Caring for cognitively impaired older patients in the general hospital: A qualitative analysis of similarities and differences between a specialist Medical and Mental Health Unit and standard care wards

doi:10.1016/j.ijnurstu.2014.02.002

International Journal of Nursing Studies

Volume 51, Issue 10, October 2014, Pages 1332-1343

https://doi.org/10.1016/j.ijnurstu.2014.02.002 Get rights and content

Abstract

Background

Around half of people aged over 70 years admitted as an emergency to general hospital have dementia, delirium or both. Dissatisfaction is often expressed about the quality of hospital care. A Medical and Mental Health Unit was developed to provide best practice care to cognitively impaired older patients. The Unit was evaluated by randomised controlled trial compared to standard care wards. Part of this evaluation involved structured non-participant observations of a random sub-sample of participants and the recording of field notes.

Objectives

The aim of this paper is to compare and contrast the behaviours of staff and patients on the Medical and Mental Health Unit and standard care wards and to provide a narrative account that helps to explain the link between structure, process and reported outcomes.

Design

Field notes were analysed using the constant comparison method.

Setting

A large hospital within the East Midlands region of the United Kingdom.

Participants

Patient participants were aged over 65, and identified by Admissions Unit physicians as being ‘confused’. Most patients had delirium or dementia.

Results

Sixty observations (360 h) were made between March and December 2011. Cognitively impaired older patients had high physical and psychological needs, and were cared for in environments which were crowded, noisy and lacked privacy. Staff mostly prioritised physical over psychological needs. Person-centred care on the Medical and Mental Health Unit was mostly delivered during activity sessions or meal times by activities coordinators. Patients on this unit were able to walk around more freely than on other wards. Mental health needs were addressed more often on the Medical and Mental Health Unit than on standard care wards but most staff time was still taken up delivering physical care. More patients called out repetitively on the Unit and staff were not always able to meet the high needs of these patients.

Conclusion

Care provided on the Medical and Mental Health Unit was distinctly different from standard care wards. Improvements were worthwhile, but care remained challenging and consistent good practice was difficult to maintain. Disruptive vocalisation may have been provoked by concentrating cognitively impaired patients on one ward.

Section snippets

Background

People with dementia are prone to develop acute physical illness leading to hospital admission. About 50% of people over the age of 65 in general hospital have delirium, dementia or both together (Boustani et al., 2010, Goldberg et al., 2012, RCP, 2005). Dissatisfaction is often expressed about the hospital care for such people (Alzheimer's Society, 2009, Nichols and Heller, 2002, RCP, 2011). Concerns include lack of dignity and respect for patients, insufficient assistance to eat and drink,

Methodology

Field notes taken during a structured non-participant observational study and analysed using the constant comparison method aiming to compare and contrast the behaviours of staff and patients observed on the unit and standard care wards.

Participants

Participants for this study were drawn from patients recruited to the TEAM trial. The TEAM trial recruited 600 patients admitted for acute medical care to a large English National Health Service teaching hospital providing sole emergency medical services for its

Results

Many aspects of care were similar between the two settings. These are discussed first, evaluating the range of needs of the patients, the ward environment and how staff met physical needs. The effectiveness of the intervention is then discussed, by the main areas of enhancement: improved staffing and skill mix, introduction of the person-centred care approach, programme of organised activity and the environment. Appendix 2 gives details of the coding framework.

All extracts from the field notes

Discussion

We observed patients with high levels of physical and psychological needs being cared for in a challenging environment. Most patient care on both ward types was task orientated and most patients spent much of their day inactive. All patients on the Unit were cognitively impaired, but even with this case mix of patients, care was improved. However, the care was variable, and some patients benefited more than others from the innovations on the specialist unit. At times staff on all wards

Conflict of interest

No conflict of interests.

Funding

This article presents independent research funded by the United Kingdom National Institute for Health Research (NIHR) under its Research for Patient Benefit scheme (PB-PG-0110-21229). The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.

Ethical approval

The study was approved by the Nottingham Research Ethics Committee (10/H0403/16).

Contributors

Study conception and design: SG, KP, RH, JG; Data collection: SG, KW; Qualitative analysis: SG, KW, KP; Interpretation and paper drafting: SG, KP, KW, RH, JG. All authors contributed to editing and approved the final text.

Acknowledgements

We would like to thank Jil Mamza, Louise Howe and Caroline May for their work coding the data.

References (40)

P. Clissett et al.
The challenges of achieving person-centred care in acute hospitals: a qualitative study of people with dementia and their families
Int. J. Nurs. Stud.
(2013)
D. Edvardsson et al.
Person-centred care of people with severe Alzheimer's disease: current status and ways forward
Lancet Neurol.
(2008)
Alzheimer's Society
Counting the Cost: Caring for People with Dementia on Hospital Wards
(2009)
M. Boustani et al.
Impact and recognition of cognitive impairment among hospitalized elders
J. Hosp. Med.
(2010)
Bradford Dementia Group
DCM 8 User's Manual
(2005)
L. Bradshaw et al.
Six month outcomes following an emergency hospital admission for older adults with mental health problems indicate complexity of care needs
Age Aging
(2013)
L. Bradshaw et al.
Carers for older people with co-morbid cognitive impairment in general hospital: characteristics and psychological wellbeing
Int. J. Geriatr. Psychiatry
(2013)
D. Brooker
Person Centred Dementia Care: Making Services Better (Bradford Dementia Group Good Practice Guides)
(2007)
Canadian Dementia Resource and Knowledge Exchange
Knowledge Broker Q+A
(2013)
K. Charmaz
Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis
(2006)

J.L. Cummings

The neuropsychiatric inventory: assessing psychopathology in dementia patients

Neurology

(1997)

Dalhousie University

Canadian Dementia Knowledge Translation Network (CDKTN): CDKTN Goals

(2012)

Department of Health

The NHS Outcomes Framework 2012/2013

(2012)

P. DePaulo

Sample size for qualitative research

QUIRK's Marketing Research Review

(2000)

J. Dewing

Concerns relating to the application of frameworks to promote person-centredness in nursing with older people

J. Clin. Nurs.

(2004)

J. Gladman et al.

Better Mental Health: Care for Older People in General Hospital. Final Report NIHR Service Delivery and Organisation Programme

(2012)

S. Goldberg

Confused older patients’ experiences of care on a specialist medical and mental health unit compared with standard care wards

(2012)

S. Goldberg et al.

Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial)

BMJ

(2013)

S. Goldberg et al.

The prevalence of mental health problems amongst older adults admitted as an emergency to a general hospital

Age Ageing

(2012)

A. Griffiths et al.

Preparation to care for confused older patients in general hospitals: a study of UK health professionals

Age Ageing

(2013)

Cited by (27)

Feasibility of a two-part person-centred care initiative for people living with dementia in acute hospitals: A mixed methods study
2021, International Journal of Nursing Studies Advances
Citation Excerpt :
The process of completing the personal profile with a family member was an opportunity for nurses to develop a relationship with the carer. Previous research suggests that nurses do not routinely include families in their conception of person-centred care (Clisset et al., 2013; Goldberg et al., 2014; Jamieson et al., 2016). In this study, how nurses understood families and how families can enhance person-centred care in hospital for people living with dementia was unclear and may have affected implementation.
The personal profile offers a potentially useful tool to support person-centred care of people living with dementia in hospital. To date, how profiles can be implemented into nurses’ work practices is not established.
The aim is to establish the feasibility of a Person-Centred Care package, including a personal profile and staff education program to enhance implementation.
Exploratory convergent mixed methods approach.
Four units of a tertiary health service, two intervention units and two comparison units set in southeast Queensland, Australia.
Person living with dementia and family carer dyads and staff.
Practicality was determined using participation logs, audit and review of meeting minutes. Acceptability was determined using interviews with family carers and nursing staff. Efficacy was evaluated using pre-post comparison survey design, assessing staff knowledge using the Dementia Knowledge Assessment Scale and person-centred care using the Person-centredness of Older People with cognitive impairment in Acute Care-revised scale.
Practically, the personal profile was distributed to 95 and 73% of patients in the two intervention units. Of the 18 people living with dementia who consented to participate, only 6 (33%) had a This is Me form completed. The three-part education program was well attended (n = 190 participants). In terms of acceptability, carers’ (n = 5) experienced variable quality of engagement from nurses. In interviews, nurses (n = 18) experienced increased confidence to engage carers, in part attributed to local leadership, but attitudes towards care appeared to be influenced by perceived time constraints. For efficacy, completion of both surveys at all time points and in all units was 50% and higher. Dementia knowledge significantly improved in the intervention group (p < .01) however there was no difference in self-ratings of person-centred care.
The feasibility of a Person-Centred Care package, including a personal profile and a focused program of staff education was partially achieved, with the education component adopted into the organisation's continuing education program. Implementation research is required to enhance the element of coherence, how completing the personal profile is an investment in person-centred care rather than simply completing another form.
‘Socialised care futility’ in the care of older people in hospital who call out repetitively: An ethnographic study
2020, International Journal of Nursing Studies
Citation Excerpt :
Calling out is associated with a general decrease in quality of life (Hurt et al., 2008) and poor patient outcomes (Dewing and Dijk, 2016). Care quality can rapidly deteriorate around the patient, with frustration, avoidance and overt disregard for their psychological (and sometimes physical) needs (Goldberg et al., 2014). Calling out can also significantly increase the cost of care (Murman and Colenda, 2005), due to increased use of pharmaceuticals to control or suppress the behaviour.
People living with dementia may call out repetitively, sometimes called disruptive vocalisation, or verbal agitation. In literature and policy, patients who call out repetitively are assumed to be expressing an unmet need, which should be met. Yet there has been little systematic study of this patient group in an acute hospital setting.
To better understand patients who call out repetitively and to identify what care looks like in an acute hospital setting.
Ethnography.
Ten acute geriatric medical wards in two hospitals.
30 cognitively impaired patients who were calling out repetitively, and 15 members of hospital staff.
Semi-structured interviews with hospital staff, 150 h of ward observations and informal conversations with staff, scrutiny of medical and nursing documentation, and measures of patient health status.
Patients who called out were moderately or severely cognitively impaired, often had delirium, were very physically disabled, and many were approaching the end of life. Most hospital staff were found to hold contradictory views: that calling out represents distress or unmet need, but that nothing can be done to alleviate the calling out. During informal conversations, most staff also tended to say that they intuitively recognised when intervening was likely to alleviate calling out. During observations, many staff appeared to and spoke of the ability to ‘block’ calling out. As a result we argue that social, emotional and physical needs may get overlooked. We argue that some calling out is due to a need that is unmeetable. We also found that while staff would talk about strategies for identifying need, observations and hospital documentation did not support evidence of systematic attempts to identify potential need.
Calling out repetitively within a hospital setting is difficult for staff to understand and to respond to. This is because many of these patients are severely cognitively impaired, often immobile and dependent on their professional carers. We argue that a form of socialised care futility is communicated between staff and is used to rationalise becoming unresponsive to calling-out. We explain this phenomenon as resulting from two protective mechanisms: defence of staff's professional identity as competent practitioners; and defence of staff as having personal morality. Socialised care futility risks good quality care, therefore systematic strategies to assess and manage possible need should be developed, even if calling out remains irresolvable in some cases.
Quality of acute care for persons with cognitive impairment and their families: A scoping review
2018, International Journal of Nursing Studies
Citation Excerpt :
In addition, care needs to follow a daily routine that is tailored to older persons and their families during the hospital stay (Andrews, 2012; Angerhausen, 2008; Bray, 2015; McConnell and Karel, 2016). Research demonstrates that guided activity decreases challenging behaviours (Goldberg et al., 2014), yet the promotion of activity is often absent on the wards (Clissett et al., 2013a). Therefore, providing meaningful activity through planned, separate activity and integrating activities of daily living into nursing care is conducive to quality of care (Goldberg et al., 2014; Moyle et al., 2016).
An increasing number of older persons with cognitive impairment use inpatient services for co-occurring acute illness. Research has demonstrated that persons with cognitive impairment face more adverse health outcomes during hospitalization than their age counterparts without cognitive impairment. As hospitals tend to be ill equipped to meet the complex care needs of this population, various initiatives underscore the need to better utilize existing evidence to improve quality of care.
To map the extent of knowledge about quality of acute care in inpatient settings, and to synthesize knowledge on strategies to improve quality care for persons with cognitive impairment and their families.
A scoping review using Arksey and O’Malley’s methodological framework.
CINAHL and Medline were searched and reference lists of pertinent articles screened to identify publications regarding acute care for persons with cognitive impairment.
Two reviewers independently screened and identified publications based on eligibility criteria. Publications were included if they targeted acute care issues relating to persons with cognitive impairment 65 years or older, their family members, or health professionals caring for them, and were published after 2000 in English or German. Publications were read and data were extracted using a predefined template. Thematic analysis was conducted by two reviewers.
Of the 1445 identified publications, 66 were included. Quality of acute inpatient services pertained to structural (such as staff capacity and knowledge) and process dimensions (such as forming a caring relationship, assessing and intervening). Strategies identified to improve care quality included interventions at the point of care, such as specific tools and specialist roles to improve patient outcomes, as well as educational and training interventions to enable staff to care for this patient group.
There is a discrepancy between clearly defined best practice for persons with cognitive impairment utilising inpatient services, and the quality of care actually experienced by patients, family members, and staff. Research reveals a sobering picture of inadequate care and manifold challenges encountered by this patient group, family members and staff alike. Promising strategies to improve care quality target health professionals’ knowledge and capacity to work with this group and include specific tools and models of care, such as specialist roles and units. Organisation-wide efforts to ensure quality care for this patient group are needed, as is further research to determine which implementation and intervention strategies achieve the most beneficial outcomes for all involved.
Interactions that support older inpatients with cognitive impairments to engage with falls prevention in hospitals: An ethnographic study
2024, Journal of Clinical Nursing
Difficulties and challenges experienced by nurses in eldercare institutions in Albania: A qualitative content analysis
2024, PLoS ONE
The use of constant observation with people with dementia in hospitals: a mixed-methods systematic review
2023, Aging and Mental Health

View all citing articles on Scopus

^☆: Trial registration: Clinical Trials NCT01136148.

View full text

Caring for cognitively impaired older patients in the general hospital: A qualitative analysis of similarities and differences between a specialist Medical and Mental Health Unit and standard care wards☆

Abstract

Background

Objectives

Design

Setting

Participants

Results

Conclusion

Section snippets

Background

Methodology

Participants

Results

Discussion

Conflict of interest

Funding

Ethical approval

Contributors

Acknowledgements

Int. J. Nurs. Stud.

Lancet Neurol.

Counting the Cost: Caring for People with Dementia on Hospital Wards

Impact and recognition of cognitive impairment among hospitalized elders

J. Hosp. Med.

DCM 8 User's Manual

Six month outcomes following an emergency hospital admission for older adults with mental health problems indicate complexity of care needs

Age Aging

Carers for older people with co-morbid cognitive impairment in general hospital: characteristics and psychological wellbeing

Int. J. Geriatr. Psychiatry

Person Centred Dementia Care: Making Services Better (Bradford Dementia Group Good Practice Guides)

Knowledge Broker Q+A

Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis

The neuropsychiatric inventory: assessing psychopathology in dementia patients

Neurology

Canadian Dementia Knowledge Translation Network (CDKTN): CDKTN Goals

The NHS Outcomes Framework 2012/2013

Sample size for qualitative research

QUIRK's Marketing Research Review

Concerns relating to the application of frameworks to promote person-centredness in nursing with older people

J. Clin. Nurs.

Better Mental Health: Care for Older People in General Hospital. Final Report NIHR Service Delivery and Organisation Programme

Confused older patients’ experiences of care on a specialist medical and mental health unit compared with standard care wards

Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial)

BMJ

The prevalence of mental health problems amongst older adults admitted as an emergency to a general hospital

Age Ageing

Preparation to care for confused older patients in general hospitals: a study of UK health professionals

Age Ageing