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, occurs in even up to 80% of patients in intensive care units. According to studies it was also a common, life-threatening clinical syndrome in general hospitals among older people and persons who are 65 years and above (Girard, 2008). It seemed that symptoms of depression present in older people can be masked, for example, by a
somatic symptom and are difficult to recognize (Rice et al., 2011). Symptoms of depression were more frequent in older people with chronic diseases compared to older people without comorbidity. They were also connected with self-harm behaviour (Almeida et al., 2012) and return visits to acute care settings. Studies also suggest that loneliness is a major issue affecting older people’s quality of life. Older people's loneliness was also associated with impaired health (e.g., Peerenboom et al., 2015), increased use of health and social services (e.g., Taube et al., 2015) and increased mortality (e.g., Routasalo et al., 2009). According to the literature review, assessments of the mental status of older people in emergency nursing are infrequently studied (Figure 11).
There is a very widely shared, multiprofessional opinion that functional assessments are critical when caring for older people. Studies showed that an unmet need regarding the performance of ADLs is associated with the increased use of urgent health services by older people (Wang et al., 2016). Little is known about the systematic functional assessment protocols used in older people’s nursing in emergency departments (Figure 11).
Furthermore, according to this study’s literature review, challenges connected with the study’s questions have been topics of constant conversation between 2006 and 2020. These are critical questions for older people themselves and for their ability to continue living in their own home. Older people’s own involvement, for example, as an informant, in nursing studies is minor (Figure 10). There is also a lack of studies concerning older people's emergency nursing. Missed nursing care is a seldom studied topic with older peoples´ nursing or with emergency nursing. The literature review suggests that there are challenges and unknown details surrounding these study questions in the nursing sciences: older people’s self-medication management, the mental status of older people in accident and emergency settings, home-dwelling older people’s ADLs, the assessment protocols used in nursing, and acute care and/or emergency department nursing.
Figure 11. Knowledge gaps
Older people in Emergency department
Continuity of care Self-medication management
Systematic assessments in emergency nursing
Mental status Loneliness Activities
of daily living Involvement or
participation in nursing processes
3 AIMS AND RESEARCH QUESTIONS OF THE STUDY
The aim of the study was to investigate self-medication management, mental status such as symptoms of depression and memory disorders, the ability to self-manage ADLs at home and continuity of care among older people aged 70 years and above who had lived at home before an emergency department visit and returned home immediately after the emergency department visit. The purpose was to identify and examine factors in nursing carried out in emergency department, primary emergency duty or primary care, which lead to omission of certain aspects of required patient care in the care of older people. The study was carried out in two phases.
The research questions were:
Phase 1: Older people in emergency department 1. How do older people use acute care and why?
2. What kind of illnesses and medications do older people have, and how do they managed their own medication?
3. What symptoms of depression do older people have and what are the influencing factors?
4. What levels of memory disorders do older people have and what factors are influencing them?
5. How do older people self-manage their ADLs at home?
6. What is the situation of older people´s follow up after an emergency department visit?
Phase 2: Nurse managers in the emergency departments
1. What kind of systematic methods are in place in the emergency department regarding cases involving older people (70 years and older).
1.1 To confirm the success of patient’s self-management of medication?
1.2 To confirm the patient’s mental status or orientation?
1.3 To measure the patient’s functional capacity of daily living?
Phase 2: Nursing staff in primary emergency duty and primary care
1. Which individual and structural factors in emergency duty and primary care contribute to creating a situation where, in the care of older people (70-year-old and older),
1.1 Self-medication management is not assessed?
1.2 Signs of memory disorders are missed?
1.3 Symptoms of depression are missed?
1.4 ADLs- capacity is not assessed?
1.5 The patient does not receive instructions regarding continuity of care?