Promoting autonomy and independence for older people within nursing practice: an observational study

Although autonomy and independence are widely held to be important goals of care for older people, these terms lack precise definition and operationalization in the literature. This paper reports on observational data gathered as part of an evaluation of educational programmes in the nursing care of older people. Strategies which appear both to promote and inhibit autonomy and independence of older patients in a range of care settings are described. Recommendations are made for further research to explore the extent to which autonomy and independence are appropriate goals of care for older people with cognitive impairment.     

Autonomy for older people in residential care: a selective literature review

Autonomy is an important concept because it brings dignity to peoples' lives, regardless of physical circumstances. The United Nations (UN) Madrid International Plan of Action on Ageing emphasises the need to include older adults in autonomous decision-making processes. However, many older people living in residential care find that their autonomy is curtailed. This is largely because autonomy for older people is poorly understood, and hence, nurses working with older people need to become clear about what autonomy is and how it can be facilitated. In this, the first of three papers, the literature is reviewed specifically to establish the meaning of autonomy for older people in residential care as opposed to autonomy in a wider context. This important distinction may help nurses working with older people to begin to facilitate autonomy more effectively.     

Agenda for the future: enhancing autonomy for older people in residential care

This is the concluding paper of a three paper publications. Paper 1 focused on specifically understanding what autonomy for older people in residential care means. Paper 2 discussed the various factors that either facilitate or hinder residents autonomy and directed readers to reflect upon their practice. This final paper outlines the findings from the action research phase of a study aimed at enhancing resident autonomy. It describes just one way in which residential care units can work on enhancing residents autonomy and enables the reader to reflect upon nursing practices, which with the right approach can be resident-centred.     

Prescribing for older people in nursing homes: a review of the key issues

Prescribing of medication is one of the most common interventions that residents in nursing homes will experience. There is little doubt that medication has greatly contributed to improvements in symptom control, long-term management of medical conditions and greater longevity. However, the quality of prescribing has also been criticised and this paper outlines the issues that have proved to be most problematic and have been repeatedly highlighted in the literature. There have been numerous reports of over-use of inappropriate medicines for which there is no clinical indication or for which there is little evidence of effectiveness, and under-use of medicines that would be indicated for residents with certain medical conditions. Residents may also suffer from adverse drug events and enforced or erratic compliance. Some of these problems may arise because of the difficulties encountered by staff or a breakdown in communication when residents move from one setting to another (e.g. hospital to nursing home or vice versa).     

Improving the oral health of older people in long-term residential care: a review of the literature

Background.  Unrefutable evidence now links poor oral health with the development of preventable systemic illnesses and debilitating conditions that threaten quality of life and life itself. This is especially significant for an increasing older population who are dependent on others for care.
Aims and objectives.  The majority of studies analysing the oral health of older dependent people in long-term residential care have been undertaken by dental professionals. This critical literature review examines the issue from a nursing perspective because nursing care providers have a fundamental role in daily oral health provision for dependent residents.
Conclusions.  Multiple barriers were found to negatively impact on daily oral healthcare provision, including lack of care provider education, oral health values, availability of resources, implementation of supportive policies, documentation and oral health assessment tools.
Relevance to clinical practice.  The nursing profession, at all levels, must become pro-active in removing financial, political and workforce barriers that impact negatively on oral health outcomes. A multi-faceted approach is required to address these barriers, including development and implementation of oral health education programmes, assessment screening tools, care plans, documentation, supply of oral hygiene aids and the appointment of oral care 'champions'.     

Promoting urinary continence with older people: a selective literature review

As the population of older people increases so does the prevalence of urinary incontinence experienced. Despite its complex aetiology most of the contributing factors are reversible, when accurate assessment leads to the development of a person-centred continence care plan. This selective literature review highlights that a change in perspective among older people and healthcare professionals will enable a focus on bladder rehabilitation and proactive approaches to managing urinary incontinence, even in the very frail population. The need to design tools to facilitate such developments is discussed together with the need for greater focus on educational support that considers the wider context and the multiple factors that influence practice.     

Delirium and older people: repositioning nursing care

Aims. To critically examine the nursing care offered to older people who have been delirious. Background. Delirium occurs as a result of physiological imbalances resulting in an alteration in consciousness and cognitive impairment. Delirium is a prevalent and serious cognitive disorder experienced by older people. While there is a vast number of studies published utilizing quantitative methods, there remains a dearth of research relating to delirium in older people from a qualitative perspective. Design. A qualitative research design that utilized a critical gerontological framework underpinned this study. This framework drew on aspects of postmodernism and Foucault's understanding of discourse. Methods. Data sources included published documents on delirium, semi‐structured taped interviews with people over the age of 65 years who had been delirious (as well as their clinical notes), family members, Registered Nurses and a hospital doctor. A postmodern discourse analytic approach was used to interrogate the 20 sets of data collected. Findings. Textual analysis revealed the presence of two major discourses impacting on being an older person with delirium. These were identified as a nursing discourse of delirium and a personal discourse of delirium. A nursing discourse of delirium was largely focussed on the biomedical processes that resulted in a delirious episode. Conversely, a personal discourse of delirium highlights that there are other ways of ‘knowing’ about delirium through considering the narratives of older adults, and their families, when offering a nursing service to this group of people. Relevance to clinical practice. Nursing needs to critically examine all aspects of nursing care as it applies to older people who have delirium to ensure the rhetorical claims of the profession become the reality for consumers of health services. The use of critical gerontology provides nurses with the tools to challenge the status quo and uncover the multiple, varied, contradictory and complex representations of delirium in older people. Inherent within a personal discourse of delirium is the importance of incorporating into nursing care communicative and other relational activities, such as forming and maintaining a therapeutic relationship.     

Promoting compassionate care with the older people: a relational imperative

We have been invited to imagine a future where the care for older people goes beyond the current paradigm. This article challenges the fundamental assumptions that underlie current care practices and, instead, promotes systems and processes that elevate nourishing and stimulating relationships with basic dignity, as well as personal agency, in the later days of life. Healthcare professionals still base current care systems on a medical model that emphasises the diagnosis, treatment and cure of disease (Kane RL & West JC, 2005It Shouldn't Be This Way: The Failure of Long-Term Care, Vanderbilt University Press, Nashville, Tennessee). In contrast, we highlight principles of relating that support care to older people during the final stages of life, and promote systems, processes, and design elements that constitute compassionate care. To do so, it is necessary to move from a model that responds to the dominant regulatory environment to a model that is designed in the ongoing processes of human relationships. Specifically, we are including all dimensions of relating including relations among the residents and between and among residents' families, and all levels and functions of caretakers and the community.     

Multi‐professional communication for older people in transitional care: a review of the literature

Aims and objectives. To synthesise research‐reporting literature about multi‐professional communication between health and social care professionals within transitional care for older people, with particular attention on outcomes, enabling contextual factors and constraints. Background. Older adults experience high rates of morbidity and health care usage, and frequently transit between health services, and community and social care providers. These transition episodes place elders at increased risk of adverse incidents due to poor communication of information. Integrated multi‐professional models of care built on enhanced communication have been widely promoted as a strategy to improve transitional care for older people. However, a range of findings exist in the literature to guide service providers and researchers. Design. Comprehensive literature search and review strategies were employed to identify, describe and synthesise relevant studies. Ten databases were searched in addition to Google Scholar. Conclusions. Specified discharge worker roles, multi‐professional care coordination teams, and information technology systems promote better service satisfaction and subjective quality of life for older people when compared with standard hospital discharge. Improved multi‐professional communication reduces rates of re‐admission and length of stay indicating greater cost effectiveness and efficiency for the health and social care systems. Systems of care emphasizing information exchange, education and negotiation between stakeholders facilitate communication in transitional care contexts for older adults. Conversely, lack of dialogue and lack of understanding of others’ roles are barriers to communication in transitional care. Implications for practice. Enhanced multi‐professional communication, transitional pathways, and role clarity are required to improve the quality, sustainability and responsiveness of aged care into the future. Recommendations for further research include: (i) Investigation of pathways promoting person‐centred care planning including the older person, their family and relevant practitioners; (ii) Development of interventions aimed at improving multi‐professional communication and transitional aged care with marginalised and socially disadvantaged elders on indicators of equity and access; (iii) Investigation of changing roles for practitioners in multi‐professional teams with a focus on community‐based teams including nurses specialising in aged care and general practice.     

Students' ideals for nursing older people in practice

Aim. Drawing on research exploring nursing students’ experiences of working with older people, this paper aims to demonstrate how context and culture can impact on the realization of their ideals. Background. The principles underpinning individualized and person‐centred approaches to care resonate with those focal to gerontologic nursing. Restrictive contexts of care and pervasive workplace cultures render nurses unable to deliver care in accord with these. Design and method. This interpretive study was informed by phenomenological–hermeneutic theory. A purposive sample (n = 10) was recruited from a single educational institution. Data were generated in two phases using loosely structured interviews and supplementary activity. Themes explicating their experiences were identified via systematized detailed analysis and issues pertaining to nursing students’ orientation towards older people cut across these. Findings and discussion. Students perceived that older people were prone to depersonalization and marginalization, so sought to show respect by coming to know individuals, form human connections with them and personalize care accordingly. Giving respect, promoting personhood, asserting reciprocal identity and maintaining dignity were prominent features of this but were often frustrated by practices and cultures encountered in mainstream settings. Conclusions. Nursing students’ approaches to older people are contextual and reflect elements of person‐centred ideology. Their attempts upholding their ideals are liable to be subverted by workplace norms. Preparatory education should address these, assist students to learn how to attend to personhood in restrictive environments and offer targeted placements in age‐specific and non‐acute services. Relevance to clinical practice. Demographic trends mean that working with older people has increased significance for nurses in most settings. Person‐centredness is seen as beneficial for older people but contemporary service imperatives and enduring practices are inhibitory, preventing entrants to nursing from developing related skills.     

The educational preparation of staff in nursing homes: relationship with resident autonomy

The following paper reports on a survey of nursing homes in three health regions in England which formed part of a wider study to evaluate educational preparation for the nursing care of older people. The aims of the survey were to describe the educational preparation of staff employed within nursing homes and to explore relationships between educational preparation and one indicator of quality of care. A self-completion questionnaire was addressed to the senior nurse within a random sample of nursing homes. The instrument included a previously validated scale to measure resident autonomy. A total of 976 questionnaires were posted and 676 were returned, a response rate of 69%. The survey revealed wide variation in the educational preparation of staff in nursing homes and in the degree of contact with local centres providing nurse education. Statistically significant associations were found between resident autonomy and a composite measure of educational preparation, the proportion of qualified staff undertaking continuing professional education and the degree of contact with educational centres. The findings have implications for both purchasers and providers of education in this field.     

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.     

The importance of 'approaching' older people: a grounded theory

jonasson l‐l. & berterö c. (2012) The importance of ‘approaching’ older people: a grounded theory. International Journal of Older People Nursing 7 , 29–36
doi: 10.1111/j.1748‐3743.2010.00248.x Aims and objectives. The aim of this study was to identify and describe the ethical values in caring encounters as experienced by older patients in their daily interaction with nurses in wards for older people. Background. Ethical values and morals are important aspects that influence the quality of care. Methods. Empirical observational study including follow‐up interviews. Twenty‐two older patients participated voluntarily in this study. Constant comparative analysis, the core foundation of grounded theory was used. Results. Five categories: being addressed, receiving respect, desiring to participate, increasing self‐determination and gaining self‐confidence formed the bases for the core category. Approaching. Approaching concerns how people become closer to each other in a physical space. It also includes how people become closer to each other in a dialogue, involving verbal or bodily communication. Conclusions and relevance to clinical practice. Approaching indicates the ethical values that guide nurses in their caring encounters with older patients. These values are noted by the patient and have an individual value as well as leading to improved quality of their care. The older patient will be confident and satisfied with the caring encounter if the desired components in the nurse's approaching are exhibited.