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.     

Attitudes of nursing staff working with older people towards nutritional nursing care

Aim. The aim of this study was to examine attitudes of the nursing staff in geriatric care towards factors of importance for nutritional nursing care. Background. Studies show that nutritional risk assessment is seldom performed on older patients as routine and very few patients have a nutritional care plan. Patients in long‐term care who are easy to feed are also found to be looked upon more positively than those with high feeding needs. Methods. A total of 252 registered nurses and nurse aids working at geriatric rehabilitation and medical care clinics and resident homes participated in the study. Attitudes were examined using the Staff Attitudes to Nutritional Nursing Care Geriatric scale. The scale includes 18 items and was designed as a one to five‐point Lickert‐type scale. It gives a total score and five subscales representing the dimensions ‘Norms’, ‘Habits’, ‘Assessment’, ‘Intervention’ and ‘Individualization’. A higher score indicates a more positive attitude. Results. Of all nursing staff, 53% displayed a positive attitude towards factors of importance for nutritional nursing care and the rest displayed a neutral or negative attitude. The ‘Intervention’ dimension, dealing with nutritional problems and how to manage them, reflected the highest level of positive attitudes, which represents 71% of the nursing staff. The ‘Norms’ dimension had the lowest relative frequency of positive attitudes, 27%. The registered nurses held significantly more positive attitudes than the nurse aids did. Conclusions. Nutritional issues comprise an important and time‐consuming responsibility in geriatric care; however, nursing staff do not show an unequivocal positive attitude regarding this responsibility. The consequences this entails for the older patient need to be examined further. Relevance to clinical practice. Nursing staff play an important role in caring for patients who are malnourished or at risk for malnutrition. Positive attitudes might hinder the development of undernourishment or the further worsening of an already undernourished patient's condition.     

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.     

Hip protectors: a pilot study of older people in Taiwan

Aims and objectives. This research explores the compliance by older people in Taiwan with wearing hip protectors and whether protectors can prevent fractures or decrease injuries after falls. Background. The ageing process causes degeneration of nerves, joints, muscles and then the incidence of falls in the older people is higher than in the young. Therefore, fractures caused by falls, particularly hip fractures of older people, need to be studied. Hip protectors are designed to reduce hip fractures and hip injuries when falls occur, by distributing the impact load and absorbing the impact force generated during a fall. Design. This research was designed as a longitudinal study using purposive sampling and intervention for six months. Methods. The target population were older people at high risk for falls and the study was carried out during a six‐month period. Self‐reported data were collected by interview and questionnaires. The expert validity of the questionnaires, including demographics, high‐risk group, compliance and correct wearing of hip protectors and fall injuries, as assessed by three experts, was 0·94 and the test–retest correlation coefficient was 0·95. Individuals were excluded from the research sample if they were 24‐hour bedridden, non‐mobile or had an existing hip injury. Results. Ten female subjects participated in this study. Their mean age was 76·1 years. During a six‐month follow‐up, there were 12 falls while wearing hip protectors, however, no fractures occurred because of the falls. Conclusions. This is the first research into hip protectors in Taiwan. The reasons for low compliance by older people were (1) unaccustomed to use, (2) discomfort, (3) wearing only during the daytime, (4) lack of assistance from family caregivers. Relevance to clinical practice. Fall prevention, exercise and the use of hip protectors can significantly decrease the incidence of hip fractures. Although hip protectors are effective in reducing fall fracture risk, the compliance rate remains low. In the future, the researchers will develop a hip protector program related to teaching the correct method for wearing protectors. Helping older people learn how to overcome the discomfort of wearing hip protectors and encouraging a willingness to wear them is imperative.     

Using action research in nursing practice with older people: democratizing knowledge

Aim. This paper reports on an action research study which raised some questions about the processes of developing a sense of shared ownership in action research in a research environment which does not always have the appropriate mechanisms to support and sustain action research. Background. Action research has gained popularity in nursing and healthcare research, offering a way of developing practice‐based knowledge, which can assist in changing practice and democratizing inquiry. Methods. There are other organizational constraints on action research which arise at different levels, and which also require discussion. These can be issues about communication and ownership at a practice level and issues of funding and project management procedures. This paper reports on a study in which these issues came to the fore, and offers some thoughts on how they can affect the processes of action research. Conclusion. While the principles of action research appear to offer much towards the development of a practice‐rooted body of knowledge for nursing, unless some of the issues of ownership are resolved, it is unlikely to move beyond academic rhetoric. Relevance to clinical practice. If nursing is to engage in action research, this must be done critically and reflectively and careful attention paid to developing an inclusive and collaborative approach to knowledge and practice development. Furthermore, to develop in nursing and health care research, it must find ways to meet the requirements of funding bodies.     

Preferences and priorities for ongoing and end-of-life care: A qualitative study of older people with dementia resident in care homes

Background

The older person with dementia has a limited life expectancy and the dying trajectory can be protracted and unpredictable. For good end-of-life care, early communication, exploration of residents’ wishes, and identification of someone who can represent them, are important. In care homes the timing of these discussions, and who is involved is variable. Person-centred approaches to dementia care assume that people with dementia can actively participate in decisions about their lives. Less well understood is how this can inform end-of-life care decision making and complement information provided in advance care plans completed prior to, or at the point of admission to a care home.

Objectives

To explore how older people with dementia discuss their priorities and preferences for end-of-life care.

Methods

An exploratory, qualitative study that used guided conversations with 18 people with dementia, living in six care homes. Participants were asked about their life in the care home, their health, thoughts for the future, and wishes surrounding end of life. Data were analysed thematically.

Results

People with dementia's accounts of life in the care home, what they valued, and the impact of having dementia on how they participated in decision making, provided key insights into care preferences. Three linked themes that had relevance for thinking and talking about end of life were identified: “dementia and decision making”, “everyday relationships” and “place and purpose”. Older people with dementia's accounts of everyday experiences of care, key relationships with family and care home staff members and whether they accepted the care home as their home demonstrated what was important for them now and for the future.

Conclusion

For older people living with a diagnosis of dementia, the experience of living and dying in a care home is inextricably linked. End-of-life care planning and decision making by health care professionals, care home staff and family could be enriched by exploring and documenting the preoccupations, key relationships and wishes about everyday care of people with dementia.     

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.     

Supervisor experiences of supervising nursing staff in the care of older people

Aim To describe supervisors’ experiences of supervising nursing staff who care for older people in order to develop an understanding of the opportunities and limitations involved in supervision. Background Little is known of what group supervision of nursing staff means for the supervisor, particularly in regards to care of the old. Methods A reflective life‐world research approach, based upon phenomenological epistemonology was used. Two supervisors with 2 years experience of supervising nursing staff caring for older people were interviewed. Conclusions Results point to the need for support for supervisors in order to enable them to develop their supervisory abilities and skills. Implications for nursing management Support is of crucial importance for both the ability to supervise and the quality of supervision.     

Factors that influence intensive care admission decisions for older people: A systematic review

BackgroundThe population worldwide is rapidly ageing, and demand for intensive care is increasing. People aged 85 years and above, known as the oldest old, are particularly vulnerable to critical illness owing to the physiological effects of ageing. Evidence surrounding admission of the oldest old to the intensive care is limited.ObjectiveThe objective of this study was to systematically and comprehensively review and synthesise the published research investigating factors that influence decisions to admit the oldest old to the intensive care unit.MethodThis was a systematic review and narrative synthesis. Following a comprehensive search of CINAHL, Embase, and Medline databases, peer-reviewed primary research articles examining factors associated with admission or refusal to admit the oldest old to intensive care were selected. Data were extracted into tables and narratively synthesised.ResultsSix studies met the inclusion criteria. Three studies identified factors associated with admission such as greater premorbid self-sufficiency, patient preferences, alignment between patient and physicians’ goals of treatment, age less than 85 years, and absence of cancer, or previous intensive care admission. Factors associated with refusal to admit were identified in all six studies and included limited or no bed availability, level of ICU physician experience, patients being deemed too ill or too well to benefit, and older age.ConclusionsPublished research investigating decision-making about admission or refusal to admit the oldest old to the intensive care unit is scant. The ageing population and increasing demand for intensive care unit resources has amplified the need for greater understanding of factors that influence decisions to admit or refuse admission of the oldest old to the intensive care unit. Such knowledge may inform guidelines regarding complex practice decisions about admission of the oldest old to an intensive care unit. Such guidelines would ensure the specialty needs of this population are considered and would reduce admission decisions that might disadvantage older people.     

Caring about caring: Developing a model to implement compassionate relationship centred care in an older people care setting

Aim

This study actively involved older people, staff and relatives in agreeing a definition of compassionate relationship-centred care and identifying strategies to promote such care in acute hospital settings for older people. It was a major component of a three year programme (the Leadership in Compassionate Care Programme, LCCP) seeking to integrate compassionate care across practice and educational environments.

Background

Compassionate caring and promoting dignity are key priorities for policy, practice and research worldwide, being central to the quality of care for patients and families, and job satisfaction for staff. Therapeutic relationships are essential to achieving excellence in care but little is known about how to develop and sustain such relationships in a culture that increasingly focuses on throughput and rapid turnover.

Approach and methods

The study used appreciative inquiry and a range of methods including participant observation, interviews, story telling and group discussions to actively engage older people, relatives and staff. A process of immersion crystallization was used to analyze data with staff as co-analysts.

Findings

The study adds considerably to the conceptualization of compassionate, relationship-centred care and provides a model to aid staff deliver such care in practice, based on ‘appreciative caring conversations’ that enable all parties to gain two forms of ‘person and relational knowledge’ about ‘who people are and what matters to them’ and ‘how people feel about their experience’. Such knowledge enables staff, patients and carers to ‘work together to shape the way things are done’. The study generated a model called the 7 ‘C's that captures in detail the factors necessary to promote ‘appreciative caring conversations’.

Conclusions and implications

The study demonstrates that engaging in ‘appreciative caring conversations’ promotes compassionate, relationship-centred care but that these conversations involve practitioners taking risks. Such ‘relational practices’ must therefore be valued and accorded status. Staff require appropriate support, facilitation and strong leadership if these practices are to flourish.     

Nurses’ attitudes towards older people: A systematic review

Background

The population is ageing globally. Older people are more likely to have chronic diseases and disabilities and have contact with health services. Attitudes of healthcare professionals affect the quality of care provided and individual career preferences.

Aim

To examine the international research relating to registered and student nurses’ attitudes towards older people and the potential underpinning variables.

Methods

A systematic search of 8 databases covering English and Chinese language publications since 2000 was undertaken which identified 25 papers.

Findings

Reported attitudes towards older people were inconsistent with positive, negative and neutral attitudes being noted across registered and student nurses and appear to be slightly less positive since 2000. A range of variables have been examined as potential predictors of nurses’ attitudes with age, gender and education level being investigated most frequently but none were consistent predictors. Preference to work with older people and knowledge of ageing appeared to be associated with positive attitudes towards older people.

Conclusions

There is a growing need for registered nurses committed to working with older people, however, there is a dearth of well designed studies which investigate both the attitudes of registered and student nurses and the associated factors, and test interventions to inform workforce strategies.     

Development of a virtual learning environment to enhance undergraduate nursing students' effectiveness and interest in working with older people

Throughout the world populations are aging and there is a concomitant global need for increasing numbers of nurses who are skilled in working with older people. The aim of this study was to develop a web-based resource for use in nursing schools to help educate undergraduate nursing students about working effectively with older people. This paper details the process of developing the working with older people website, www.workingwitholderpeople.edu.au, which was launched at the end of 2006. The working with older people website was designed for use as a stand alone or self directed program and/or as a set of modules suitable for integration within individual undergraduate nursing programs. The resource is unique in its portrayal of older adults and the challenges they face in a way that is appealing to undergraduate students, and engages them in meaningful learning activities, based on authentic cases, while also providing comprehensive resources and links.