Loneliness

Loneliness is a major issue affecting older people’s quality of life (Table 9). Older people's loneliness is also associated with impaired health and depression (Peerenboom et al., 2015), increased use of health and social services (Taube et al., 2015) and increased mortality (Tilvis et al., 2011). Some research suggests that almost

one third of older people of 65 years and above report loneliness, even higher rates are found among those aged over 85 (Hauge & Kirkevold, 2012). (Table 9).

Table 9. Studies on the phenomena connected with older people and loneliness Phenomena connected with loneliness Research

Impaired health Pitkälä et al., 2009; Peerenboom et al., 2015;

Nummela et al., 2011; Eloranta et al., 2015 Increased use of health and social services Pitkälä et al., 2009; Taube et al., 2015,

Mortality Pitkälä et al., 2009; Tilvis et al., 2011,

Depression Routasalo et al., 2006; Eloranta et al., 2015;

Peerembom et al., 2015 Inner feelings, life orientation (expectations,

strength)

Routasalo et al., 2006; Tilvis et al., 2012; Hauge

& Kirkevold 2012; Taube et al., 2016

Unfortunately, loneliness of older people is a common problem in Finland. Eloranta et al. (2015), studied loneliness in Finnish older people aged 70, reporting that around one-fifth (18%) of the respondents born in the 1940 cohort suffered from loneliness at least sometimes, while the corresponding figure in the 1920 cohort was around one-fourth (26%). The analyses indicated that the effect of the cohort, born in the 1920s or the 1940s, was not a statistically significant explanatory factor of loneliness. Living status, self-rated health and memory compared to age peers were statistically significant explanatory factors for suffering from loneliness. Older people with poor self-rated health who lived alone were most likely to suffer from loneliness (Eloranta et al., 2015.)

It is also found that suffering from loneliness indicates a significant mortality risk of older people (e.g., Tilvis et al., 2011). The association between adverse health and loneliness among older people is also known. Nummela et al. (2011), in their longitudinal study about older people discovered that never or seldom experiencing loneliness was a strong predictor for good self-rated health. Loneliness was a significant contributor to poor self-rated health among older people (Nummela et al., 2011). The qualitative study about frail, home-dwelling older people’s experience of loneliness by Taube et al. (2016) found that older people felt they lived “in a bubble”, which illustrated their experience of living in an ongoing world from which they excluded due to their social surroundings and the impossibility of regaining losses.

(Table 9).

The preceding studies suggest that preventing loneliness is very important for older people’s health promotion. Cohen-Mansfield and Perach (2015) also suggest in their systematic review that it is possible to reduce loneliness by using educational interventions by focusing on the maintenance and enhancement of social networks.

Older people face many losses, such as the deaths of their spouse and friends, and feelings of loss are a part of loneliness. Studies suggest that social activity can be an excellent way to avoid loneliness. Pitkälä et al. (2009), found that socially simulating group interventions based on the effects of closed-group dynamics and peer support improved lonely older people’s cognition. A positive life orientation has also been found to predict a good survival prognosis in old age (Tilvis et al., 2012). It is very important to remember that social isolation and loneliness are common and serious, but preventable risks for older peoples´ health and wellbeing.

2.7 OLDER PEOPLE´S ADLS IN ACUTE CARE SETTINGS AND CONTINUITY OF CARE

The literature review for this topic was performed using the key words older people OR elderly OR elder OR older adults OR old aged OR older aged OR aged OR/ AND home-dwelling OR/AND home living connected with Social activity OR ADL OR IADL OR continuity of care OR/AND nursing (Figure 9).

Figure 9. Keywords in the literature review of older people’s ADL in acute care settings and the continuity of the care.

2.7.1 Functional assessments

Functional assessments are critical when caring for older people. It is known that the unmet need to perform ADLs is associated with the increased use of urgent health services by older people (Sandberg et al., 2012; Grey et al., 2013; Laudisio et al., 2015;

Wang et al., 2016). Performing ADLs, independently or with help, is essential for older people to continue living at home. It is also known that older people with pre-existing ADL impairment are at high risk of functional decline in the 30 days following ED presentation (Lowthian et al., 2017).

Older people OR elderly OR elder OR older adults OR old aged OR older aged OR aged OR/ AND home-dwelling OR/AND home living

Social activity OR ADL

OR IADL OR continuity of

care.

OR/AND NURSING

A total of 149 abstracts were evaluated and 16

articles were included in the literature review

(Appendix 4)

2.6.1 Functional assessments 2.6.2 Prevention and

rehabilitation

Wang et al. (2016) analyzed cross-sectional data from a nationally representative sample of people aged 65 years and over (n=2904) who were participating in the National Health Interview Survey in Taiwan. They discovered that an absence of available help for ADL disability was reported in 17 % of disabled older adults. These disabled older adults reporting an absence of help were more likely to be female.

After the adjustment for other factors, compared to older adults without disability, older adults with a disability and not receiving help for ADL tasks were highly related to hospitalization and emergency department visits during the past year.

Grey et al. (2013), examined functional profiles and the presence of geriatric syndromes among older people visiting emergency departments in seven countries.

They learned that functional problems and geriatric syndromes impact the multiplicity of older people visiting an emergency department. Before becoming infirm, 46% were dependent on other people in one or more dimensions of their personal ADL. This proportion increased to 67% at presentation to an ED. When in the emergency department, 26% showed evidence of cognitive impairment, and 49%

could not walk without control. Recent falls were common (37%) among the study group. Altogether, minimum of 48% had a geriatric syndrome before becoming infirm, increasing to 78% at presentation to the emergency department. This pattern was consistent across nations in this study (Grey et al., 2013.)

Researchers suggest that there is a high prevalence of absence of help to perform ADL tasks in older adults with disability and that this absence of help for ADL disability is associated with a greater burden of acute care utilization than those without disability (Wang et al., 2016). Similar associations were found by Laudisio et al. (2015), in their population-based study. The researchers (Laudisio et al., 2015) assessed the association of functional ability with a one-year period of ER visits and hospitalization rates. They discovered that disability in ADLs was associated with the increased risk of ER visits but not of hospital admission. Also, ADLs disability predicted the number of ER visits.

Sandberg et al. (2012) found relationships with healthcare utilization among older people aged 60 years and above and in their ADL dependency. The aim in this Swedish study was to examine health-care use for a six-year period among older people aged 60 or older classified as dependent/independent in ADLs and/or at/not at risk of depression. The aim also identified healthcare utilization predictors.

According to study results ADL-dependent subjects and those at risk of depression had significantly more hospital stays, except for those not at risk of depression in years 2, 4 and 5. In the study, the healthcare utilization predictors five-six years after the baseline were mainly age, previous healthcare utilization and various symptoms and in one-two and three-four years after the baseline, age, various diagnostic groups and various physical variables. Thus, although healthcare utilization patterns

seemed to be similar for the different groups, there were difficulties in finding universal predictors (Sandberg et al., 2012.)

Little is known about the systematic functional assessment protocols used in older people’s nursing care in emergency departments. Jensdottir et al. (2008), found that the documentation of the impairment of personal ADLs was poor in their study comparing nurses´and physicians´documentation of the functional abilities of older patients in acute care. The documentation was missing in 40-60% of the nurses' reports and 80-97% of the physician's reports. Still poorer was the documentation of the impairment of IADLs of which 75% were not recorded by the nurses and 85-96%

by the physicians. At the same time, cognitive function was reported in only 30-40%

of the cases (Jensdottir et al., 2008.)

Normal aging changes, acute illness, worsening chronic illness, and hospitalization can all contribute to a decline in the ability to perform the tasks necessary for living independently in the community (Graf, 2006). Sands et al. (2006) learned in their intervention study that frail older people who live without the help needed for their ADL disabilities have higher rates of admissions while they are living with unmet ADL needs, but not after those needs are met.

Objective data from a functional assessment can also help target individualized rehabilitation needs and specific in-home services, such as meal preparation, nursing care, domestic services, personal care, and/or continuous supervision, as well as the early recognition of any changes (Portegijs et al., 2016). Acute care nurses are on the front line of evaluating ADL changes and possible assistance needs to ensure that the older people can function at home.

2.7.2 Prevention and rehabilitation

There is much evidence about the efficiency and positive effects of prevention (primary-, secondary- and tertiary prevention), exercise and rehabilitation regarding older people’s ADL performance which could be used also after an emergency department visit. It is found that specialized geriatric rehabilitation is complicated but effective when properly performed. Individually tailored interventions for mobility found to be effective even in the sub-group of older people with muscolosketal pain (Lihavainen et al., 2012.) Courtney et al. (2012), found in their intervention study that notable improvements were realized in the intervention group’s IADL and ADL scores in comparison to the control group. The intervention group in this study got an individually custom-made programme for exercise and follow-up care that started in the hospital and contained regular visits in the hospital by a physiotherapist and a registered nurse, a home visit following discharge and regular telephone follow-up for 24 weeks following discharge.

Elo et al. (2012), described gerontological rehabilitation nursing in an acute hospital setting from the nursing staff´s viewpoint in their Finnish study. They suggest that nursing staff could have a more active role on the rehabilitation team, because they are with the older rehabilitation patients for the most amount of time. Ekwall et al.

(2012), explored how frail older people in acute care processes undergo their physical decline and how they adapt to their bodily changes. The main result was that physical decline was marked as arising in two scopes. One scope was the impact on the individual’s physical body (labelled individual body). The other scope was the impact on the body in its environmental context, such as the home or society (labelled contextual body). The strategies for adapting constituted the two subthemes, labeled compensating or controlling and accepting or resignation. These strategies were carried out both on an intellectual level and practical level (Ekwall et al., 2012.) Studies also indicate that older people have special needs that are not always fully met upon discharge and in the continuity of care from accident and emergency departments (Legramante et al., 2016; Hunt et al., 2006). In a Swedish qualitative study about older people's concerns regarding their needs after discharge (Gabrielsson-Järhult & Nilsen, 2016), 27 observations were recorded at hospital discharge planning meetings and analyzed with content analysis. Gabrielsson-Järhult and Nilsen (2016), found that an overarching theme emerged: being in a life transition, which reflected the older person's vulnerable and ambiguous situation in the discharge process. The theme was developed from three categories: obtaining a secure life situation, need for continuous care and support, and influencing and regaining independence. The researchers (Gabrielsson-Järhult & Nilsen, 2016) suggest that the findings highlight that older patients want to influence their care after discharge. They strive to regain independence and express their concerns about how to obtain a secure life situation through care organized to fit their individual needs. The researchers also suggest that knowledge about older people´s concerns is important for healthcare providers and social workers involved in planning and individualized care and services (Gabrielsson-Järhult & Nilsen, 2016.)

2.8 MISSED NURSING CARE MODEL AND OLDER PEOPLES EMERGENCY NURSING

Missed nursing care model is a theoretical framework and a quantitative tool developed to measure the amount and type of missed nursing care and the reasons for missing care (Kalisch, 2006; Kalisch& Williams, 2009). Kalisch´s model of missed nursing (Kalisch, 2006; Kalisch et al., 2009) has its roots in Donabedian's (1988) health care development and quality assessment process (pdca/plan-do-check-act) in other words structure-process-outcome framework. In the nursing process nurses with restricted resources make decisions about wether to delay or omit certain aspects of

care (Kalisch, 2006; Kalisch et al., 2009). This decision process is influenced by individual-level factors and structural-level factors (Figure 10). In the missed nursing care model structural human factors are, for example, number and competency level of nursing staff, its´education and experience. Material resources means, for example, availability of necessary supplies and equipment (Figure 10).

Teamwork, between the patient care team members, between nurses and doctors and nurses and support staff is also seen as a structural factor, as well as the management is (Figure 10).

Figure 10. Missed nursing care model (Kalisch, 2006; Kalisch et al., 2009)

In Kalisch's model, the term “missed nursing” derives from the English word

‘omission’ meaning unfininshed nursing care (delayed, partially completed) and needed nursing care left undone. Nursing care that is started but not completed is also classified as missed care. It is found that unnoticed or overlooked symptoms, missed nursing care, have also a direct impact on the quality and outcomes of patient care, and carry ethical (e.g., Suhonen & Scott, 2018) as well as cost (e.g., Scott et al., 2018) implications. Therefore, it is important to examine the phenomenon in detail to prevent the missing nursing care and to improve the nursing quality, ethics and cost of care, also in relation to staff well-being, adequacy and management.

It is found that missed nursing care is common for example in acute care hospitals and connected with nursing practice environment and staff adequacy, accountability and work intensification (Kalisch et al., 2011; Cho et al., 2015; Hessels et al., 2015;

Henderson et al., 2016; Srulovici& Drach-Zahavy, 2017; Sung-Hyun et al., 2017). On the other hand, it is well known that lower levels of missed or interrupted nursing have been detected in higher levels of teamwork and in so-called magnet hospitals (Kalisch & Lee, 2010, 2012; Kalisch & Xie, 2014; Chapman et al., 2017). Missed nursing is an international phenomenon.

Resource

Missed nursing care is a seldom studied topic with older peoples´ nursing or with emergency nursing.

2.9 SUMMARY OF THE LITERATURE REVIEW

A closer analysis of the references showed that the phenomena of concern are especially studied in relation to medicine and pharmacology. Emergency nursing studies were rare, as were studies about older people´s own participation or involvement and decisions in their acute nursing care. There were nearly no nursing studies about older people´s capabilities or willingness to take part in their acute care nursing either as an active author, or in being involved in nursing processes.

Furthermore, the older people were rarely informants in the studies.

Thus, how can older people become involved in their own care? This issue has not been a research topic in older people´s acute nursing (Figure 10). However, Lyttle and Ryan (2010) found seven key themes in their literature review that searched for factors influencing older people´s participation in care. These themes were the concept of participation, the need for older people to be involved, autonomy and empowerment, patients’ expectations, the benefits of participation, factors influencing participation and precursors to participation. Their review suggests that future initiatives should focus on supporting nurses and other health-care professionals in developing the competencies required to facilitate greater participation by older people who wish to become more involved in their own care (Lyttle & Ryan, 2010.)

Penney and Wellard (2007), explored older people´s participation in their care in acute care settings. In their qualitative study, thematic analyses identified that older people equated participation with being independent. Older people also highlighted the complexity of the notion of participation when describing situations in which they were unable to participate in their own care. The difficulties communicating with health-care professionals and an inability to administer their own medications in in-patient settings were identified as barriers to participation. Researchers recommended that understanding what consumers believe participation means could provide a starting point for developing meaningful partnerships between health professionals and people receiving care (Penney & Wellard, 2007).

A Swedish study about patient participation in emergency department care learned that young and well-educated patients fought more to participate in their own care and thus received less attention for basic needs than older and less-educated patients (Frank et al., 2011).

Mylläri (2017) explored the quality of ED care of older adults. In this qualitative research, 21 community-dwelling older adults (aged 74-94) who had visited an urban

ED in Tampere, Finland, were interviewed. Five main criteria for high-quality care emerged: accessibility of care, care that proceeds in a meaningful way and results in a desirable outcome, patient wellbeing during the ED visit, positive interaction between patients and staff and that ED users’ different needs considered equally. In this study, the interviewees believed that the medical aspect of care was of high quality, but they were uncertain of whether they would receive help that corresponded to their needs. In addition, they spent a larger proportion of time waiting rather than being examined and receiving treatment. Some of the study participants felt that they received extremely good care, but others had negative experiences concerning lack of information, being left alone, uncomfortable circumstances, inadequate symptom relief, and insufficient consideration of feelings of hunger and thirst. The interviewees had both negative and positive experiences regarding interactions with staff members. Mylläri (2017) suggests that it is crucial to minimize random variation in quality of care.

The informants in the literature review studies were mostly someone other than the patients, or the home-dwelling older people themselves. There were as many population- based cohort studies or surveys as there were studies that used register data. Cross-sectional register data studies were common. These sources of information were used in all study questions, especially regarding health-care services use, morbidity of older people and medications. The data registers were usually patient registers (hospital, primary, community or home care) or different kinds of medicine registers. Population- based cohort studies or surveys and those using register data were common among Finnish studies. Intervention studies, mostly randomized control trials, were in the minority. Most of those related to the continuity of older people’s care or medications, but there were also a few connected with the rehabilitation or the prevention of loneliness in older people.

Studies suggest challenges connected with older people’s medication (Bell et al., 2013) and older people’s self-medication skills (Meranius & Engström, 2015). There are studies regarding medication errors in nursing (Metsälä & Vaherkoski, 2013;

Karttunen et al., 2020), older people’s medication mismanagement (Swanlund, 2008), and polypharmacy regarding multiple medications (e.g., Ahonen, 2011). Most studies used national or organizational register data sources. Studies seldom researched older people’s own experiences, knowledge, willingness, or capability in self-medication management (Figure 11).

The mental status impairment of older people in acute care settings is found to be highly prevalent (e.g., Han et al., 2009). An acute confusional state, i.e. delirium,

The mental status impairment of older people in acute care settings is found to be highly prevalent (e.g., Han et al., 2009). An acute confusional state, i.e. delirium,

In document Older people in emergency department (sivua 53-0)