Elderly Care Unit Research Articles

Hypocapnia and its relation to fear of falling

Clague JE, Petrie PJ, Horan MA. Hypocapnia and its relation to fear of falling. Arch Phys Med Rehabil 2000;81:1485-8. Objective: To determine if hypocapnia occurs in patients with fear of falling and to explore potential causes of hypocapnia. Design: Observational study in patients who fall with and without fear of falling. Setting: Rehabilitation wards of an elderly care unit. Patients: Consecutive fallers with (n = 20) and without (n = 10) fear of falling. Main Outcome Measures: End-tidal CO2 (PETCO2) and respiratory rate (RR) responses were measured during sustained isometric muscle contraction (SIMC) (40% of maximum voluntary contraction of quadriceps for 2min) and during a 5-meter walk. Falls efficacy scale (FES) and Hospital anxiety and depression scale (HAD). Results: Patients with fear of falling had significantly higher FES and HAD scores (p <.01). During SIMC, baseline and nadir PETCO2 levels were significantly lower in patients with a fear of falling (p <.01). During the 5-meter walk, PETCO2 was lower at baseline, at nadir, and at the end of the walk in the fear of falling group than in controls (p <.01). RR was higher at nadir and end of the walk in the fear of falling group than in controls (p <.02). Conclusions: Hypocapnia may occur in patients with a fear of falling during SIMC and walking. Anxiety seems to be the main cause, but muscle weakness may contribute. Breathing or relaxation techniques and reconditioning may have a role in treating fear of falling in the rehabilitation setting. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Rhetoric and reality in stroke patient care

The aim of this study was to identify aspects of the process of care that might help explain the improved outcomes associated with stroke units. Three different care settings for stroke patients, an elderly care unit and general medical ward in an inner-city teaching hospital and a stroke unit in another teaching hospital in the same city, were compared using non-participant observational methods. Nurses on the stroke unit and general medical ward usually engaged in standardised and functional interaction with patients, while nurses on the elderly care unit were observed to adopt a more personal and attentive approach with patients. Rehabilitation nursing was rarely observed on the stroke unit, never on the general medical ward but always on the elderly care unit. There was evidence of effective communication between nurses and therapists on the elderly care unit but this was not observed on the stroke unit. On the elderly care unit the team appeared divided, with therapists and nurses on one side and medicine on the other, while on the stroke unit the divide was between doctors and therapists on one hand and nurses the other. On the general medical ward there was no team working. The observed lack of rehabilitation nursing, nurses’ disengagement from the team and nurses’ observed lack of warmth towards patients on the stroke unit were all surprising findings. Further research needs to examine whether such findings would be reproduced in stroke units elsewhere. If so, it might be that the better outcomes achieved on stroke units are despite rather than because of the nursing they receive there.

'Scraps': hidden nursing information and its influence on the delivery of care.

What nurses commonly describe as 'scraps' are defined as the personalized recordings of information that is routinely made on any available piece of paper (hence scraps) or in small notebooks. The use of scraps is common in practice and has been noted in research from across the globe. Drawing on an empirical study it is argued that scraps are a unique combination of personal and professional knowledge that informs the delivery of care. The overall aim of the study was to discover how nurses define and communicate information about patients and the delivery of care to each other on an elderly care unit. The processes by which information was constructed and the organizational structure and interactions that influenced this were also identified. The research design was an ethnographic one that involved: observations of formal nursing end of shift reports (23 handovers) and informal interactions between nurses (146 hours); interviews (n + 34) with registered nurses, student nurses and nursing auxiliaries; and analysis of written records. Data were collected from five acute elderly care wards at a district general hospital in the south of England. A grounded theory analysis was undertaken which revealed that scraps may have a significant role in the communication of information and the delivery of care. Therefore a categorization of scraps within three main themes was undertaken. First, the analysis revealed the processes involved in the construction of scraps. Second, the content and role of scraps in influencing the delivery of care was exposed. Finally, the potentially confidential nature of scraps and consequent problems of storage and disposal was recognized. The findings are discussed in relation to a suggested model of the interrelationship between paperwork, scraps, handovers and the delivery of nursing care. It is concluded that scraps are significant in facilitating nursing care and that this should be recognized in research, education and practice.

An Exploration of Individuals' Expectations of their Stay on an Elderly Care Unit

This article describes the elements of a qualitative cross-sectional study which explored the relationship between the expectations and the experience of 20 individuals with regard to their stay on an elderly care unit. The study data were gathered using semi-structured interviews and analysed using content analysis techniques. The participants were found to hold a variety of expectations about the tangible and conceptual elements of their experience. Their comments focused primarily on the outcomes experienced rather than on the processes occurring. Their expectations appeared to change in conjunction with both time and experience, with common themes emerging. The study concluded that the participants' expectations were formed on hunches and/or previous information. They described their situation largely in terms of a mismatch between their expected and actual experience or with regard to unexpected situations. The results suggested that the unit concerned might usefully provide additional information to those admitted. They also raised some broader issues of potential interest to occupational therapists as a whole.

The modified Rivermead Mobility Index: validity and reliability

Purpose : This paper presents the evaluation of the following psychometric properties of the Modified Rivermead Mobility Index (MRMI): face/content validity, responsiveness, testretest reliability, inter-rater reliability and internal consistency. This mobility scale represents a further development of the Rivermead Mobility Index (RMI). In its new form the scoring was adapted from a two-point to a six-point scale. The number of test items was reduced from fifteen to eight items in order to measure mobility-related items that physiotherapists consider being essential for demonstrating treatment effects in patients following a stroke. Method : A consensus exercise with forty-two physiotherapists attending a stroke care conference established face/content validity. Inter-rater and test-retest reliability were examined by assessing thirty patients by two independent raters selected from a pool of eight physiotherapists in two different settings, an elderly care unit and a stroke rehabilitation unit. All patients were hospitalised and had experienced a stroke within the past six weeks. Responsiveness was examined by calculating the effect size statistic on the admission and discharge score of sixteen acute patients following stroke. Results : The results showed that the modified RMI was: responsive to change (effect size = 1.15), stable when tested on two occasions (paired t-test = 0.732; p 0.47), highly reliable between raters (ICC = 0.98; p<0.001) with high internal consistency (Cronbach's alpha = 0.93). Conclusions : These results suggest that when using the Modified RMI to assess patients in the early stages following stroke, similar results can be obtained by different raters, regardless of experience. However there needs to be a difference of more than 4.5 points (degree of measurement error at 95% confidence level) in the overall score to detect true changes in the patient's level of mobility.

Older People In Hospital

Abstract. We describe the evolution of an Aged Care Unit (ACU) in a S00 bed teaching hospital in the Australian Capital Territory (ACT). Demographic data on overall hospital usage by older patients in the ACT is presented to give a perspective on the role of the ACU, showing ACU patients to be older, sicker and more complex. A survey of patients' expectations of hospitalisation showed that regaining independence and returning home were their main priorities. Achieving these goals is an important indicator of quality care.

Falls among Elderly-Concepts, Knowledge and Acting of Staff Working at an Elderly Care Unit

Trauma and death caused by fall is quite common among elderly people despite the fact that research literature exensively document internal and external factors of influence. The question is whether research resultats are divulged to the clinical area or not. The aim of this study was to find out how staff working with geriatric care act in connection with a fall, what their concept and knowledge are of «trauma by fall» among elderly people. A questionnaire was developed to cover these aspects and a randomized sample of 14 professionals working at a geriatric unit was chosen. The results showed that the staff was well informed about the effect of dizziness and impaired balance on fall accidents. On the other hand they had less knowledge of fall triggering factors not belonging to normal aging, eq; lack of sleep, lonliness or migration. There seems to be a need for further education.

Interrater reliability and the assessment of pressure-sore risk using an adapted Waterlow Scale

Objective: the purpose of this paper is to highlight the issue and the complexity of the assessment of interrater reliability in the assessment of pressure sore risk. Design: an empirical study undertaken to assess the interrater reliability of an adapted Waterlow Scale is described. The scores obtained from 15 patients on two wards are presented. Each patient was assessed daily by two different nurses over a period of 7 days. A total of 210 assessments were obtained. Interrater reliability was assessed using two statistical techniques: percentage of agreement and correlation. Setting: the elderly care unit of a district general hospital in the North of England. Participants: twenty-eight ward staff and the research corrdinator. Results: the statistical tests showed a weak/moderate degree of interrater reliability.A comparison of the reliability coefficients obtained from these tests with a visual examination of the actual scores obtained by the raters is made and discussed in relation to the clinical acceptability of reliability coefficients. Conclusions 1. The relationship between statistical acceptability and clinical acceptability needs to be further explored particularly in relation to the assessment of pressure sore risk. 2. Further investigation into the reliability of risk assessment tools is needed toidentify if and under what circumstances they are effective and what training in the use of the tool is needed to improve and maintain reliability and theraby be of any real practical use.

Pain management for special populations—pediatric, geriatric, and intensive care unit patients

The treatment of pain in children, the elderly, and intensive care unit patients presents some unique problems. Here a unifying theme is emphasized: the difficulty in adequately assessing pain in patients who are often unable to communicate. Also addressed are the differences in pharmacokinetics and pharmacodynamics from neonates to the elderly. Finally, common pain syndromes in each group, the associated treatments, and recent controversies are discussed. Because of changing demographics, pain treatment for these groups will become increasingly important. Only in the past 10 years has pediatric pain been treated with the same energy as adult pain; application of the newest techniques still lags far behind these patients' adult counterparts. Pain treatment in the elderly will inevitably become a larger problem as our population ages. Finally, recent advances in technology enable us to sustain patients with increasingly severe illnesses. Thus, pain management in these special populations will take on progressively greater importance.

Pain and distress among elderly intensive care unit patients: Comparison of patients' experiences and nurses' assessments

OBJECTIVE: To investigate elderly intensive care unit (ICU) patients' experiences of pain and distress, as well as interventions aimed at reducing these conditions, and to compare these experiences with the way nurses and assistant nurses, respectively, assess their patients' responses related to these issues. DESIGN: Descriptive, correlational, comparative. SETTING: Two medical-surgical ICUs at county hospitals in two medium-sized cities in Sweden. SUBJECTS: Fifty-one elderly patients, 44 nurses, and 37 assistant nurses in two Swedish ICUs. METHODS: Data were collected through personal interviews with patients and questionnaires completed by each nurse and assistant nurse responsible for the patients. RESULTS: Patients' experiences of pain and distress do not fully agree with nurses' and assistant nurses' assessments; nor is there consistency between the views of nurses and those of assistant nurses. Nurses overestimated patients' breathing and intellectual problems. Assistant nurses assessed that patients received more assistance to relieve physical pain, physical discomfort, fatigue, and fear than patients reported. Compared with nurses' assessments, assistant nurses also perceived patients to suffer less from physical discomfort, breathing problems, and fatigue. CONCLUSIONS: Nurses need more systematic procedures to assess patients' distress and pain experiences. To reduce the discrepancies observed between nurses and assistant nurses, organization of care should optimize the possibilities for the caregivers to carry out the desired assessments and interventions with a high degree of continuity and communication among staff.

Student nurses' lived experience of the sudden death of their patients.

This phenomenological study looks at the lived experience of third-year student nurses caring for dying patients in surgical, medical and elderly care units. Informal interviews were tape recorded and interpretive analysis was applied to narrative accounts of the nursing students' experiences. Themes which emerged from the students' narrative accounts included sudden death experience, vulnerability and support. These are evaluated in terms of their meaning for students and the possible implications for clinical care. In addition, the use of students' narratives is also suggested as a valuable learning tool both within clinical and academic frameworks.

An Audit of Environmental Factors Affecting Patient Safety in Three Elderly Care Units

An Audit of Environmental Factors Affecting Patient Safety in Three Elderly Care Units

Staff Knowledge of Inhaler Devices on an Acute Elderly Care Unit

Staff Knowledge of Inhaler Devices on an Acute Elderly Care Unit

An inpatient bed for acute nursing home admissions

Some older patients are admitted directly to nursing homes without a comprehensive assessment. To determine whether a hospital assessment bed might provide better assessment, treatment and a more appropriate placement for selected older people. Setting a single bed in an elderly care unit of a district general hospital. Older people who general practitioners thought needed nursing home care but whose social workers felt might benefit from inpatient assessment. Type of treatment needed (acute care, rehabilitation, palliation, long-term care) and placement (home, nursing home, residential home or hospital). of 34 patients assessed, 22 (65%) needed further clinical assessment or care and 26 (75%) left hospital for places other than nursing homes. Inpatient assessment is a successful way of assessing the needs of some older people who would otherwise have been admitted directly from their homes to nursing homes.

Nutritional assessment in elderly care--a team approach.

This work began in February 1996 when nationally questions were being asked about the nutritional care patients were receiving in hospital. Within the Elderly Care Unit the multi-disciplinary team was also questioning the nutritional care patients received. The main concern raised was the lack of consistent nutritional assessment occurring within the unit. A multi-disciplinary nutritional group was formed to address this area of concern. It developed an assessment tool that identifies those patients at risk and provides guidelines for appropriate action.

Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies

Objectives: To identify clinical characteristics of elderly inpatients that predict their chance of falling (phase 1) and to use these characteristics to derive a risk assessment tool and to evaluate...

Redefining 'doing something': health professionals' views on their role in the care of stroke patients.

Stroke has traditionally been considered, both by lay people and by many people working within the health services, to be a tragic yet essentially uninteresting condition, possibly because of its associations with old age, chronicity and the widespread perception that very little can be done about it. This study explored health professionals' views about their role in caring for people with stroke, and about what they gained from and contributed to this work. Questionnaires were distributed to staff working on an elderly care unit, a general medical ward and a stroke unit. Nurses and physiotherapists were positive and reported that they had much to offer people with stroke, and many rewards to gain from their work. Occupational therapists reported that in theory they had much to contribute to people with stroke, but in practice lack of resources and staff shortages prevented them from fulfilling their potential. Speech therapists also complained of scarce resources, and of a lack of recognition of their specialty, but felt able to contribute to improving peoples' quality of life. Both psychologists reported that their work with people with stroke was satisfying and stimulating. However, with the exception of the consultant on the stroke unit, doctors reported feeling they had little to offer, and little to gain from working with people with stroke. Therapists on the elderly care unit, and speech therapists in all settings reported difficulties within the multidisciplinary team. Although each profession had different concerns and priorities, the majority seemed to have a positive approach to their work with people with stroke. Similarly, the majority reported that the best thing about their work was when people recovered, although professions defined recovery differently.

Which pressure sore risk calculator? A study of the effectiveness of the Norton scale in Hong Kong

This study aimed to evaluate the effectiveness of the Norton score in predicting the likely occurrence of pressure sores compared to the Waterlow scale in Hong Kong. Two elderly care wards (one male and one female) were chosen, the sample size was 185 and the mean age of subjects was 80.4. Each newly admitted patient was assessed using both the Norton calculation and the Waterlow calculation. At the end of the research, there were eight patients who had sore formation. The results indicated that the Norton score identified six out of the eight patients, while the Waterlow identified seven of them. The Waterlow calculation, however, seems to have misidentified 72 patients as being in the ‘at risk group’. In view of a fear of the misdirection of resources, the Norton score was found to be the better of the two and its use in the elderly care units in this study should be continued until a better scoring system is found.

Elderly patients' participation in discharge decision making: 2

This article is the second in a two-part series describing a study that explored patient participation in discharge decision making. The study focused on the participatory relationship between older patients and nurses and was performed in two phases. As reported in the previous article (Vol 5(15): 914-16, 929-32) the first phase involved group interviews with primary nurses from two elderly care units. This article reports the findings of the second phase which involved a series of interviews with five elderly patients during their hospital admission. The data from both phases of the study were analysed using the software package Ethnograph. Unlike nurses, the patients in this study had little understanding of the term 'participation'. They were mainly concerned with being given information and reported having unmet information needs. They felt that they did have a role in discharge decision making but were unable to fulfil it, consequently they relied upon nursing staff to take the lead in the decision-making process.

Elderly patients' participation in discharge decision making: 1.

This article is the first of a two part series describing a study that explored patient participation in discharge decision making. The study involved two phases and focused on the participatory relationship between older patients and nurses. In phase one, the author conducted a group interview with primary nurses at two elderly care units specializing in rehabilitation. The second phase involved a series of interviews with five elderly patients during their hospital admission. The data from both phases of the study were analysed using the Ethnograph software package. This first article discusses the views of the nurses while the views of patients are addressed in the second article. Phase one of the study showed that the nurses interviewed had an elaborate understanding of participation. They tended to stress practical examples of participation rather than stating the reasons why it should be encouraged. Informants recognized the need to involve patients in decisions about their discharge from hospital. However, they viewed elderly patients as being both passive and reluctant to participate in decision making. Several reasons were given for this which were seen as resulting from patient rather than nursing behaviour. Part two of this article will appear in Vol 5(17): 26 September.