the medication management role in their daily practice. It is pertinent to examine ward dynamics to ensure that graduate nurses have ready access to experienced health care professionals. Through collegial support, graduate nurses should also be encouraged to critically examine the different possibilities when making clinical judgments about monitoring patient medications.     

Caring for patients with dementia in an acute care environment

Although hospital nurses are skilled in meeting the acute health needs of the elderly, they may not have the expertise required to manage the behavioral disturbances typically seen in this population. Using the Progressively Lowered Stress Threshold Model (PLST), this article helps identify factors that may precipitate undesirable behaviors in the acute care setting and suggests strategies to help nurses prevent or control them.     

Clinical major option: a model for implementing critical care nursing into baccalaureate preparation

What was initiated as a directive from a provincial government in an attempt to increase the number of critical care nurses has evolved into an exciting educational opportunity for many nurses and student nurses in the year 2000. Between 1993 and 1997 there has been significant downsizing of acute care beds across Canada (Code Blue: Critical Care Nursing in Nova Scotia, 1998). At the same time patient acuity has increased, due to shorter hospital stays, and the number of nurses working full-time has decreased with the increased use of casual nurses. Several studies at both the provincial and national levels report current and future shortages of specialized nurses (emergency, critical care and perioperative). It is expected that this shortage will continue into the future, a shortage that is driven by technological advances, as well as an aging general and nursing population. Continued shortages of these acute care nurses will result in fierce competition for skilled nurses as well as aggressive recruitment and retention strategies (Code Blue: Critical Care Nursing in Nova Scotia, 1998). It is generally agreed within the nursing community that specialty nurses in critical care require a unique body of knowledge that is not acquired in a basic undergraduate nursing program (Fitzsimmons, Hadley, & Shively, 1999). This specialized knowledge can be gained informally through experience; however, it is largely developed in additional formal education programs. The purpose of this article is to outline a strategy for the delivery of specialty education at three educational levels in acute care nursing with three streams: emergency, critical care and perioperative nursing. This clinical major option is to be delivered in partnership among the Queen Elizabeth Hospital II, the Health Science Centre and Dalhousie University School of Nursing, Halifax, Nova Scotia, Canada. This model of offering specialty education in university preparation could be a template for preparing nurses in the new millennium.     

Getting to know you: a national view of acute renal care.

The American Nephrology Nurses' Association's (ANNA's) newest Special Interest Group (SIG) is Acute Care. This SIG recently developed a survey to obtain information about the practice areas from acute care ANNA members as there is a lack of data about this subset of nephrology nurses. The survey was designed to begin to explore the practice of acute care nurses and was distributed via e-mail to 1000 ANNA members who are registered acute care nephrology nurses. There were 246 responses to the survey. While the tool was not developed and confirmed as a reliable and valid tool, it was a first attempt to describe this population of nephrology nurses. Results of this survey of acute care nurses were presented at the Acute Care SIG networking session during the ANNA National Symposium in Dallas, Texas in April, 2007 The presentation, "Getting to Know You: A National View of Acute Renal Care," was presented by Acute Care SIG Members' Mary Rose Kott, MS, RN, CNN; Sue Fallone, MS, RN, CNN; Helen Williams, BSN, RN, CNN; Maureen Craig, MS, RN, CNN, CCNS; Billie Axley, BSN, RN, CNN; and Michelle Krueger, BSN, RN, CNN. The results are highlighted here.     

Patients who present with dementia: exploring the knowledge of hospital nurses

With the older population growing, there is likely to be an increase in the numbers of people with dementia on acute hospital wards. This article presents some of the findings from a Masters study (Ballard 2005) that explored the knowledge, understanding and implications for care of adult nurses working with patients who present with dementia in general hospital wards. Kitwood's 'malignant social psychology' and 'person-centred approach' were used as the theoretical framework to develop a questionnaire distributed to nurses. The findings about nurses' knowledge and understanding of person-centred dementia care and gaps in this area are discussed, and implications for future education and training of nurses presented.     

Cultural awareness: bridging the gap between caregivers and Hispanic patients

The healthcare environment is undergoing rapid change. Healthcare settings have shifted from acute care to encompass a variety of other locations. The healthcare work force is changing from a common ethnic origin to include a multitude of ethnic and racial groups. The patient population also embraces a plethora of different cultural backgrounds. By the year 2080, an estimated 51.1% of the population will be composed mostly of Hispanics, followed by African Americans and Asians. This dynamic transformation has created a critical need for nurses to become more knowledgeable and culturally aware to care for and work with people of other cultures. This article attempts to sensitize nurses to the important roles culture and ethnicity play in the delivery of optimal nursing care. The domain of intercultural communication and its importance in providing culturally competent, patient-relevant care is discussed.     

Meeting the continuing education needs of rural nurses in role transition

BACKGROUND: The community health center (CHC) model of care delivery is gaining acceptance throughout Canada's newly created rural health regions. The resulting change in nursing functions presents a challenge to regional health authorities to ensure the attainment and maintenance of practice competencies. METHOD: This qualitative study examined strategies used in selected parts of Canada to prepare and support rural diploma-prepared nurses for role transition from acute care into CHCs. RESULTS: In light of CHC nurses' increased degree of autonomy, skill level, and focus on community wellness, the findings indicate a need for additional educational preparation and supportive strategies for transitioning nurses. CONCLUSION: Regions should educate the public and staff about the principles of primary health care, population health, and factors that determine health to help stakeholders understand their community, the current gaps in service delivery, and the role of CHC nurses. Key players at the provincial level should work together to address competency issues and continuing education needs of nurses in career transition.     

The evidence-base for stroke education in care homes

RESEARCH QUESTIONS: 1. What are registered care home nurses' educational priorities regarding stroke care? 2. What are senior care home assistants' educational priorities regarding stroke care? 3. How do care home nurses conceive stroke care will be delivered in 2010? STUDY DESIGN: This was a 2-year study using focus groups, stroke guidelines, professional recommendations and stroke literature for the development of a questionnaire survey for data collection. Workshops provided study feedback to participants. Data were collected in 2005-2006. STUDY SITE: Greater Glasgow NHS Health Board. POPULATION AND SAMPLE: A stratified random selection of 16 private, 3 voluntary and 6 NHS continuing care homes from which a sample of 115 trained nurses and 19 senior care assistants was drawn. RESULTS: The overall response rate for care home nurses was 64.3% and for senior care assistants, 73.6%. Both care home nurses and senior care assistants preferred accredited stroke education. Care home nurses wanted more training in stroke assessment, rehabilitation and acute interventions whereas senior care assistants wanted more in managing depression, general stroke information and communicating with dysphasic residents. Senior care assistants needed more information on multidisciplinary team working while care home nurses were more concerned with ethical decision-making, accountability and goal setting. CONCLUSIONS: Care home staff need and want more stroke training. They are clear that stroke education should be to the benefit of their resident population. Guidelines on stroke care should be developed for care homes and these should incorporate support for continuing professional learning in relation to the resident who has had a stroke.     

Creating a cultural shift. A gerontological enrichment program for acute care.

As the number of older adults in acute care rises, acute care specialty nurses must gain gerontological knowledge in their nursing practice with older patients. A blend of two bodies of knowledge and competencies is required to care effectively for older adults in the hospital. To this end, a gerontological enrichment program was developed to improve care to hospitalized older patients by augmenting acute care nurses competencies with gerontological skill, knowledge, and abilities. This article will explain the implementation details, the anticipated outcomes for nurses and older acutely ill patients, the evaluation process, and the strategies that are in place to maintain the gains.     

Nurses in adult day care centers

Adult day care services are community-based group programs designed to support adults' personal independence by promoting their social, physical, and emotional well-being through an individual plan of care. Nurses are in a prime position to care for this population because they deliver holistic care and promote health. Scant literature is available that addresses how nurses provide care for this population. The purpose of this article is to describe how nurses can care for the adult day care population and to present an illustrative case study that demonstrates how nurses can positively affect the health of older adult day care clients.     

Critical aspects of nursing in aged and extended care

An ageing Australian population and improving medical retrieval technology have led to an increasing need for nurses to manage complex and acute health issues of ageing and chronic disability In a study of aged and extended care involving nurses, residents, allied health professionals and family members, investigators used semi-structured interviews to identify critical aspects of nursing The aim of the study was to begin to identify and illustrate a theoretical framework of 'critical' nursing activities for aged and extended care Two important themes to emerge were the structure of the health care setting and the characteristic behaviours of people associated with it These themes reinforce the importance of treating people as individuals and of describing caring criteria in ways which reinforce holism