In the first study phase the older people at the ED were aged 70 to 97 years old and more than two-thirds were women (68%). Most participants reported that they had full responsibility for their own medication management. Participants reported more diagnosed illnesses and prescribed medicines, especially for mental illnesses and
0 5 10 15 20 25
insomnia than were mentioned in their medical records. Seven per cent of them suffered from serious or mild depression. Anxiety about falls was common. The ADL assessment results varied among the eight domains: 45% to 89% of the participants had an independent IADL status in each domain. The need for assistance was found in every domain but varied markedly from one domain to the other, 6% to 34%. Self-assessments of “unable” were also found for each section’s ADL status in each domain. One fourth (25%) of the participants received help from community services and nearly the same proportion employed private help and paid for the service themselves. Over half of the participants’ last healthcare visit was within a month (17% within a week; 13% within two weeks; and 23% within a month). The most common reason for an acute hospital visit was a physician´s referral (53%). The results in this study suggest gaps in clinical practice that warrant the attention from health care professionals (Figure 23).
The study’s results suggest that there are challenges and a need to support older people’s self-medication management, mental status and ADLs. Also, the continuity of older peoples´ care weren´t completely clear according to older people themselves and the patients´ records. However, this indicates that home-dwelling older people have the capabilities to cope and handle complicated situations, like multimedications. Systematic assessment protocols can be used to evaluate when, for example, older people’s ADLs, or orientation in emergency nursing were weak or unclear. The documentation regarding nursing in the participants’ medical records was minor. (Figure 23).
Figure 23. Summary of the study´s results
Because of first study phase results and the literature review suggestions more information about older peoples´ emergency nursing care related to study topics were needed. Researchers background in the head of social welfare and health care services, experience and knowledge, strengthened that need. In the second study phase the questionnaire (3/2019) to nurse managers in the Emergency departments (7 asked/5 answers) revealed that measures for assessing older people’s self-management of medication, signs of memory disorders and signs of depression, and fuctional assessment were very rare or missing. Finally, a structured questionnaire (2/2020) to nursing staff (N=185/ n=59) working in the primary emergency duty and primary care revealed many structural and individual factors in nursing care leading to missed care concerning study topics.
Most of the structured factors contributing to missed nursing care were connected to resources, labour resources and material resources. Also, teamwork and the communication as a structural factor among the patient and the patient care team members, between nurses and physicians, and between the nurses and support personnel and the family of older peoples´ were mentioned many times. If communication defective, or missing it, is leading to missed nursing care.
Competence level, including the education and experience of nursing staff and lack of adequate measurements and processess were the most common missing resources related to labour and material resources.
Older people in emergency department
The quality of nursing documentation was weak and not focused on the questions of study interest
Self-medication management
Mental status Continuity of care processes
were insufficient and partly unclear.
Experienced challenges and/or needs
for support in every domain
ADL/
IADL
The individual factors contributing to missed nursing care were mostly connected to the nurse´s judgement about the importance of assessment of older people’s self-medication management, signs of memory disorders, or signs of depression and functional assessment. It seems that assessment or evaluation weren’t important if it was not the reason for coming to the emergency duty or primary care. Nurses also believed, had an attidude, that they would notice if older people have problems or decline with study interest, without any assessment, and the assessments weren’t needed.
Older people’s continuity of care and missing instructions about it, nurses thought to be related to lack of communication between emergency team members, especially between nurses and doctors who are taking care of the older people. Communication with older people’s family and other personnel were also mentioned. Other structural factors were also mentioned like missing instructions and unusable forms.
Only one of the answeres thought that it is on other health care workers responsibility.
The participants (nursing staff) were busy, because of lack of time they priorised other responsibilities instead of assessment of older people’s self-medication management, signs of memory disorders and signs of depression, functional assessment and reporting the continuity of care. There are many reasons behind the feelings of business and lack of time, structural and individual factors, contributing to missed nursing care. Those factors behind the feelings of business should be identified.
In the structured questionnaire nursing staff reported many kinds of structural and individual factors which lead to missed nursing care connected to older people’s emergency care and the study topics (Figure 24). Management is also one important factor behind the missed care, it seems that demand for care (assessment of older people’s self-medication management, signs of memory disorders, signs of depression, functional assessment, continuity of care) in the emergency duty, or primary care weren’t clear enough to be priorised in nursing care.
Figure 24. Factors contributing to missed nursing care of older people’s assessment of self-medication management, identification of signs of memory disorders and signs of depression, assessment of ADL and provision of instructions regarding continuity of care.
Individual and structural factors that lead to missed nursing care
6 DISCUSSION
This study was made in two phases. In the first phase of study a patient-oriented approach was used in which older people themselves were asked about their self-medication management, social activity, mental status and use of health-care services. It is a challenge for care continuity to empower older people and recognize these common threats to their ability to manage at home on their own. There has been an increase in the literature over the past ten years that promotes patient involvement in health care at all levels of the decision-making process. This study suggests that the involvement of older people in their emergency care, or nursing, has not yet been clearly clarified. More research and more support by nurses and other healthcare professionals is needed to develop the competencies required to facilitate greater participation by older people in their care.
In the second phase of the study nurse managers and nursing staffs’ views about the study´s interest was under clarification. Missed nursing care is a seldom studied topic with older peoples´ nursing or with emergency nursing and this study brings new knowledge about the phenomena.
The researcher’s interest was in home-dwelling older people and nursing in acute care settings. The research topics were common challenges for older people (medication management, orientation, ADLs, continuity of care) because of their importance to both older people themselves (continuity, living at home) and to the acute care, nurses who need to become familiar with older patients´ needs and identify the gaps in the care provided to them. Identification of missed care is important because it can be prevented. This point of view of the study is also connected with the bigger picture of active and healthy aging and good health and functional capacity of older people. For example, the latest form of the National Framework for High Quality Services for Older People (2017), highlights themes connected to study interests like guaranteeing the functional capacity of older people, arranging service counselling for clients, the personnel performing the services, the structure of the age-friendly services, and technology (Ministry of Social Affairs and Health in Finland, 2017).
The results strengthen many of the evidence-based and well known issues connected with these research topics, but they also give new information and raise new questions. This study’s patient oriented data were collected over a year (18 months) in 2004 to 2005 by interviewing older people and reviewing medical records. More data was collected via e-mail questionnaire (2019) to nurse managers in the Emergency departments and finally, from nursinf staff (2020) working in the primary emergency duty and primary care. The challenges concerning the study interest remain today, unfortunately, according to the literature review, other recent study
results and this study’s result. The challenge for continuity of care is to provide clinically advanced nursing in acute care settings and to optimize care for older people to ensure they can function when they return home after an emergency visit.