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.     

Patient autonomy in nurse-led shared care: a review of theoretical and empirical literature

AIM: This paper presents a review of the theoretical and empirical literature addressing patient autonomy and how nurses can support patient autonomy. BACKGROUND: Nurse-led, shared care settings provide needs-based care to patients who are encouraged to participate actively in their care. Patient autonomy is a complex ethical concept with many different meanings. As a result, nurses must solve various problems to foster patient autonomy successfully. METHOD: Two methods were used to identify literature for the review: (a) a search of the MEDLINE, Embase, CINAHL and Online Contents databases and the keywords 'patient autonomy' in combination with 'nursing', and the Dutch Central Catalogue for material published from 1966 to 2005; (b) ethical and nursing literature was selected on the basis of its identification of positive and negative freedom. We reviewed qualitative empirical research to explore the patients' views of autonomy. FINDINGS: Negative freedom emphasizes freedom of action and freedom from interference by others. Positive freedom stresses the idea that people should direct their lives according to their personal convictions and individual reasons and goals. The most prominent theories fitting negative freedom are those defining autonomy as self-governance and self-care. Theories fitting positive freedom are those focusing on autonomy in caring, autonomy as identification, autonomy as communication and autonomy as goal achievement. In the empirical literature, two studies centred on patient autonomy in home care, one in nursing home care and three in hospital settings. To achieve autonomy, patients prefer a mixed approach that combines features of negative and positive freedom. CONCLUSION: Nurses cannot rely exclusively on one model of autonomy to foster patient autonomy. Rather, it requires in-depth knowledge of, and interaction with, patients in the context of each particular nursing encounter because people express their autonomy through particular courses of action.     

Nurses' perceptions of quality and the factors that affect quality care for older people living in long-term care settings in Ireland

Aim. The aim of this research was to determine the factors that facilitate or hinder high quality nursing care for older people in long‐term care settings in Ireland. Background. The quality of care for older people living in long‐term care has been identified as an issue of concern in many nursing research studies. While many factors which have an impact on care have been identified, it is difficult to determine key factors from current research. Method. This was a mixed method study, which involved qualitative and quantitative approaches. A self‐response questionnaire was generated from data gathered by interview and analysis of literature. Information was collected from 498 nurses working in long‐term care settings within a Health Board. A 68% response rate was achieved. Factor analysis was used to identify facilitating and hindering factors of quality care for older people. Results. Nine factors where identified six facilitating factors of quality and three hindering factors of quality care. The six factors, which facilitate quality, were: an ethos of promoting independence and autonomy; a homelike social environment; person centred, holistic care; knowledgeable, skilled staff; knowing the person and adequate multidisciplinary resources. The three factors which hindered quality care; these were: a lack of time and patient choice, resistance to change and bound by routine. Conclusions. The findings of this research provide nurses with a clear set of facilitating and hindering factors of quality care for older people and reveal some of the complexities and challenges of providing this care. Relevance to clinical practice. Long‐term care is the home of many older people and attention within these environments to the facilitating and hindering factors of quality is required. It is hoped that the factors generated in this study add to understanding in relation to quality care and the factors that influence this.     

Factors influencing older patients' participation in care: a review of the literature

lyttle d.j. & ryan a. (2010) Factors influencing older patients’ participation in care: a review of the literature. International Journal of Older People Nursing 5 , 274–282
doi: 10.1111/j.1748-3743.2010.00245.x Background. Over the past 10 years, there has been an increase in the literature promoting patient involvement in health care at all levels of the decision-making process. Aim. To review the literature on factors influencing patient participation in care with a particular focus on the perspective of older people. Method. Various search engines were used to conduct the review and articles were identified through the following databases; CINAHL, CSA ILLUMINA, Science Direct, Blackwell Synergy, the Cochrane Library, OVID, SAGE, AHMED, BNI and MEDLINE. Research studies ranging from 2000–2007 were selected for inclusion on the basis that they investigated patient participation and/or older peoples’ involvement in health care. Findings. Seven key themes emerged from the literature: the concept of participation, the need for older people to be involved, autonomy and empowerment, patients’ expectations, benefits of participation, factors influencing participation and precursors to participation. Conclusions. Although patient participation has received considerable attention in the literature, this review highlights the dearth of research from the perspective of older people. There is a general consensus that preference for participation should be assessed and not assumed, and the review offers a sobering reminder that participation should not be achieved at the expense of patient autonomy and choice. Relevance to practice. Quality care and the most productive use of resources are dependent on the public’s engagement with health service providers. However, despite being central to contemporary nursing practice, this review suggests that the reality is not matched by the rhetoric. Future initiatives should focus on supporting nurses and other healthcare professionals to develop the competencies required to facilitate greater participation by older people who wish to become more involved in their care.     

Spheres of clinical nurse specialist practice influence evidence-based care for patients with atrial fibrillation

PURPOSE: The purpose of this article is to review atrial fibrillation (AF) and its consequences, to present sources of published evidence-based guidelines for management of AF, and to highlight multifaceted clinical nurse specialist (CNS) interventions that promote positive outcomes for patients with AF. RATIONALE: The number of people with AF is expected to increase from 2.3 million to more than 5 million in the next 50 years. AF is associated with increased mortality, morbidity, healthcare expenditures, and decreased quality of life. Recognition of the growing number of AF cases and adverse consequences of AF led to development of evidence-based guidelines for AF management. Although nurses in diverse settings are accountable for providing evidence-based care for patients with AF, the guidelines have not been widely disseminated to nurses. DESCRIPTION: This discussion includes a review of the adverse consequences of AF and a summary of management of recently detected AF with a focus on recommendations for nursing activities/interventions that are supported by evidence-based guidelines. Multifaceted strategies directed toward nurses and nursing practice, patients/clients, and organizations/systems that are linked to published CNS competencies and outcomes are highlighted. OUTCOMES: CNS influence in all 3 spheres of CNS practice promotes positive outcomes that include improved patient/client functioning and self-management, reduced complications of treatment, decreased fragmentation of care, advancement of professional nursing practice, adherence to regulatory standards, and development of patient care processes that are supported by published guidelines. CONCLUSIONS: With the use of the strategies discussed, clinical nurse specialists, whose spheres of influence include nursing and nursing practice, patients/clients, and organizations/systems, promote improved patient outcomes through implementation of evidence-based guidelines for AF management.     

The use of touch to enhance nursing care of older person in long-term mental health care facilities

The self-care deficits experienced by older clients in long-term mental health settings, because of cognitive impairment, are likely to impact upon the clients' higher-order needs. The practice of nursing the elderly involves a lot of personal contact, during the delivery of fundamental physical care. While physiological and safety needs are crucial to clients in long-term settings, higher-order needs need also to be addressed. From the clients' perspective nurse's use of touch provides comfort, warmth and security, although there is a dearth of empirical evidence of these benefits. This paper explores the nurse's use of touch, the impact of touch and the experiences of touch on the older person in long-term settings. Because of the dearth of research in the use of touch with elderly clients in long-term care mental health facilities, a review of the literature was performed on the topic. This revealed that touch by nurses is frequently associated with routine tasks within nursing, and is less likely to be a caring touch intervention. Recommendations include further research on the topic and caution with widespread adoption of caring touch as an intervention.     

Promoting effective continence care for older people: a literature review

Recent United Kingdom guidelines have identified the need for integrated continence services within health regions. While there is evidence of improvements in community services there is little evidence that the quality of nursing care offered for older people with urinary incontinence in care settings has improved. This literature review identifies some of the underpinning issues that impact on continence promotion for older people. Despite evidence that older people suffer physical, social and psychological distress as a result of mismanaged urinary incontinence, costs of promoting continence are higher in financial terms than containing incontinence. The extent of the problem is difficult to identify in terms of how many older people are affected by different types of urinary incontinence. Nurses' attitudes are found to affect the quality of continence care delivered, and there continues to be a lack of evidence around sustainable strategies for continence promotion in care settings.     

Involvement of older people in care, service and policy planning

In line with other helping professions nursing has moved from traditional views of technical expertise as the prime shaper of health care, to a more equal relationship with service users and patients which respects their expertise, knowledge, goals and choices. This philosophy has underpinned the movement to involve older people in care, policy and planning activities. The literature review presented in this paper highlights the growing literature on this subject with respect to older people and maps the key issues and debates for nursing.     

Promoting aesthetics to enhance nursing services

Nursing is a client-oriented profession dedicated to helping people. Nurses are responsible to both help relieve client physical and psychological symptoms and assist clients as necessary to die with dignity. As such, nursing schools should strengthen not only science and professional skills, but also student aesthetics. Today, fast changing medical technology is improving the treatment of diseases and extending average life spans. The National Health Insurance System in Taiwan, however, is increasingly restricting nursing manpower and raising staff workloads. Nurses are increasingly required to sacrifice ethical principles and conduct technical operations in medical settings defined by stringent cost controls. Nursing aesthetics cannot provide appropriate levels of care dignity and quality to clients under severe time and emotional distress constraints. Burnout, dissatisfaction, strained doctor-nurse relationships and lower quality care are all-too-frequent results. Under the circumstances, nursing functions are negatively influenced and fine nursing service is difficult to achieve. This article reviewed the literature to discuss the definition and meaning of aesthetics and relative factors that are difficult to define in clinical settings. This article may assist nurses to present aesthetics, upgrade care quality and further enhance nursing services.     

Practice development in aged care nursing of older people: the perspective of ageing and spiritual care

This third paper on older people nursing and spirituality moves beyond the literature reviewed in the two previous papers, exploring directions for the practice and continuing research in this field. Issues of chronic illness challenge nurses working with older people to focus on continuing health promotion and opportunities for spiritual promotion of resilience and transcendence. The changes from monocultural to multicultural societies challenge nurses to know how to provide culturally and faith appropriate care. The extension of palliative care to the needs of those growing older and dying is noted as an important area for developing spiritual care. It is asserted that spiritual assessment forms a basis for the provision of spiritual care for all of these themes. Ethical perspectives of older people nursing must be carefully addressed as frail and vulnerable older people struggle with issues of compromised autonomy. Further research should focus on spirituality as seen through the eyes of older people and examine the interface between nurses and patients, where the relationship becomes the guiding basis for practice. Education in nursing courses and through continuing programmes of education is needed to ensure adequate understanding of spirituality in the nursing role.     

Achieving dignity for older people with dementia in hospital

The quality of care for people with dementia in general hospital settings has attracted widespread concern. While organisation-wide strategies are needed to address many of the issues, the nursing role is critical to articulating and promoting good practice. This article focuses on promoting dignity for older people with dementia and offers a number of strategies to help individual nurses and nursing teams reflect on and promote good 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.     

Reconstructing mental health nursing in home care

BACKGROUND: Psychiatric care for people in Sweden with long-term mental health problems has shifted from institutional to community and home settings. AIM: The aim of this study was to explore and describe mental health nurses' experiences of how structural changes in mental health nursing influence interaction when providing home care to patients with long-term mental health problems. METHOD: We conducted interviews with 11 mental health nurses who provided home care to people with long-term mental health problems. The constant comparative method of grounded theory was used for data collection and analysis. FINDINGS: The process of attempting to reconstruct mental health nursing by entering into the everyday reality of people with long-term mental health problems was identified as the core category. Central to this process was a change in perspective from nurse-controlled to client-centred care. This led to changes in moral values, assessment of client needs, and ways of meeting clients and establishing relationships. However, attempts to reconstruct mental health nursing according to a client-centred perspective became problematic when clients were at risk of harming themselves. In these situations, respondents felt the need to make decisions for clients, and this was experienced as burdensome and lonely. CONCLUSIONS: Our study indicates that the process of reconstructing mental health nursing in line with a client-centred perspective is incomplete. Opportunities to interact with people with mental health problems in the home environment may lead to a broader perspective on the daily lives of these people, but also to a realization that home care cannot be modelled on institutional care.     

Supporting family carers using interative multimedia

ACTION (Assisting Carers using Telematic Interventions to meet Older persons' Needs) is a nursing led Pan-European project (1997-2000). Its primary aim is to maintain the autonomy, independence and quality of life of frail older and disabled persons and their family carers by the application of telematic technology. This article describes the development of two multimedia programmes created as part of the ACTION project. Programme 1 'Planning ahead' helps family carers and frail older people to think about and plan for the future. Programme 2 'Break from caring' assists carers and older people to explore the range of respite care options available. Both programmes have been developed using a multimethod, user-centred approach. Preliminary evaluation data have indicated that frail older people and their carers have used the programmes to assist them when making difficult decisions such as selecting a nursing home, or exploring the use of respite care facilities.     

The factors that influence nurses' use of physical restraint: A thematic literature review

Lane C, Harrington A. International Journal of Nursing Practice 2011; 17 : 195–204 The factors that influence nurses' use of physical restraint: A thematic literature review Difficult clinical situations in both hospitals and aged care facilities might lead to the use of physical restraint on older people. This literature reviewed aimed to identify the factors that influence nurses' use of physical restraint on people aged over 60 years. The prevalence of restraint use in aged care facilities was shown to be between 12% and 47%, with 7% to 17% for hospitalized patients. Database searches retrieved studies published after 1992 that highlighted nurses' use of physical restraint on older people in both acute and aged care settings. The analysis revealed two reasons for decisions to use physical restraint that were categorized as ‘patient safety’ and ‘nurses' workload’. It is important for nurses to understand the nursing culture that perpetuates restraint use, and to consider patient‐centred nursing as an instigator for change.     

Supporting independence in hospitalized elders in acute care

Planning for care of the older adult is especially important during critical illness states when recovery can be uncertain. Patients often present to the ICU with complex illness; therefore, targeting measures to prevent functional status decline is important for hospitalized elders, who are at risk for prolonged recovery from critical illness. Addressing and planning for the needs of hospitalized elders, including the integration of strategies to target independence, is a key area of focus for nursing care. This article provides a review of the literature on strategies for promoting independence during acute illness and includes recommendations for practice, education, research, and policy to promote optimal care for hospitalized elders in acute care.     

Health promotion for frail older home care clients

AIM: This paper reports a study evaluating the comparative effects and costs of a proactive nursing health promotion intervention in addition to usual home care for older people compared with usual home care services alone. BACKGROUND: An ageing population, budget constraints and technological advances in many countries have increased the pressure on home care resources. The result is a shift in nursing services from health promotion to meet the more pressing need for postacute care. For frail older people with long-term needs, these changes combine to create a fragmented system of health service delivery, characterized by providing nursing on demand rather than proactively. METHODS: A two-armed, single-blind, randomized controlled trial was carried out with older people > or =75 years and eligible for personal support services through a home care programme in Ontario, Canada. Participants were randomly allocated either to usual home care (control) or to a nursing (experimental) group. In addition to usual home care, the nursing group received a health assessment combined with regular home visits or telephone contacts, health education about management of illness, coordination of community services, and use of empowerment strategies to enhance independence. The data were collected in 2001-2002. RESULTS: Of the 288 older people who were randomly allocated at baseline, 242 (84%) completed the study (120 nursing group; 122 control group). Proactively providing older people with nursing health promotion, compared with providing nursing services on-demand, resulted in better mental health functioning (P = 0.009), a reduction in depression (P = 0.009), and enhanced perceptions of social support (P = 0.009) at no additional cost from a societal perspective. CONCLUSIONS: Home based nursing health promotion, proactively provided to frail older people with chronic health needs, enhances quality of life while not increasing the overall costs of health care. The results underscore the need to re-invest in nursing services for health promotion for older clients receiving home care.     

Trends and challenges in the management of tracheostomy in older people: the need for a multidisciplinary team approach

The trend towards increasing representation of older people as recipients of health care in acute care settings is matched with a corresponding increase in the numbers of older people undergoing tracheostomy.The reasons for tracheostomy in this age group are varied, including respiratory failure, neurological injury/event and carcinomas. Further, current research supports early tracheostomy for patients requiring medium to long-term ventilation and unconscious patients at risk of airway obstruction. In spite of this increase very little has been written about decision making and ongoing nursing care for these patients.There is an abundance of literature on the physiological processes of aging and the problems related to comorbidities; however, there has been very little exploration of how these impact on the occurrence of complications and other outcomes for older patients with a tracheostomy, and the consequent implications for care provision. This article examines clinical issues of significance to older people with tracheostomy and outlines the implementation and benefits of a multidisciplinary team approach.     

Safer handling practice for nurses: a review of the literature

The lifting and handling of people is an integral part of nursing care and has been blamed for a high incidence of back injuries to nurses. Changes to nursing practice have been dictated by this level of injury following the passing of health and safety legislation in 1992. This review seeks to evaluate the growing body of research from a range of disciplines in order to establish an evidence base for the moving and handling of patients. It identifies that studies considering the impact of changes in practice on patient outcomes are lacking. The term 'safer handling practice' has been used by the author to indicate a new way of thinking in relation to moving and handling people in health and care settings. A definition of safer handling practice has been derived from the literature with concomitant implications for training. Using this body of knowledge alongside studies investigating mobility of older people, the literature was used deductively to ascertain that safer handling practice has the potential to influence positively the mobility of older people. The author suggests further research to be conducted in the field of safer handling practice.