DEPARTMENT – NURSE MANAGERS AND NURSING STAFFS´ VIEW
As a result, of the e-mail questionnaire to nurse managers in seven emergency department, there were no systematic used measurements available in care of older people. Even if the review was only little, sight over emergency departments and results of it are not generalized, it strongly suggests that systematic protocols for assessments and the measurements are needed. It is also important to consider that the patient´s medication list, or checking the list of medication is very important and some how the “first step” but not the same thing as assessesment of the self- medication management of older people. According to questionnaire of nurse managers measurements used in emergency departments for assessment of older people’s self-medication management, signs of memory disorders and signs of depression and functional assessment warrants further exploration.
As a result of the structured questionnaire to nursing staff it was found many structural and individual factors contributing to missed nursing care related to assessment of older peoples´ self-medication management, signs of memory disorders, signs of depression, functional assesment and relaying the continuity of care.
Lack of time or busyness was mentioned often. Busyness in nursing care is often mentioned topic in public conversation almost all around the world. According to missed the nursing care model of Kalisch (e.g. Kalisch, 2006; Kalisch et al., 2009;
Kalisch & Williams, 2009; Kalisch & Lee, 2012) labour resources includes factors like the number and types of nursing staff, competency level of nursing, and their education and experience. Lack of any of those factors might arise feelings of busyness in nursing staff. Also, busyness is often related to nursing processes itself.
It is important that the nursing processes in the emergency department are clear
enough and fluently connected with patients other caring processes. This spares nurses time for timely and effective nursing care. In the emergency department timely and effective nursing care means good skills in controlling the clinical situation of each patient, including their individual needs. This is very important when caring for the older people in the ED. Creative and careful analysis of the busyness in nursing is most important when missed nursing care is a problem related to time pressure and competing demands, and of course, an adequate nurse staffing is needed to prevent it.
Other mostly mentioned factors continuing to missed nursing care in the emergency department were lack of systematic assessment protocols and lack of measurements.
It is well known that missed signs of memory disorders and missed signs of depression and also missed signs of mental confusion of older people in the emergency department are common (Bradford et al., 2009; Hammami et al., 2012;
Hölttä et al., 2012; Boman et al., 2015; El Hussein et al., 2015). This is a strong evidence for the need develop emergency nursing care in a way that the assesment of older peoples´self-medication management, signs of memory disorders and signs of depression, functional assessment and fluent continuity of care are possible. Without common systematic protocols and easily available measurements it is not possible.
Good teamwork and communication are important parts of successful emergency care. It is also found that the level of nursing teamwork impacts the nature and extent of missed nursing care in the acute care hospitals (Kalisch &Lee, 2010). In the nursing staffs answers the lack of communication between emergency team or between nurses and doctors were mentioned often contributing to missed care of older people.
Also, the lack of communication with other caring people and relatives of older people were mentioned, as well as a factor contributing to missed care in the emergency. These factors were identified very clearly in the free comments of nursing staff. It is known that relatives of older people have important role in providing aftercare (e.g. Deminenko, 2018) and their presence in counselling improves older peoles´ involvement in their own care (e.g. Paavilainen et al., 2009).
Nursing staff also suggests that the assessments of older people are needed only if defects in it (for example, signs of memory disorders or depression, functional decline) or lack of it (for excample self-medication management) are the reason for presenting to emergency department. They also believed that they would notice the problems without special assessments, if older people have those. Their judgement about the importance of assessments in the older peoples´ emergency care was not high and the assessment of older peoples´ self-medication management, signs of memory disorders and signs of depression, functional assessment weren´t apparently a part of nurse´s usual practise. This implies about nursing staffs believes and attitudes. It is also connected with the management; were there the demand for the older peoples´ assessment of self-medication management, signs of memory
disorders and signs of depression, functional assessement and telling the continuity of care in the emergency nursing care? Or was it more a question about lack of gerontological nursing skills? More investigation is needed to clarify the issue.
Continuity of care and clarifying the continuity of care for older people after an emergency visit was seen less missed nursing care compared to other claims, 39% of participants said they tell the continuity of care for the older people always after the visit in the emergency. Missing instructions about continuity of care nurses thought mostly to be related to lack of communication and teamwork inside of the emergency team but also with other personnel connected to older peoples´care. Disharge of older people was also seen complicated if there were a lot of people connected with it like other social and health care workers, family etc. Lack of communication with older people’s family was also mentioned. Other factors contributing missed care were missing instructions and unusable forms. Only one of the participants thought that it is another health care works responsibility. It is important to notice that all the factors connected to missed continuity of care are possible to prevent, for example improve teamwork skills and involving older people’s family toward discharge (Palonen, 2015).
All these factors, structural and individual, which nursing managers and nursing staff mentioned continued to be missed in the emergency department, primary emergency duty and primary nursing suggests that there might be a need for better gerontological nursing skills in the emergency nursing.
It is very important to prevent missed care in the emergency nursing. Unnoticed or overlooked assessment of self-medication management, signs of memory disorders and signs of depression, functional assessment and obscurity in continuity of care might be critical issues and barriers to continue living at home for older people.
Missed care also have a direct impact on the quality, safety and outcomes of older peoples´ care. It is very important to notice that it also carries ethical (e.g., Suhonen
& Scott, 2018) and cost (e.g., Scott et al., 2018) implications.
The study’s results support the need for more knowledge regarding the implications for nursing practice, as there is still a lack of information concerning the emergency nursing of older people. These implications include the requirement for an interdisciplinary approach to improve referral guidelines and staff training, as well as for the proper distribution of information between social and health care sectors in order to ultimately optimize the quality and continuity of care for older people. It is also found that there is a big variation in the consistent care processes of emergency care (e.g. Mylläri, 2017), as well as the entirety of social and health care services available for the older people in different cities and areas (Malmström et al., 2017). Better quality services which correspond to older peoples´needs are possible to achieve only by paying attention to emergency services overall, as well as to other
social and heathcare services available, the entirety of services. This is a huge challenge but also a possibility to improve regarding the advanced nursing care delivered within emergency departments.