Provide a written critique of a qualitative international peer-reviewed article in terms of the strengths and weaknesses relating to research questions, methods, sampling strategies, data collection, analyses, findings and conclusions.
PAPER TO CRITIQUE.
Falling behind: a substantive theory of care for older people with cognitive impairment in acute settings
Anita Nilsson MSc, RNT,
Birgit H Rasmussen PhD, RNT,
David Edvardsson PhD, RN
First published: 4 March 2013Full publication history
DOI: 10.1111/jocn.12177View/save citation
Cited by: 7 articles
Article has an altmetric score of 3
Correspondence: Anita Nilsson, PhD Student, Department of Nursing, Umeå University, Umeå 901 87, Sweden. Telephone: +46 90 786 9114.
Aims and objectives
To develop a theoretical understanding of the processes hindering person-centred care of older people with cognitive impairment in acute care settings.
Although person-centred care with its holistic focus on the biopsychosocial needs of patients is commonly considered the gold standard care for older people with cognitive impairment, the extent to which care is person-centred can increase in acute care settings generally.
Grounded theory inspired by Strauss and Corbin.
The study used a grounded theory approach to generate and analyse data from a Swedish sample of acute care staff, patients and family members.
The substantive theory postulates that staff risks ‘falling behind’ in meeting the needs of older patients with cognitive impairment if working without consensus about the care of these patients, if the organisation is disease-oriented and efficiency-driven, and if the environment is busy and inflexible. This facilitated ‘falling behind’ in relation to meeting the multifaceted needs of older patients with cognitive impairment and contributed to patient suffering, family exclusion and staff frustration.
The theory highlights aspects of importance in the provision of person-centred care of older people with cognitive impairment in acute settings and suggests areas to consider in the development of caring environments in which the place, pace and space can meet the needs of the older person.
Relevance to clinical practice
The proposed substantive theory can be used to critically examine current ward practices and routines, and the extent to which these support or inhibit high-quality person-centred care for older patients with known or unknown cognitive impairments.
Despite the high number of older patients with cognitive impairment in acute care, research has repeatedly shown that their individual and multidimensional needs are not always met by the care provided (Royal College of Psychiatrists 2005, Jones et al. 2006, Cowdell 2010b). For example, acute hospital stays have been found to increase the risk for complications such as delirium, pressure sores, frailty, incontinence, falls and fractures (Mecocci et al. 2005, Labella et al. 2011). The hospital stay can also be a stressful and threatening experience for people with cognitive impairment because it often means sharing space with strangers, being in an unfamiliar setting and having one’s private space invaded (Edvardsson & Nordvall 2008). Person-centred care (PCC) has recently emerged as a holistic model of care for older people, which includes a subjective first-person perspective of illness and acknowledges each person’s holistic and multidimensional needs (Brooker 2007). However, studies continue to indicate that the care of older people with cognitive impairment in acute care settings falls short of being person-centred (Borbasi et al. 2006, Moyle et al. 2011, Tadd et al. 2011). This study aimed to develop a theoretical understanding of the processes hindering PCC of older people with cognitive impairment in acute care settings.
Person-centred care is described as a care philosophy and model of care that outlines the gold standard of care for older people with dementia (Kitwood 1998, SIGN 2006, National Board of Health & Welfare 2010). In addition to dementia, the concept has increasingly been used to advocate for quality care from the patients’ perspective in treatment for chronic diseases and acute hospital care as well (McCormack & McCance 2006, Peek et al. 2007, NHS Confederation 2010, Ekman et al. 2011b). The fundamental values of PCC are maintaining patients’ holistic well-being; acknowledging each patient as a person with biopsychosocial needs; respecting individual values, preferences and needs; promoting physical and emotional comfort; and fostering a consistent and trusting relationship in which the person’s family is involved in care (Talerico et al. 2003). PCC also seeks to understand behaviours and symptoms from the patients’ perspective (Stewart et al. 2003).
Even though PCC has been associated with higher satisfaction with care and work (Lehuluante et al. 2011), increased patient satisfaction and lower costs (Charmel & Frampton 2008), several studies show that acute care settings struggle to implement PCC (Cowdell 2010a, Moyle et al. 2011, Tadd et al. 2011). A contemporary focus on business models of care with tensions between patient flow, revenue, and income and individual needs and preferences have been suggested as an influencing factor (Hagenow 2003, Tadd et al. 2011). Other factors that may work against PCC of older people with cognitive impairment in acute care settings include a high level of specialisation and a strong staff focus on physical and biomedical symptoms (Harrison & Zohhadi 2005, Borbasi et al. 2006, Cowdell 2010a), ageist attitudes (Courtney et al. 2000, Jacelon 2002, Harrison 2007), routine-based care and resistance to change (Murphy 2007, Ploeg et al. 2007), and a shortness of specific knowledge about geriatric illness and needs (Scherer et al. 2008).
We found no theory that conceptualised PCC of older people with cognitive impairment in acute care settings. Thus, the study aimed to develop a theoretical understanding of the processes hindering PCC of older people with cognitive impairment in acute care settings.
The study used a grounded theory approach inspired by Strauss and Corbin (1998) to develop a substantive theory on PCC of older people with cognitive impairment in acute care. The theory generation was based on participant observations, medical records, policy documents and qualitative research interviews from a convenience sample of Swedish acute care staff, patients and family members.
The study was conducted in a 20-bed cardiology ward at a university hospital in Sweden. Heart failure, myocardial infarction or various arrhythmias were the most common conditions, and the mean length of stay for patients over 70 years was 3·2 days (41% of all patients). Day shifts involved one registered nurse (RN) and one licensed practical nurse (LPN) being responsible for six to seven patients, night shifts involved one RN and one LPN being responsible for the whole ward with occasional support from staff on nearby wards. Thus, the nurse–patient ratio fluctuated.
Data collection and analysis
A total of 110 hours of ethnographic-style observations (Wolf 2007) were completed over a period of six months in 2010–2011, mainly by the principal investigator (PI). The observations were initially unfocused and participatory in that the PI participated in activities at the unit to obtain an overall feel for the culture of the ward and to gain insight into the care provided to older people with cognitive impairment. As theoretical and empirical questions developed, informal and formal interviews were conducted with staff, patients and family members. Informal interviews were performed ‘in the moment’ during participant observations to complement and clarify observations, whereas formal interviews were planned in advance and aimed to focus more on the evolving theory. Informal interviews were documented through field notes, and formal interviews were recorded digitally. All interviews were transcribed for analysis. Staff interviews mainly concerned their experiences and strategies for caring for older patients with cognitive impairment, and the patient and family interviews explored their perspectives on the processes of care and their experiences of being at the unit. Ward documents such as handover sheets, medical records, and mission statements were also used as data. Data collection and analysis were performed in a dialectical fashion inspired by the principles of grounded theory. Initial sampling was complemented with theoretical sampling, which involved returning for more focused interviews and observations as analytic categories emerged. This was performed to gain a deeper understanding in relation to the emerging theory by exploring dimensions and properties of categories (cf. Strauss & Corbin 1998). An example of this was the emerging discovery that older patients’ cognition was not routinely evaluated by staff, and interviews revealed that the attention to and interest in patients’ cognition differed among staff members As we wanted to understand how common cognitive impairment was among older patients, together with if and how staff explored this condition, and how different stages of cognitive impairment impacted on the care provided, one stage of data collection involved the research team screening older patients with the Short Portable Mental Status Questionnaire (Pfeiffer 1975) independently of staff assessments.
Data analysis moved from open, line-by-line coding to reduction and clustering of categories. Open codes with related conditions or consequences were grouped into emergent categories (axial coding), and the properties and dimensions of those categories were explored. Through constant comparison of open codes and categories, the analysis moved to a more selective coding where categories were integrated and the theory refined. A core (central) category representing the main theme of the analysis was found, and the theory was developed around that category. The problem, the central barrier for PCC, was ‘falling behind’.
The substantive theory was grounded in a total of 110 hours of observation, about 100 informal interviews with staff, patients and relatives, 11 formal interviews with one patient, one family member and nine staff (three LPN, four RN, two doctors), and focused observations of three older patients with cognitive impairment.
The study was performed in accordance with the Declaration of Helsinki, and the university Human Research Ethics Committee approved the study Dnr 2010-10-31. Participants were informed about the study verbally and in writing, and informed consent was obtained verbally. For patients with cognitive impairment, informed consent was provided by significant others. All participant names have been changed to protect anonymity.
As shown in Fig. 1, the substantive theory postulates that interprofessional factors such as having conflicting views of the older patients’ cognitive status, different approaches to patient care and inconsistent documentation of patient needs contribute to staff falling behind in meeting the needs of older patients with cognitive impairment. Organisational factors such as organising care by diseases and routines rather than by patient needs and subjectivity, and environmental factors such as having a fast pace and limited space also contributed to falling behind in meeting the needs of older people with cognitive impairment. Falling behind ultimately means that it is difficult for staff to provide proactive PCC to patients with cognitive impairment and signs of patient suffering, family exclusion and staff frustration can emerge.
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A visual representation of the substantive theory.
Falling behind in meeting the needs of older patients with cognitive impairment
This core category emanated from three interrelated categories: working without consensus about the care of older patients with cognitive impairment, working within a disease-oriented and efficiency-driven organisation, and working within a busy and inflexible environment. ‘Falling behind’ meant that patient needs associated with cognitive impairment went largely unnoticed until they escalated and emerged as problems that disrupted the usual flow or threatened safety issues at the unit. One of the nurses, Lena, described how the needs of patients who did not disrupt the order of the unit were overlooked until something happened that needed attention:
When the patient is calm, no problem. But when it is impossible to reason with them, when they get upset, that’s when you have to do something.
Thus, falling behind meant becoming reactive rather than proactive, as interventions had to be taken in response to unmet needs that had escalated into manifest problems. Examples of this included patients developing hyperactive delirium, wandering off from the ward, invading other patients’ private space, and/or removing cannulas or disconnecting medical equipment. Falling behind also involved having to find instant solutions to manifest problems such as giving sedatives when behaviours or events became unmanageable, or making last-minute alterations when it was discovered that a patient was about to be discharged without support at home.
A recurrently emerging issue in the data was that ‘falling behind’ had consequences for patients, family members and staff. For patients, being in a context where staff’ fall behind could result in suffering as we repeatedly observed signs of fear, worry and anxiety, together with physical manifestations of suffering such as constipation, incontinence and/or delirium. The consequences for family members involved experiences of exclusion from not being explicitly welcomed and involved in care, and the responsibility to make contact and keep informed was usually left to family members. For staff, the consequences of falling behind included experiences of frustration and dissatisfaction from not being totally satisfied by the quality of care currently provided to older people with cognitive impairment.
Three categories contributed to staff falling behind in meeting the needs of patients with cognitive impairments. Categories and their properties are conceptualised below.
Working without consensus about the care of older patients with cognitive impairment
The three constituent properties of this category are having conflicting views of patient cognitive status, having different approaches to patient care and having inconsistent documentation of patient needs.
Having conflicting views of patient cognitive status
Staff at the unit did not routinely assess the cognitive status of older patients, and when cognitive assessments were made, these were based on subjective judgements rather than on established tools or procedures. This resulted in occasions such as when one staff member subjectively concluded that a patient had impaired cognition, while other staff members subjectively disagreed. On other occasions, staff members reported impaired cognition, even though a comprehensive assessment revealed an undetected hearing deficit. Dr Arne described how cognitive impairment was commonly overlooked by staff because they did not perform valid and reliable cognitive assessments:
I think we’re overlooking patients with cognitive impairment because many of them are fantastic at hiding their handicap. Also, we don’t ask them the right things or expose the patients to that type of tests here.
Cases were also observed in which the cognitive status was neither documented nor communicated despite the patient having a diagnosis of dementia. This meant that staff could not use this previous knowledge to create a shared view of older patients’ problems and needs.
Having different approaches to patient care
The unit had clear guidelines and a shared approach to diagnostics, treatment and care for cardiology-related conditions, which were implemented for all arriving patients. However, there were no guidelines, protocols or other indications that the unit had a standardised approach to care for the specific needs related to cognitive impairment. We found that what actually happened with patients with cognitive impairment was subjectively and haphazardly dependent on individual staff members. Having different approaches to care became evident when staff described the care of anxious patients. The physicians said that the nurses provided extended interactions to anxious patients’ and that this was often enough to calm them. Nurses, in contrast, described that they rarely could provide such extended interactions. Some staff members reported that relatives were used as a resource, while others stated that relatives were very rarely contacted. A preliminary interpretation is that these different approaches to care were related to the lack of standardised evidence-based guidelines or protocols for care of these patients at the unit, as such standardised approaches aim to reduce interpersonal differences.
Having inconsistent documentation of patient needs
The content of patient documentation also indicated inconsistencies. It was difficult to obtain a picture of the patient as a person through what was documented, as patient notes were characteristically limited to the inclusion of medical information. A few staff members devoted space in the documentation to biopsychosocial needs, but such information was usually absent. This meant that the more holistic information that could inform the provision of PCC to patients as people with individual needs was inconsistently provided. Nurse Caryn illuminated the lack of consensus among staff about documenting cognitive impairment:
I don’t think we have a set heading that we document beneath. Instead you have to search in the text if you want to get information about the patient’s cognition.
Working in a disease-oriented and efficiency-driven organisation
The two contributing properties for this category were organising care by disease and not by patients’ multifaceted needs, and organising care by routines and not by patient subjectivity.
Organising care by disease and not by patients’ multifaceted needs
The unit was highly specialised in cardiology, which meant that if patients had co morbidities or other needs exceeding the specialty of the ward, they had to be transferred to other clinics. The wife of one patient expressed her thoughts on the drawbacks of a highly specialised care:
Health care could probably see the person a bit more as a whole and not just direct itself to the acute problem. All the transits to different clinics for other diseases raise the price, is time-consuming, and seem unnecessary from the patient’s perspective.
The high level of specialisation also meant that patients with cognitive impairment were not in the centre of attention for professionals at this unit. There seemed to be limited interest in diagnosing and managing forms of cognitive impairment, and this was not actively attended to until becoming unmanageable. In those cases, referrals to appropriate consultants were made. An example of having disease as the organising principle was the staff notion that older patients with cognitive impairment did not fit the system and policies of the unit, as they often presented comorbidities and demanded more time than the unit could handle. Nurse Sara expressed it this way:
I don’t think that older people with cognitive impairments fit in here with us. I don’t mind them if they’re at their right place, like in the geriatrics ward. But it’s difficult to combine cognitive impairments with acute care. And we should ask ourselves to what extent we should treat people with dementia.
Organising care by routines and not by patient subjectivity
There was a strong focus within the unit to make the organisation increasingly efficient, for example by shortening lengths of stay. Patients were often called to various tests and treatments with very short notice based on organisational needs for effectiveness, and this could create anxiety among older patients. Nurse Annie described how older people could suffer from organising care based on efficiency:
This increase in efficiency happens when gaps at various labs are to be filled on short notice. That doesn’t work with older people who get worried and anxious if they’re not prepared.
Another dimension of organising care by routines and not by patients’ subjective needs was the staffing model. Rotation of staff was high between different wards, a conscious strategy to keep staff competence and flexibility of the organisation high. Rotating staff meant that older patients with cognitive impairment could meet as many as 19 different staff members during a two-day hospital stay. This created barriers for staff getting to know individual patients and obstructed staff continuity. The remarks of Nurse Sam illustrated how the lack of staff continuity and limited documentation created frustration and a lack of engagement in older patients with cognitive impairment:
We rarely have the same patients for very long, instead we are moved between different units. It can be very frustrating when we have a patient with cognitive impairment and the notes only say that he’s confused! So sometimes you tend to think that I’m only to have this patient for one day, and then you don’t get so involved.
Working within a busy and inflexible environment
This category had two contributing properties: being out of pace with patient needs and being out of space with patient needs.
Being out of pace with patient needs
The physical environment of the ward was characterised by a high pace, numerous people and frequent movements of patient transports, professionals and students, and high patient turnover. Another dimension of this busyness was the sound of the ward. It was often quite noisy, with a mix of loud laughter and talking, telephones ringing, televisions blaring, and patients’ alarms and surveillance equipment from the nearby cardiac intensive care unit going off. This busy environment was quite different from the calm and stimuli-reduced environments commonly argued as beneficial for older people with cognitive impairments and thus contributed to falling behind in meeting the needs of these older patients. The following excerpt from an interview with nurse Sven captured the view of many that the physical environment was out of pace with patient needs:
Our environment isn’t good. If you’re in the dining room you’ll see people running off and on the whole time. And in a big ward room there is a lot of movement and talk between the patients and noise from the TV, and there are many other unfamiliar sounds from buzzing signals etc., that can create anxiety, especially at bedtimes.
Being out of space with patient needs
Another property of being in a busy and inflexible environment was the limited space on the ward. Most patients shared rooms with three others, and communal space for social interaction was limited at the ward. This made it difficult for family to spend time on the ward, and relatives worried about being in the way. One wife felt that her presence at the ward was not appreciated by staff and said that she avoided spending time at the ward because she did not want to be in the way:
I’m the kind of person that doesn’t want to be in the way. I worry that I’m causing a bother…
The limited space also made it difficult for staff to meet individual needs of privacy and worked against the involvement of relatives. As such, the limited space contributed to care falling behind in meeting these older patients’ needs. The limited space also meant that it was difficult to bring tests and procedures to patients without intruding into the private space of other patients and/or exposing the person undergoing the examination. Thus, older patients were often transported out for examinations and were by that exposed to additional unfamiliar environments that could be stressful.
The aim of this study was to develop a theoretical understanding of the processes hindering PCC of older people with cognitive impairment in acute care settings.
The theory indicates that having conflicting views of cognitive status, different approaches to care, inconsistent documentation of patient needs, organising care by disease and routines rather than patients multifaceted needs and subjectivity, and having a fast pace and limited space contribute to staff falling behind in meeting the needs of older people with cognitive impairment. The theory also suggests that a shared view of cognitive status, shared approaches to care and consistent documentation of needs, organising care by needs and subjectivity and adapting pace and space to individual needs can contribute to staff being a step ahead to meet the needs related to old age and impaired cognition.
The first category, ‘working without consensus about the care of older patients with cognitive impairment’, indicates that a lack of shared understandings into the care of older patients with cognitive impairment can inhibit the provision of high-quality PCC. Previous work has suggested that older patients with cognitive impairment can be viewed as low-priority cases among acute care nurses (Moyle et al. 2011), and that these patients can become overlooked as nurses might not fully understand the cognitive condition and its management (Borbasi et al. 2006). This indicates a need to acknowledge this large and growing group of acute care consumers and to develop guidelines and staff consensus to support high-quality, proactive care to prevent adverse outcomes. Standardised assessments of cognitive status were not commonly carried out in admitted older patients. Previous studies have recommended formal assessment of cognition when older patients are admitted to hospital to facilitate adequate care and to avoid complications (Maslow & Mezey 2008, Labella et al. 2011). Not identifying signs and symptoms of dementia or delirium have been shown to hinder early diagnosis, medication and other management strategies that can minimise suffering (Borbasi et al. 2006, Arnold & Mitchell 2008, Moyle et al. 2008). Furthermore, standardised and detailed documentation in the patient record can contribute to a continuity and transparency that can support PCC (Ekman et al. 2011a).
The properties in the second category, ‘working within a disease-oriented and efficiency-driven organisation’, confirm previous findings that the organisational culture influences the nature of interactions between staff and patients (McCabe 2004, Henderson et al. 2009, Kirkley et al. 2011, Wolf et al. 2012). Our theory suggests that organising care according to acute diseases and routines rather than to patients’ multifaceted needs and subjectivity contributes to staff falling behind in meeting patients’ biopsychosocial needs. Similar findings emerged in a recently published ethnographic study on the everyday practices in a cardiology ward. This study described how a predominantly medical culture of efficient diagnosis and treatment restrained the nursing perspective, worked against PCC and contributed to nurses’ experiences of ‘being one step behind’ in relation to patient needs (Wolf et al. 2012). Acute care staff have previously reported not having the time, knowledge or skill to deliver high-quality care for older patients with cognitive impairment (West et al. 2005, Borbasi et al. 2006). This suggests that healthcare organisations increasingly need to recognise and support staff for example through developing and implementing protocols and guidelines (Brooker 2007). A previous study showed that a majority of acute nursing staff reported providing the best possible care to older people with cognitive impairment, while rarely assessing older patients’ cognitive condition or working with evidence-based care protocols (Nilsson et al. 2012). Thus, it seems that these issues are in need of increased attention in the acute care setting.
The third category, ‘working within a busy and inflexible environment’, showed the influence of the environment on the staff’s ability to provide PCC. It was discovered that shortcomings in the environment contributed to staff falling behind in meeting the needs of older patients with cognitive impairment. It has been described that busy and anonymous environments without space for social interactions are experienced to threaten a sense of security, continuity and belonging for patients and families (McCloskey 2004, Nolan 2007).