The first question of the questionnaire handled older peoples´ self-medicine management and missing evaluation of it. Most of the reasons for missed evaluation of older peoples´self-medication management were connected with structural factors
of nursing care like labor resources and material resources (Table 27). Over one third of the answers (44%) didn´t keep it important if self-medication management wasn´t connected with the reason for coming to emergency duty or primary care (Table 27).
Two items, individul factors related to nurses attitudes and beliefs, didn´t get any support and 34% of the answers told they always assess patients´self-medication management and register it in patient records (Figure 18).
Table 27. Factors contributing to missed evaluation of older people self-management of medication
Structural factors n % Individual factors n %
There is no agreed protocol regarding the evaluation of self-mediacation of management at my work place
29 49 It is not usually related to the reason why the patient come to the emergency duty or primary care, and it is therefore not necessary
26 44
There are no agreed measures in place for evaluating self-medication management at my work place
29 49 I would be able to tell if the patient was not capable of self-medication management, there is no need for separate many other things to do.
26 44 Older people are not usually responsible for their medical treatment, so there is no need for its assessment
I do not know how to assess the self-medication management of an older people
4 7
I always assess patients’ self-medication management and register it in patient records (opposite)
20 34
Beause of other reason, what? You can write it down under (other/own) 4 7 -I don´t have time for it
-The list of medication I check always
-Different kinds of patient records are problematic. Patients don´t have up-to-date medication list with themselves and as an informants of their medication they are not trusworthy.
-I make a mark to the patient record if there is something wrong with the medication -Older people don´t take their medication lists with them, not even in situations they are specially asked for it. They also have a lot prescriptions from private doctors.
f
Figure 18. Missed evaluation of older people’s self-medication management by nursing staff (N=59)
Structural factors, especially material (46%) and labor (36%) resources in nursing were emphasized as a reason for missed signs of memory disorders. In addition, nurses individual factors affected too (Table 28). The assessment of memory disorders wasn´t priorized if it wasn´t the coming reason (34%) for attending the ED.
Also, nurses believed that they would notice signs of memory disorders without assessment if older people have those (Table 28). Also other reasons for missed signs of memory disorders were both structural and individual (Table 28). All items got support when searching for reasons of missed signs of memory disorders in nursing (Figure 19).
0 5 10 15 20 25 30 35
Table 28. Factors contributing to missed evaluation of older peoples´ signs of memory disorders
Structural factors n % Individual factors n %
There is no agreed protocol regarding the evaluation of signs of memory disorders at my work place
27 46 It is not usually related to the reason why the patient came to the emergency duty or primary care, and it is therefore not necessary
20 34
I don’t have time to evaluate the patient’s signs of memory disorders because there are so many other things to do.
21 36 I would be able to tell if the patient has signs of memory disorders, there is no need for separate assessment
15 25
There are no agreed measures in place for evaluating of signs of memory disorders at my work place
18 31 Older peole have always some amount of signs of memory disorders so there is no need for its assessment
3 5
It has not been determined as a responsibility of nursing care at my work place
6 10
I do not know how to assess the signs of memory disorders of an older people
6 10
I always assess patients’ signs of memory disorders and register it in patient records.
(opposite)
16 27
Because of other reason, what? You can write it down under.(other/own) 5 8 -It is too busy all the time
-I evaluate the signs of memory disorders individually, if it is necessary
-It´s too hard to find out; not mentioned in the patients records and the evaluation time (time in emergency) is too short for that, or memory disorders don´t show up.
-I mark in the patients´ record if it worries me, or have an influence on older people’s capability to continue living at home
- Sometimes older people themselves refuse the evaluation of signs of memory disorders or from functional assessment.
f
Figure 19. Missed evaluation of signs of memory disorders of older people by nursing staff (N=59)
Missed signs of depression were mostly connected with structural factors of nursing care like lack of time (Table 29). On the other hand, over half of the aswers (53%) thought that if signs of depression is not the reason for older people coming to emergency it is not necessary to assess (Table 29). Two items, individul factors related to nurses attitudes and beliefs, didn´t get any support (Figure 20).
0 5 10 15 20 25 30
Table 29. Factors contributing to missed evaluation of older peoples´ signs of depression
Structural factors n % Individual factors n %
I don’t have time to evaluate the patient’s signs of depression because there are so many other things to do
21 36 It is not usually related to the reason why the patient came to the emergency duty or primary care, and it is therefore not necessary
31 53
There is no agreed protocol regarding the evaluation of signs of depression at my work place
17 29 I would be able to tell if the patient has signs of depression, there is no need for separate assessment
0 0
There are no agreed measures in place for evaluating of signs of depression at my work place
11 19 Older peole have always some amount of signs of depression, so there is no need for its assessment
0 0
It has not been determined as a responsibility of nursing care at my work place
6 10
I do not know how to assess the signs of depression of an older people
6 10
I always assess patients’ signs of depression and register it in patient records (opposite) 8 14 Because of other reason, what? You can write it down under.(other/own) 2 3
-It is too busy all the time
-Signs of depression never leaves unnoticed
f
Figure 20. Missed evaluation of signs of depression of older people by nursing staff (N=59) 0
5 10 15 20 25 30 35
Structural factors, connected with labour and material resources were the mostly agreed reason for missing functional assessment (Table 30). Over half of the answers (54%) indicated that because there is no agreed protocol for assesment of older peoples´functional capacity, it is missed (Table 30). Two items, individul factors related to nurses attitudes and beliefs, didn´t get any support (Figure 21.)
Table 30. Factors contributing to missed assessment of older peoples´ functional capacity
Structural factors n % Individual factors n %
There is no agreed protocol regarding the evaluation of older peoples ADLs capacity at my work place
32 54 It is not usually related to the reason why the patient came to the emergency duty or primary care, and it is therefore not necessary
15 25
There are no agreed measures in place for evaluating of older peoples ADLs capacity at my work place at my work place
25 42 I would be able to tell if the patient has problems with ADLs capacity, there is no need for separate assessment
0 0
I don’t have time to evaluate the older peoples ADLs capacity because there are so many other things to do
17 29 Older peole have always some problems with ADLs capacity, so there is no need for its assessment
0 0
It has not been determined as a responsibility of nursing care at my work place
6 10
I do not know how to measure the older peoples ADLs capacity
4 7
I always assess patients’ ADLs capacity and register it in patient records (opposite) 4 7 Because of other reason, what? You can write it down under. (other/own) 6 10 -I evaluate the older peoples ADLs capacity with open text in the patient record
-It is too busy all the time.
-The functional assessment is hard to make in emergency because older people are in there so short time. Even you are suspecting its decline.
-It is (decline of ADLs capacity) often the reason for older peoples´ coming to emergency. Its hard to evaluate if the situation is new, or have been on longer time, during the emergency visit. It is hard to evaluate during the visit time if the ADLs are good enought to cope at home.
Sometimes we (and paramedic) do “cause of worry notifications” of these older people.
-I marke to patient record if there is something to worry about
-The functional assessment is done in primary care visit and marked in patient record. If there is need for evaluation of signs of memory disorders or meeting a social worker, it is programmed
-The ADL are so individual that functional assessment is easier to evaluate if you already know the person or meet her/him regularly
f
Figure 21. Missed assessment of functional capacity of older people by nursing staff (N=59) When asking about the continuity of care, 39% of answers were opposite of items, answers agreed that they always check the continuity of the care with the patient and made a patient record of that (Table 31). On the other hand 12% thought that older people always already have some appointments in health care services and there´s no need for speaking about continuity of care (Table 31). Team work and communication between nurses, doctors and other personnel were mentioned several times (Table 31). Two items (structural and individual factor) were left without support (Figure 22).
0 5 10 15 20 25 30 35
Table 31. Factors contributing to missed raporting of continuity of care
Structural factors n % Individual factors n %
There are no agreed measures regarding the discharge and the continuity of the care in place at my work place
12 20 Older peole have always some appointments in health care services already, so there is no need for speaking of continuity of care
7 12
There is no agreed protocol regarding the discharge and the continuity of the care on place at my work place
7 12 Usually there is no continuity of care
for the older people after disharge 3 5 I don’t have time to tell patient his
continuity of care because there are so many other things to do
3 5 I would be able to tell if the patient doesn’t know his continuity of care, there is no need for separate telling
0 0
Disharge has not been determined as a responsibility of nursing care at my work place
3 5
I don’t know what continuity of care means with these older people
0 0
I always check the patients continuity with the care with the patient and register it in patient
records (opposite) 23 39
Because of other reason, what? You can write it down under. (other/own) 5 8 - The disharge plan we are using is worthless and unusable. It is also too busy all the
time.
- There are many reasons why continuity of care remains unclear for older people.
The best is to give it in written and in addition, go through together with older people before he/she is leaving the emergency
- There are so many other people and professionals connected with older peoples´care that continuity of care is hard to ensure. Patient him/herself, family members, home care, other professionals etc. Very important is the communication in the emergency team to avoid the information disconnects, especially with doctors and nurses who are taking care of the older people. Teamwork is very important in the emergency duty. And the communication with older people’s family members.
- We haven´t any common protocol for discharge but I try to speak with older people clearly and advice what is the continuity of care
- I think that disharge is on doctors´ responsibility
f
Figure 22. Missed telling the continuity of care of older people by nursing staff (N=59).
In the end of the items (5) and its´ options (10) there were a place for a free comment.
This possibility was used over twenty times, twenty-four (24) comments were given.
Three (3) of those were opposite of items like ”Signs of depression never leaves unnoticed” or “I evaluate the older peoples ADLs capacity with open text in the patient records”. The rest nineteen (21) were more detailed explanations for the missed care or completing the chosen options like: ”There are so many other people and
professionals connected with older peoples´care that continuity of care is hard to ensure.
Patient him/herself, family members, home care, other professionals etc. Very important is the communication in the emergency team to avoid the information disconnects, especially with doctors and nurses who are taking care of the older people. Teamwork is very
important in the emergency duty. And the communication with older people’s family members” or “It is too busy all the time “or completing the option “other reason” like
“Sometimes older people themselves refuse the evaluation of signs of memory disorders or from functional assessment”.