ACUTE GERIATRIC EMERGENCY WARD AKKUNA : Educational brochure for the family members involved in the care path of patients admitted into AKKUNA.

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ACUTE GERIATRIC EMERGENCY WARD AKKUNA

Educational brochure for the family members involved in the care path of patients admitted into AKKUNA.

LAHTI UNIVERSITY OF APPLIED SCIENCES LTD

Bachelor of Health Care Degree programme in Nursing Anna Smirnova

Balazs Fleischhauer

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Abstract

Authors

Smirnova, Anna Fleischhauer, Balazs

Type of publication Bachelor’s thesis

Published Spring 2020 Number of pages

44 Title of publication

Acute geriatric emergency ward AKKUNA

Educational brochure for the family members involved in the care path of patients admitted into AKKUNA.

Name of Degree

Bachelor of Health Care Abstract

Ageing is progressively affecting populations around the world. Global increase in elderly population is affecting the demand for elderly health care services. The phenom- enon can also be seen in Finland, where every municipality chooses how to meet the growing demand. Acute geriatric emergency ward AKKUNA located in the Central hospital of the Päijät-Häme region is one of the facilities aimed at providing its elderly residents with inpatient health care services.

The purpose of this practice-based thesis is to produce an informative brochure aimed at educating the relatives of the patients admitted to AKKUNA regarding the specifics of its work, as family plays an important role in the life of an elder.

The goal of the thesis is to establish a better communication line between the patient’s relatives and the staff of AKKUNA.

The theoretical part of the thesis focuses on the topic of geriatric medicine, gerontological nursing, elderly population in Finland, units specializing in geriatrics in Finland and family’s role in elderly care. The educational brochure created as a part of this thesis is based on both the theoretical part of the thesis and the authors’ practical knowledge gained from working at the ward of AKKUNA.

The brochure will be available for use of the patients and health care professionals of the Acute geriatric emergency ward AKKUNA in the Central hospital of the Päijät- Häme region. The brochure is to be available in English, Finnish and Russian languages.

Keywords

Geriatrics, gerontological nursing, elderly, elderly care, Acute geriatric emergency ward, AKKUNA

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Tiivistelmä

Kirjoittajat Smirnova, Anna Fleischhauer, Balazs

Julkaisun tyyppi Opinnäytetyö

Julkaistu Spring 2020 Sivumäärä

44 Julkaisun otsikko

Akuuttigeriatrian päivystysosasto AKKUNA

Osastoesite AKKUNA:n potilaiden hoitopolkuun osallistuville omaisille

Tutkinto

Sosiaali- ja terveysalan ammattikorkeakoulututkinto Tiivistelmä

Väestön vanheneminen on vaikuttavaaympäri maailmaa. Vanhusväestön maailmanlaajuinen kasvu vaikuttaa ikääntyneiden terveydenhuoltopalveluiden tarpeeseen. Ilmiö näkyy myös Suomessa, missä kunnat vastaavat terveydenhuollon järjestämisestä. Päijät-Hämeen keskussairaalassa sijaitseva Akuuttigeriatrian päivystysosasto AKKUNA on yksi tavoista, jonka tarkoituksena on tarjota sairaalahoidon palveluita ikääntyvälle väestölle.

Tämän toiminnallisen opinnäytetyön tarkoituksena on tuottaa osastoesite AKKUNA:n potilaiden hoitopolkuun osallistuville omaisille, jotta heillä on käsitys osaston

toiminnasta. Omaisten osallistuminen vanhuksen elämään on tärkeää.

Tämän opinnäytetyön tavoitteena on vahvistaa viestintäyhteyttä potilaiden omaisten ja AKKUNA:n henkilöstön välillä.

Opinnäytetyön teoreettinen osa keskittyy geriatriseen lääketieteeseen, gerontologisen hoitotyöhön, vanhusten väestöön Suomessa, geriatriaan erikoistuneisiin yksiköihin Suomessa ja perheen rooliin vanhusten hoidossa. Opinnäytetyön yhteydessä tehty osastoesite perustuu sekä opinnäytetyön teoreettiseen osaan, että AKKUNA:ssa työskennelleen työmme jäsenen käytännön tietoihin.

Tämä opas tulee potilaiden ja terveydenhuollon ammattilaisten saataville Päijät- Hämeen keskussairaalan Akuuttigeriatrian päivystysosastolle. Osastoesite on saatavilla englannin, suomen ja venäjän kielillä.

Asiasanat

Geriatria, gerontologinen hoitotyö, vanhukset, vanhustenhoito, Akuuttigeriatrian päivystysosasto, AKKUNA

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1 INTRODUCTION ...1

2 GERIATRICS ...3

2.1 Definition of geriatrics in the health care settings ...3

2.2 Gerontological nursing ...3

2.3 Effects of ageing ...4

2.4 Assessment methods used in geriatric medicine ...5

2.4.1 Comprehensive geriatric assessment ...5

3 ELDERLY IN FINALND ...8

3.1 Service entitlements ...8

3.2 Service availability ...9

3.2.1 Service availability in the region of Päijät-Häme ...9

4 UNITS SPECIALIZED IN GERIATRICS ...11

4.1 Acute geriatric emergency ward ...11

4.1.1 Common causes of hospitalizations amongst elderly at AKKUNA ...12

4.2 Examples of other specialized in geriatric medicine heath care units across Finland ...13

4.2.1 Tampere, Pirkanmaa ...13

4.2.2 Turku, Varsinais-Suomi...13

4.2.3 Vantaa, Uusimaa ...14

5 FAMILY’S INVOLVEMENT ...15

5.1 Family’s role in life of an elder ...15

5.2 Family’s role in the care path of an elder...15

6 PURPOSE AND GOAL OF THE THESIS ...17

6.1 Practice-based thesis...17

7 FINAL PRODUCT OF THE THESIS ...19

7.1 Creating quality guideline ...19

7.2 Guideline and its contents ...19

7.3 Evaluation and feedback ...20

8 THESIS PROCESS ...22

8.1 Schedule and implementation ...22

8.2 Information search ...22

9 DISCUSSION ...24

9.1 Discussion in regard to the thesis ...24

9.2 Discussion in regard to the educational brochure ...25

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9.4 Ethical considerations ...26

9.5 Implications for further studies ...26

LIST OF REFERENCES ...27

APPENDICES ...33

Appendix 1 Brochure in English ...33

Appendix 2 Brochure in Finnish ...34

Appendix 3 Brochure in Russian ...35

Appendix 4 Evaluation form ...36

Appendix 5 Research permission ...37

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1 INTRODUCTION

At the beginning of the year of 2019, the National Institute for health and welfare of Fin- land, has reported that at this point in history the need of the home care services offered for elderly has been the greatest of all time. As the need of extra services has increased, the demand for comprehensive assessment of services and meeting the needs of elderly have grown respectively. However, the actual availability of specialized expertise has declined since 2016. More expertise in gerontological social work is needed. (THL 2019a;

THL 2019b.)

Naturally, there has also been an increase in the rate of the visits of the Emergency department amongst elderly in the last couple decades. Multiple sources support the idea that older patients at higher risk getting hospitalized and do require more resources. Some elderly end up visiting the Emergency departments on frequent basis, even though it would be more beneficial for them to seek help outside of the Emergency department (other local health care facilities), resulting in unnecessary overcrowding of the emergency departments. In order to bring a change into the vicious circle of unnecessary frequent visits to the Emergency department, it is essential to bring an improvement into the continuity of care. When it comes to elderly, establishment of some sort of assessment system for the ones being at greater risk of visiting the Emergency department and proper evaluation of the fragile individuals should be addressed in order to bring a change. (Legramante, Morciano, Lucaroni, Gilardi, Caredda, Pesaresi, Coscia, Orlando, Brandi, Giovagnoli, Di Lecce, Visconti & Palombi 2016; Ukkonen 2019.)

According to the Constitution of Finland, it is the responsibility of the state to provide its residents with the access to adequate social and health services as well as to promote the health of the population (Suomen perustuslaki 731/1999, 19 §). It is up to an individual’s home region to provide him or her with specialized health care (Erikoissairaanhoitolaki, 3

§). In compliance with the aforementioned laws, the region of the Päijät-Häme offers various outpatient and inpatient health care services aimed at the improvement of the well- being of the elderly population (PHHYKY 2019b, PHHYKY 2019c).

The ward named Acute geriatric emergency ward (in Finnish: Akuuttigeriatrian päivystyso- sasto), also known as AKKUNA, is situated in the Päijät-Häme central hospital is one of the means of meeting the growing demand of various health care services for elderly. As the ward belongs to the specialized medical care and bears a combination of uncommonly used words in daily language, there tends to be confusion as of what the ward is specialized in. Additionally, there is hardly any information available on the specifics of the unit in question on the internet. Due to the beforementioned lack of general knowledge, it has

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been requested by the management of the Acute geriatric emergency ward for a give- away explanatory brochure that can be used as a guideline primarily aimed at educating the patient’s relatives regarding the specifics of the unit, as relatives play an important role in the care process of an elderly (Larivaara, Lindroos, Heikkilä & Aaltonen 2009, 183). As the concept of multilingualism is growing in Finland (Pyykkö 2017, 110-111), it has been also requested that the brochure would be available in the following commonly used in Finland languages: Finnish, English and Russian. The thesis itself is to provide information on the elderly health care services in Finland and work behind the Acute geriatric emergency ward. Additionally, it will be looked into the concepts behind geriatric medicine and the importance of the family’s involvement in an elder’s life. It will also be elaborated based on what criteria the final product of the thesis, meaning the guideline, has been created. The final product is to be evaluated by the health care staff working at the ward of AKKUNA before being put in use.

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2 GERIATRICS

Populations all around the globe are ageing in a rapid manner, which can be seen as both a challenge and an opportunity. The demand for both primary and specialized elderly care along with long-term care facilities increases along with the need for trained workforce.

The demand has been acknowledged in Finland, where one of the Europe’s oldest population resides. As the elderly population increases, it is essential to ensure availability of the services corresponding with the client needs. (THL 2019e; THL 2019f; WHO 2019a.) Most of the medical specialties concentrate on short-lived, infectious or ‘single-organ’ conditions that tend to affect younger population. However, with the change of the structure and needs of the general population, the concept of geriatric medicine has been discovered and defined in the United Kingdom in the 1940s, demonstrating the benefits of specialized and skilled assessment of elderly patients both to those very patients and to hos- pitals. During present days, geriatric medicine has proven to be beneficial to general, acute and other specialized medical fields. (Oliver, Burns 2016.)

2.1 Definition of geriatrics in the health care settings

The term “geriatric” is used when referring to elderly, specifically with regard to their healthcare (Hornby & Wehmeier 2001, 536). In most of the developed countries the stage at which an individual is considered to be an elder is at the chronological age of 65 years.

Depending on, for example an organization or geographical location, the definition and age limits may vary. In reality, however, geriatric medicine is not always limited to one’s chronological age. (WHO 2002; Blundell & Gordon 2015, 3.)

When it comes to health care, geriatric medicine is defined as a medical specialty that tar- gets those physical, mental, functional and social conditions which are diagnosed in elderly patients' acute and chronic illnesses, rehabilitation, prevention and terminal care (Tilvis 1999; Blundell & Gordon 2015, 3). As a result of changes occurring in one’s body when aging (bone fragility, multimorbidity, decrease in functionality in various systems of the human body, frailty) (Kortebein & Means 2013 1-25) and with regards to the elderly patients’ complexity, a geriatric patient requires a comprehensive assessment (Holroyd- Leduc & Reddy 2012, 1).

2.2 Gerontological nursing

According to the Canadian Gerontological Nursing Association (2010), gerontological nursing can be defined as a dynamic relationship between nurse and elderly client aimed

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at promoting health and wellbeing. Special attention is paid to clients’ own unique experiences, personal knowledge and understanding of themselves. In that interaction nurses contribute with their knowledge of gerontology and geriatrics along with the nursing skills and expertise. Gerontological nurses support clients in maintaining their well-being holistically by continuously assessing and managing physiological care in order to minimize ad- verse events correlated with, for example, polypharmacy, diagnostic or therapeutic proce- dures, or environmental factors. (Canadian Gerontological Nursing Association 2010, 6- 13.)

Gerontological care should, however, be considered as holistic complex that cannot be unambiguously defined and should be continuously used when practicing nursing care for elderly. Nurses specialized in this field are required to have theoretical knowledge related to the homeostatic needs of elderly. The ability to work in multidisciplinary teams of health care professionals in various environments and situations is essential. Interaction skills are therefore emphasized in gerontological nursing. Relationship-centered approach acknowledges the importance of each health care participant’s intertwined relationship.

The approach supports the provision of quality care, quality work environment, and overall high organizational performance. (Canadian Gerontological Nursing Association 2010, 11- 13; Tarhonen 2013, 4-7.)

2.3 Effects of ageing

The process of ageing is defined by impairment of individual’s physiological function while advancing with time and resulting in heightened susceptibility to disease and mortality.

Ageing can be classified as follows: chronological (years lived since birth), biological (physical changes experienced), psychological (cognitive processes experienced), and social ageing (experienced roles within society). All of the organs and systems of a human body are affected by ageing in one way or another: body fat and water composition, bone and muscle mass reduction, changes in the functions of immune, cardiovascular, gastrointestinal, endocrinal, pulmonary and renal systems, postural, visual and auditory percep- tions. The mentioned changes subsequently increase risks of getting ill or suffering an in- jury. Older people are additionally prone to become frail, which is a combination of decreased ability of performing daily tasks due to lack or decrease of factors such as, for example, strength and endurance, making an individual affected more prone towards developing dependency and/or death. Frailty closely correlates with increased age, disease and disability but is, however, a separate concept. (Blundell & Gordon 2015, 7-11.)

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2.4 Assessment methods used in geriatric medicine

Medical assessment of a geriatric patient is essentially similar to the assessment of any other adult patient, as it involves gathering one’s medical history, performing the needed examination, analyzing the problem list and creating the management plan. However, with elderly patients the medical history alone might be very time consuming and difficult due to the factors, such as multiple, sometimes unspecific symptoms, various existing co-mor- bidities, polypharmacy with possible side-effects, sensory and cognitive impairments, social and environmental settings. As a result, careful history-taking is essential. Collateral information gathering should also be considered by looking into the patient’s previous medical records and, if appropriate, involving family members or the caregivers into the process. The understanding of the patient’s current social lie is important to know as the social support structures have a greater impact on an elder’s life and functional abilities.

The medication history is worth looking into, as in case of polypharmacy, the routine use of five or more medications (WHO 2019b, 11), the potential side-effects might be harmful.

(Blundell & Gordon 2015, 3.)

Physical examination of an older patient also is required to be more thorough compared to the ones performed to adults. A rather detailed general examination is required when observing non-specific presentations. Various assessment tools can be used to achieve that:

cognitive assessment (Confusion assessment method -CAM, Mini-mental state examination - MMSE, Geriatric depression scale - GDS, Abbreviated mental test – AMT, Six-Item Screener - SIS), nutritional assessment (Malnutrition universal screening tool - MUST, Mini-nutritional assessment - MNA, Body mass index - BMI) sensory assessment (visual acuity, otoscopy), musculoskeletal and gait assessment (physical examination), pressure area inspection (Braden tool, physical examination), postural blood pressure measure- ment. Whether a problem or multiple have been established, it should be dealt with by a management plan containing clearly defined goals. Comprehensive Geriatric Assessment (CGA) is part of that process. (Blundell & Gordon 2015, 3, 22-23, 34-37, 54-57.)

2.4.1 Comprehensive geriatric assessment

One of the examples of models used in order to holistically assess an older person is a Comprehensive geriatric assessment (CGA). CGA is an interdisciplinary (involves multiple health care professionals’ input) and multidimensional (accounts for issues outside the diagnosed underlying condition) tool that provides health care professionals with a problem lists and therefore is aimed at developing goal-driven interventions to tackle identified issues. (Welsh, Gordon & Gladman 2014.)

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CGA’s main domains are: physical health, mental health, functional ability, social circumstances, environmental factors. When looking into a geriatric patient’s physical health it is essential to focus not only on the symptoms that the patient is presented with but also to look into comorbidity factors, previously undiagnosed conditions, medication review with possible side effects, nutritional (MUST, MNA, BMI) and frailty statuses (musculoskeletal and gait assessment) compromising one’s daily-life performances. Mental health factors are to be assessed by checking up on the individual’s cognition and mental capacity (CAM, MMSE, AMT, SIS), mood/anxiety and fears (GDS). An individual’s functional capability can be assessed by observing whether one is mobile with or without aid, whether the posture is well-balanced and whether the individual is restricted from participating in any activities due to physical limitations. Additionally, functional capability can be assessed by the tool named Activities of Daily Living (ADLs). ADLs can be divided into Basic Activities of Daily Living (BADLs) and Instrumental Activities of Daily Living (IADLs) (Holroyd-Leduc

& Reddy 2012, 4). BADLs are aimed at getting an insight of an individual’s capability of performing daily basic tasks of self-maintenance (dressing, bathing, toileting, eating, conti- nence indoors mobility), IADLs therefore refer to the activities correlated to one’s inde- pendence within the community (finance management, medication management, shop- ping, housekeeping, meal preparation, and means transportation) (Holroyd-Leduc &

Reddy 2012, 4-6). Insight into one’s social circumstances can be gained by learning whether the patient has any formal (home care, trustee) or informal (family, friends, private-sector services) caretakers. Environmental circumstances relate to one’s housing conditions and its safety, aiding equipment and service availability, transportation possibil- ities. (Blundell & Gordon 2015, 12-13.)

While being a multidimensional, as mentioned in the previous paragraph, tool, CGA is also an interdisciplinary tool, meaning that it involves multiple health care professionals’

assessments. In the settings of a health care facility where interdisciplinary approach can be used the following health care professionals can be involved (not necessarily simultaneously and some only upon the need): doctor/geriatrician or another specialized doctor if needed, nurse, physiotherapist, pharmacist, gerontologist, social worker, specialized in other medical fields professionals. While every health care professional can only make an input within his or her own area of specialization, the idea is to benefit from all the gathered data by sharing it openly and using it for the benefit of the patient. Within the multidisciplinary team, nurses frequently spend the most time with the patient, making them a logical team-leader. CGA can be performed in outpatient health care settings as well.

(Welsh, Gordon & Gladman 2014; Blundell & Gordon 2015, 12-13; PHHYKY 2019a.)

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CGA is not limited to assessment only. After the completion of the initial assessment, the list of determined health issues and vulnerabilities the patient experiences are being made, after which the management plan and overall goals are established and put into ac- tion. (Blundell & Gordon 2015, 12-13.)

Comprehensive geriatric assessment has proven to be a reliable assessment method when it comes to geriatric medicine (Cochrane 2017). One of the first models of CGA has been put in use in the city of Hastings, England the 1960s (Devas 1974) and now it is being used and accepted internationally (Cochrane 2017). The CGA module is also used amongst Finnish geriatricians with their own alterations (Kerminen 2016).

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3 ELDERLY IN FINALND 3.1 Service entitlements

Until the year of 2013, when the Act on Support of the Functioning of the Elderly and on Social and Health Services for the Elderly has been commenced, the legal status of elderly population in Finland has been indeterminate (Mäki-Petäjä-Leinonen & Karvonen- Kälkäjä 2017, 9-10). The purpose of the act is to aid the well-being of the elderly population and promote their ability to participate in the preparation of decisions affecting their living conditions along with service development within municipalities by improving access to quality social and health services (Laki ikääntyneen väestön toimintakyvyn tukemisesta sekä iäkkäiden sosiaali- ja terveyspalveluista, 1 §).

The Act on Support of the Functioning of the Elderly offers various ways of achieving the stated goals. Every municipality has a list of obligations aimed at aiding the well-being of the aging population and providing social and health services in adequate quality along with promoting the wellbeing, health and functional capacity. Additionally, the municipality is obliged to propose a plan offering support for the aging population, to continuously evaluate the competence of the provided services, to dispense appropriate resources, to set up a council for the elderly and to provide various welfare services such as counseling. An elder person is to be provided with adequate social and health services, the need for which is assessed at the individual level and with personal views taken into account. The act states the requirements that are to be fulfilled in order for the services to be qualitative:

sufficient number of specialized staff, adequacy of the premises and the self-supervision of the operating unit and of the authorities. (Mäki-Petäjä-Leinonen & Karvonen-Kälkäjä 2017, 9-11.)

Most of the services used by elderly are not related to health care services (THL 2019c).

However, the very availability of the services outside of the health care sector has a great impact on the quality of life and health of an elder (THL 2019c). Elderly in Finland are entitled to, at least, the minimum livelihood pension (Kansaneläkelaitos 2019) and, if needed, aid devices (crutches, walker), home care services organized by the municipalities, offering the day-to-day assistance and nursing at home, public health care services are to be accessible (Laki ikääntyneen väestön toimintakyvyn tukemisesta sekä iäkkäiden sosiaali- ja terveyspalveluista, § 14-15). Additionally, every Finnish resident aged over 75 years is entitled to an assessment of service needs within 7 working days since filing the request (Sosiaalihuoltolaki 1301/2014, 36 §). The aim of such an assessment is to screen whether an older person is eligible of receiving welfare services such as home and housing

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services, family care support, institutional care by taking into account various factors:

physical, social, mental performance, resources, social network, existing benefits (PHHYKY 2019d). Timely service assessment is important as only 0-1% of people that turn 75 years old are in actual need of long-term care facilities, thus in order to decrease the need for later institutionalization home care and supporting housing must be developed timely to meet the needs of the elderly (Sosiaali- ja terveysministeriö 2017, 20).

3.2 Service availability

The cornerstone behind Finnish health policy is to provide everyone living or residing in Finland with adequate and high-quality health care services, disregarding their socio-economic background and current status, economic conditions or area of residence. The goal is not, however, always achieved. (THL 2018.)

The need for services provided at home is increasing as a result of the reform of national ageing policy and service structures aiming to enable older people to continue living at home for as long as possible, until the end of their lives (THL 2019f).

The progression with which the elderly population of Finland increases can be traced in the growth of demand of the elderly care services. The number of clients using home care services as well as the staff employed to perform the task has been increasing. However, not all the municipalities can meet the demand. During the course of the years 2016-2018, the number of clients in need of daily home care services has increased by 4,000. When asked about the adequacy of home care by those responsible of providing the service, almost one in two (46%) have responded that the demand is not being met. In addition to that, over time the clients become frailer and the number of clients in need of more demanding service is constantly increasing. Some of the home care clients visit the emergency care unit on a frequent basis. In 2018, it has been reported by the National Institute for Health and Welfare that 66,8% of the home care units around Mainland Finland have the possibility of offering their services during nighttime. The availability of the nursing staff per client in the round-the-clock facilities is under 0,7 workers per client in 71,7% of the facilities of Mainland Finland (the minimum rate is 0,5 workers per client within the public sector). (THL 2019b; THL 2019g.)

3.2.1 Service availability in the region of Päijät-Häme

In the year of 2017 10,6% of the population of the region of Päijät-Häme was aged 75 or more, while the average percentage across Finland was 9,1%. The need for services increases due to the aging population, causing a significant lack of sustainability. Aging rate

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at the region of Päijät-Häme is high (between the years of 2018 and 2040 the number of people aged over 75 and 85 years will increase by 76% and 148% respectively). The dependency ratio is currently the highest in Päijät-Häme, comparing to the rest of the country. Most of the Päijät-Häme elderly reside in the city of Lahti. (Olkkonen-Nikula 2018, 11- 18.)

Functional capacity of the elderly population in Päijät-Häme is on the same level with the country’s average, thus, the need for services for the population is medium. The biggest concerns in the area are loneliness, feeling insecure, moderate to severe memory illness, substance abuse and mental health problems. (Olkkonen-Nikula 2018, 19-26.)

Across Finland, slightly less than 90% of the people aged over 75 reside either at home without regular home care or with home care services, Lahti being one of the cities with the most people living at home (Linna, Mikkola, Peltokorpi & Tyni 2016, 32-33). 17,5% of the aged over 75 years population of Päijät-Häme are regularly using elderly care services (home care, 24-hour facility care, family or formal care) (Olkkonen-Nikula 2018, 27-28).

According to the Act on Support of the Functioning of the Elderly and on Social and Health Services for the Elderly, the municipality shall provide counseling services in support of the well-being, health, functional capacity and independent living of the elderly (Laki ikääntyneen väestön toimintakyvyn tukemisesta sekä iäkkäiden sosiaali- ja terveyspalveluista, 12 §). In Päijät-Häme, Palvelu-Santra provides the region’s population with guid- ance regarding the availability of both private-sector and public services. If the client's situation in the initial survey is demanding, the client's matter is referred to the client counselor. Contact can be anonymous and the customer's information is not recorded, if wished.

When the situation requires, the client supervisor/counselor makes a home visit to the client, where the service needs are assessed and based on that a service plan is drawn.

Customer counseling is responsible for organizing the services, their coordination and provision of interdisciplinary consultation if required. (Olkkonen-Nikula 2018, 36-39.) Evaluation, follow-up and rehabilitation health care facilities are available. Existing hospital network capacity is evaluated to be sufficient. The Acute geriatric emergency ward AK- KUNA unit operates in conjunction with the Päijät-Häme Central Hospital, which carries out a comprehensive geriatric assessment of elderly patients arriving to the hospital via the Emergency department. In addition, patients can be referred to the Emergency ward for the follow-up care. So-called “Home hospital” operates in collaboration with the Emer- gency department providing hospital care is at the patient's home, which can also be a nursing home. Treatment is always temporary and of short duration and is aimed at re- placing inpatient care. (Olkkonen-Nikula 2018, 52-57.)

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4 UNITS SPECIALIZED IN GERIATRICS 4.1 Acute geriatric emergency ward

The Acute geriatric emergency ward (later mentioned either by this name or as “AK- KUNA”) is situated in the Central hospital of the Päijät-Häme region. The ward is specialized in treating those residents of the region that are over 70 years old and need immedi- ate hospitalization and round-the-clock monitoring (PHHYKY 2019a). Additionally, pre- and post-operative care of hip fracture patients aged over 70 is offered, the number of hip fracture patients taken care at the ward simultaneously is limited to 4 out of the 10 patient- placements available (as per Autumn of 2019). Patients arrive to AKKUNA via the Emer- gency department of the Päijät-Häme Central hospital, in case if after being assessed in the Emergency department they cannot be discharged home (for example in case of an acute infection, acute delirium, heart failure, general condition deterioration). Before admitting a potential patient to AKKUNA, the staff of the Emergency department also evalu- ates the patient's age (over 70 years old), lifestyle, ability to function (rate at which for, example, home care services are used), and baseline disease status in order to gain an insight whether AKKUNA is the right place for the patient in question to receive treatment (PHHYKY 2019a). Along with treating the condition diagnosed at the emergency room or diagnosing a yet undiagnosed condition and then treating it, the idea is to screen for the elderly living in the region that would benefit from a comprehensive geriatric assessment (CGA).

While being a ward specialized in geriatrics on its own, AKKUNA is operating under the same management as the Emergency ward (not to be confused with the Emergency department). As the result of this collaboration the wards share the head and the assistant head nurses, physiotherapists, pharmacist, secretaries, maintenance workers and the discharge nurse. The aforementioned specialists are not necessarily introduced into every patient’s care paths, but rather are involved upon a request of either the patient’s own nurse or the doctor. Most of the nurses working at both AKKUNA and the Emergency ward do job rotation, meaning that they are equipped to work in both wards. Generally, the patients are divided between 3 nurses in the morning shift, 2 nurses in the evening shift and 2 during the night shift. In charge of the ward is a senior physician specialized in geriatrics, a geriatrician. Otherwise the ward does not have a permanent attending physician.

Specialized or specializing in either acute care or gerontology physicians do job rotation in the Emergency department, the Emergency ward and the Acute geriatric emergency ward. During the office hours (8:00am to 4:00pm) of the weekdays (Monday-Friday) there are two physicians (the senior physician and the attending physician) dividing their round-

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ups. During weekends and national holidays, only one attending physician is available at the ward. Outside of the attending’s working hours, a triage doctor and an on-call doctors are available. Depending on the patient’s underlying conditions or symptoms an attending physician may consult other medical field specialists, like a surgeon or internist. Further- more, services of a gerontologist, are at the disposal of the ward.

The multifaceted assessment done at the ward during a patient’s stay is aimed at improving the overall quality of life of elderly of the region, as the demand of health care services, such as nursing homes and home care, has been growing exponentially during the past few decades (THL 2019b). The ultimate goal of the comprehensive geriatric assessment is to preserve an elder's ability to live at home, possibly, with the help of home care services (Finne-Soveri 2013).

In addition to assisting patients in performing daily tasks (mobility, hygiene, nutrition, medication intake), nurses perform certain assessments that are a part of the comprehensive geriatric assessment (MNA, Audit65, orthostatic test, gathering of the background information). With the help of physiotherapists, nurses also play an important role in rehabilitation and mobilization of patients whose mobility is temporary limited (hip fracture patients, pain management patients). The average hospital-stay at the ward of AKKUNA lasts from 2 to 4 days, after which the patient is either discharged home with the help of home care services, or without those, if they are not needed or the patient’s care path continues at another follow-up care ward (PHHYKY 2019a). Upon one’s discharge from the ward, the attending physician sums up the provided care and draws up the follow-up care instruc- tions or interventions in the patient’s discharge papers. Patient’s own nurse takes care of the discharge process by organizing or coordinating the needed follow-up services.

The aforementioned information is based on the data available from the open internet sources, like the Päijät-Häme hospital’s page, as well as it is based on one of the text au- thor’s experience as a nurse at the ward in question.

4.1.1 Common causes of hospitalizations amongst elderly at AKKUNA

In 2015, the most common admission reasons for an Emergency department of Päijät- Häme, amongst individuals aged over 65 years, were general feeling of weakness/tired- ness, followed by pulmonary issues, gastrointestinal pain, chest pain and heart rhythm disorders, fever, vertigo, leg pain, urinary symptoms, paralysis. Patients are often presented with more than a single problem. The cause behind the visit could also be related to social problems, loneliness, fears and increasing alcohol use. (Hiekkanen & Orre 2015.) The city Tampere recorded over 3300 elderly patient visits throughout the years 2011-

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2012, due to the deterioration of the general state, the reason for which were more often the following conditions: indisposition, pneumonia, urinary tract infection, pyelonephritis, bladder infection, unspecified fever, heart failure, infectious gastrointestinal conditions, bronchitis and vertigo (Haapamäki, Huhtala, Löfgren, Mylläri, Seinelä, Valvanne 2014, 19- 20). Approximately half of the elderly patients attending Emergency department is discharged home, while roughly another half is hospitalized (Haapamäki et al 2014, 18-19, Hiekkanen & Orre 2015.).

As patients admitted to AKKUNA arrive via the Emergency department, the causes of their arrival to the ward corresponds with the ones mentioned in the previous paragraph. It is also common to admit elderly that have been experiencing gait issues and, as result, end up falling (without having trauma requiring surgical intervention) and are in need of rehabilitation and, if needed, pain management. Additionally, hip fracture patients’ pre- and post-operative care is one of the specialties of AKKUNA.

4.2 Examples of other specialized in geriatric medicine heath care units across Finland

Every municipality is to provide its residents with adequate specialized medical care upon the need (Erikoissairaanhoitolaki, 3 §). The following chapters describe some of the examples of units specialized in geriatric medicine across Finland. There is, however, no similar geriatric-led emergency ward that operates around the clock in Finland (Luustoliitto 2019).

4.2.1 Tampere, Pirkanmaa

Tampere University Hospital provides geriatric care in an out- and inpatient ways in the Hatanpää hospital. The Acute geriatric emergency ward V3 works in a similar manner with the Acute geriatric emergency ward AKKUNA. Geriatric patients arrive via the Emergency department and are in need of the hospital stay because of an underlying condition and for the geriatric assessment. In a form of specialized outpatient polyclinical care, in the Geriatric center geriatric and neurological illnesses and syndromes in the elderly are being looked into. A referral from a doctor, typical reason for which is suspected memory illness, impaired functioning, or need for proper memory diagnostics, is required. (PSHP 2019.)

4.2.2 Turku, Varsinais-Suomi

The Geriatric outpatient clinic of the city of Turku is intended for the local elderly people who are unable to be examined and treated at home or in a local health center, but do not, however, need emergency care. A referral to the clinic is required from a local health care

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clinic or home care worker. Interdisciplinary and multidimensional geriatric assessment is being done throughout a single day while the patient resides in the clinic. Around half of the assessed patients can be discharged home, 45% of the assessed ones is transferred to Acute care wards, 2% to rehabilitation wards and another 2% to Turku University Hos- pitals. (Turun kaupunki 2017.)

4.2.3 Vantaa, Uusimaa

Peijas Hospital, as a part of the Helsinki University Hospital, has two wards specialized in acute geriatric care, AKOS1 and AKOS2. The ward AKOS1 has the capacity of 20 placements and AKOS2 has 28 patient-placements. The wards are primary admitting elderly patients in need of either emergency assessment or short-term, not requiring specialized care, hospital stay. Typically, a newly admitted patient may suffer from acute case of confusion, general state deterioration or an infection. Patients mainly are referred to the wards via the emergency polyclinics. (Vantaa 2019.)

Additionally, the Katriinan hospital’s Ward 1, has the capacity of 25 placements and works as both geriatric assessment and rehabilitation unit. Special attention is paid to muscle strength training, balance improving and good nutrition. Outpatient care geriatric assessments are done also in the Katriinan hospital. A referral from a doctor is required. (Vantaa 2019.)

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5 FAMILY’S INVOLVEMENT

In social work, family has always been considered an important partner and a unit pos- sessing significant impact on the quality of lives of the people living together, which is par- ticularly true for the more dependent members of the family (Larivaara, Lindroos, Heikkilä 2009a; Larivaara, Lindroos, Heikkilä 2009b). Relatives are an important source of care and support for patients, especially the elderly ones (Pennbrant 2013). The availability of support from relatives can be of the similar level of importance and usability as the help of aid services (Creer, Sturt & Wykes 1982).

5.1 Family’s role in life of an elder

Involvement of family, other relatives and friends in an elder’s life, is one of the corner- stones of the well-being of an older person, as a part of staying socially active (THL 2019d).

As becoming older, an individual becomes more prone to acquiring quality of life changing somatic and mental illnesses, the treatment or management for which also becomes bur- den on both primary and specialist care. The need for a variety of life aiding tools, such as glasses, hearing aids, canes, rollators, and other mobility aids for the home, increases.

With an increase of changes and deterioration of the general ability to perform daily tasks, an elder’s reliance on his or her family members rises respectively along with the general need of help with performing daily tasks. Family members, especially the spouse and children, are the most important means of support for elderly. However, due to demographical changes occurring within modern societies (smaller families, decreased number of children, common-law marriages) and narrowing of the concept of the family the availability of support has declined significantly for many. The lesser availability of offering support for elderly is often accompanied by the fact that the children themselves may be old and have their own illnesses, or may live a busy life of their own, live far away, even abroad. (Lari- vaara et al. 2009, 177-182.)

5.2 Family’s role in the care path of an elder

In elderly care, a patient- and family-centered approach is essential for achieving quality care. When working with an elderly person it is important to gain a comprehensive insight on the individual’s situation. In the health care settings, it might often occur to be challeng- ing to interview an elderly due to many illnesses that slow down activity in one way or another or vision and hearing impairment. At the stage of planning or starting any treatment, it is also important to identify the family member who is most responsible for the patient

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and gain an insight on the situation from the caregiver’s perspective without, however, ne- glecting or impairing an elder patient’s own rights. Family history is often not as informative from the perspective of heredity, as it is from the perspective of understanding social support structures and this will include knowing which family members are involved (Blun- dell & Gordon 2015, 3). Social history is essential to building an understanding regarding arrangements for formal or informal care, functional capabilities, living circumstances and the impact of the illness on the people involved (Blundell & Gordon 2015, 3). If there is a chance of interviewing the elderly spouse, it is very helpful to meet them together, naturally respecting the patient's wish. Old couples are often very interdependent, both physi- cally and emotionally. (Larivaara et al. 2009, 170-180, 183-188.)

In practice, the co-operation with the patient’s relatives starts when an elder arrives to any health care unit’s reception with a relative involved into his or her life and with whom most of the conversation may have to take place. From the outset, it is important to establish that the communication occurring with the relative does not exclude the patient himself from the entire picture. While a family-centered approach to care for the elderly is essential, one has to bear in mind that is often the case that the elderly may not want to involve his or her members into more intimate or uncomfortable matters. Therefore, the elderly should also have the opportunity to have a discussion with a health care professional face-to-face, as it is also sometimes the case that the elderly themselves have a more re- alistic picture of their lives. (Larivaara et al. 2009, 183-188.)

In addition to providing reliable information on the quality anamnesis and participating in elderlies’ lives, relatives have also been lately heavily relied on when an elderly patient is discharged from hospital care to home care (Pennbrant 2013).

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6 PURPOSE AND GOAL OF THE THESIS

In order for the thesis to be relevant and functional, it is essential to identify its purpose and goal. A goal represents a general and long-term vision that are desired to be

achieved. Meanwhile, a purpose defines strategies to achieve the already identified goals.

(Lapin ammattikorkeakoulu 2014-2016, 5.)

The purpose of this practice-based thesis is to produce a quality guideline primary aimed at educating the relatives of the patients but also the patients themselves admitted to the Acute geriatric emergency ward regarding the specifics of its work. In theory, the availability of the guideline will benefit not only the patients and their relatives but also the nurses in the Emergency department (who often have the initial contact with the patients and sometimes their relatives) and the nurses at the Acute geriatric emergency ward that can give the hand-out guideline to the relatives coming to visit their loved ones. Thus, while the purpose of the thesis is to create a guideline, the overall goal is to establish a better communication line between the patient’s relatives and the staff of AKKUNA and units involved into its work by informing the relatives about the specifics of the work being done at the unit.

In addition to producing a guideline, the thesis itself is going to be used as a report used to justify the guideline. Information on the elderly health care services and work behind the Acute geriatric emergency ward is to be documented based on one of the thesis’ authors as well as with the use of online available evidence-based resources. In addition to those it will be elaborated based on what criteria the final product of the thesis, meaning the guideline, has been created. The thesis will be primary using information applicable to the Finnish population and services, not comparing it to the global trends.

Another goal behind the creation of the final product of this thesis is to provide the aforementioned guideline available in the following commonly used in Finland languages: Finn- ish, English and Russian, as the number of clients who are native to other than Finnish language has been increasing (Väestöliitto 2019).

6.1 Practice-based thesis

The thesis in question is a practice-based one. The idea behind such a type of thesis is to produce, for instance, an object like a poster or a booth, event such as exhibition, activity or product like a manual or guidelines and write an explanatory report along with it. As the name suggest, creation of this type of thesis is usually correlated to the working life, which

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is usually to benefit directly from the final product. In our case the target group includes not only the commissioner of the thesis, but also its clients (patients and their relatives).

Disregarding that the thesis is practice-based, its theoretical part is still essential and is not to be neglected as it is still correlated to the final product, which in this case is an educational brochure/ guideline, which is commissioner-requested. (Vilkka & Airaksinen 2003, 57-58; Vuori 2018.)

We, the authors of this thesis, have chosen to make our thesis using the practice-based framework due to its simplicity and straightforwardness.

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7 FINAL PRODUCT OF THE THESIS 7.1 Creating quality guideline

Essentially, a quality brochure that is aimed at promoting anything is to state what it has to offer in a clear manner, highlighting the benefits of the provided services with justifying the benefits and guiding the reader through essential to the topic processes (Itä-Suomen yliopisto 2011, 3). The purpose of the brochure created as a final product of this thesis is only to be explanatory, meaning that it is solely aimed at explaining the principles and corner- stones behind the work done at the ward of AKKUNA, not promoting anything. However, similarly to the brochures created for the marketing environment (Itä-Suomen yliopisto 2011, 3), the contents of the brochure in question created have been completed with taking into account the public, or customers, that is to be created for: Why do we want to approach relatives of the patients in AKKUNA? What do we want to tell them? How can the health care staff, relatives and, ultimately, patient benefit from it? How can the information be delivered in the most understandable manner?

Patient education materials are aimed at being beneficial for patients as well as health care service providers (Elsevier clinical solution 2015, 2). Education materials play an important role of keeping patients, as well as, in our case their relatives, informed of the care provided and gift an opportunity of participating in the health care process (Elsevier clinical solution 2015, 2-3).

In order for an educational brochure to be comprehensive, it is to be easily understood by the readers by including simple to understand reliable information and excluding the use of professional jargon. Design of the material is not to make the ability of the reader to comprehend information more difficult but is, on the contrary, to reinforce the material’s key messages. Written part is to be succinct, not lengthy, as well as up-to-date and reliable. Preferably, materials are to be available in multiple languages. (Harvard T.H. Chan School of public health 2010; Elsevier clinical solution 2015, 4-6.)

7.2 Guideline and its contents

Upon completing research on creating a quality guideline, the authors of this thesis have started to work on the brochure. Practical information, such as visiting hours and descrip- tion of the ward’s premises, have been based on the information publicly available at the web-site of the Central hospital of the Päijät-Häme region, as well as authors’ own

knowledge. Theoretical information used can be traced withing the theoretical parts of this thesis. A tri-fold educational brochure has been created. The layout of the brochure has been kept simple, making it visually easy to focus on the written text. The written contents

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of the brochure have been kept succinct and are based on both theoretical materials used in this thesis and practical knowledge gained from a worker’s perspective. The color- scheme has been kept black and white in regards with the fact that the brochure is most likely to be printed with a black toner. The images used are intended to make the material more appealing for the reader. Splitting pages into three parts lines have been added in order to make brochure-folding simpler. The brochure has been created with the Microsoft Office Word 2017 and fonts and settings available in it. The images used have been obtained from the Pixabay platform (https://pixabay.com/) offering royalty free photos.

The brochures have been created in three languages (English, Russian and Finnish) to make it available for people native to the mentioned languages. It is important to note that the translations have not been completed by a professional translator, thus there might be natural differences in the word-to-word translations of the texts. The core ideas and com- ponents are, however, the same.

7.3 Evaluation and feedback

Before submitting the final product of this thesis to the staff of AKKUNA, its structure and content have been proof-read by multiple people in order to gain preliminary feedback and make changes if needed. Upon the completion, brochures in various languages have also been shown to the supervising teacher.

An evaluating form engaging the staff of AKKUNA into giving our work written feedback has been created by taking into account the sources used when creating the guideline.

Prior to getting the feedback form an official permission to do so has been obtained from the Päijät-Häme Central hospital representative (Appendix 5).

Authors’ versions of brochures in Finnish, English and Russian languages have been presented to the workers of AKKUNA. The evaluating form has, however, been created in Finnish language only, the language primary used at the ward, and therefore only covers the feedback for the brochure created in Finnish language. Throughout almost two weeks of the brochures and feedback form being available at the ward, feedback from a few workers has been received. The feedback has been mostly positive in regards of the layout of the brochure and the information provided with it. Some feedback suggested that the language used in the brochure could be further simplified. A single form has been re- turned expressing disagreement with the informativeness, layout, order and language use in the brochure with remarks made within the brochure itself. It has been agreed that the workers will have time to further evaluate brochures during January 2020. Once all of the feedback is gathered, it is intended to implement the wanted changes into the brochures.

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Therefore, the versions of brochures attached to this thesis (Appendix 1-4) may be modi- fied in accordance with the wishes of the ward’s personnel.

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8 THESIS PROCESS

8.1 Schedule and implementation

The thesis in question along with its final product have been completed in a group of two students. The idea of working on a thesis as such, with it resulting in a creation of an explanatory guideline that can be used in the working field, has been planned along with completion of the courses preparing for the thesis writing during the academic year of 2018-2019. Due to versatility of the interests of both authors of this work, starting with the beginning of 2019 multiple wards’ and clinics’ situated in the city of Lahti management nurses have been contacted and asked whether there would be a need for a guideline of any sort with an emphasis of there being a possibility of having the guideline translated into multiple languages. As a result, during the summer of 2019 the management of the ward of AKKUNA has responded to the offer positively and now the work in question is being done. Therefore, for the commissioner for this thesis project is the management of the Acute geriatric emergency ward. The application for the thesis process has been sent in the beginning of the autumn 2019. After a supervisor’s name has been revealed to the authors of the thesis, a meeting with one of the authors of the thesis and the supervisor in question has been held. Upon agreeing on the common rules of working on this project, the thesis plan has been started to be worked on in autumn 2019. Once the thesis plan has been reviewed and approved by the supervisor, the work on the actual thesis took place, along with which the finalization of the guideline itself has been started as well. As one of the authors, works at the ward for which the guideline is to be created, the insight of the needs of the ward in question is gathered naturally. In addition, in October 2019 during one of the weekly staff meetings, it has been announced to the workers of the Acute geriatric emergency ward by the head nurse that a guideline for relatives is to be made. The staff has been given an opportunity to write down their wishes for the guidelines to be made, as they are the ones primary benefiting from it upon the completion of this work. As the guideline’s layout and contents are created, it is planned to have the staff review the work. In case if the work has flaws, it would be corrected until before its final completion. The final work is to be given out to the ward’s management in both printed and e-versions to put to use.

8.2 Information search

In order to scientifically support the ideas presented in the thesis, various evidence-based sources (e-books), databases (Ebsco) and scientific medical journals (Duodecim) accessed via Masto-Finna, the national digital library portal have been used. Whether an

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article or an e-book, the key words when searching for reliable information via Masto- Finna have been related to the topic of geriatrics (in English: geriatrics, elderly, in Finnish:

geriatria, vanhus, ikäihmiset) and cognates to these. For example, when searching for a source combining multifaceted materials on the topic of geriatric, the word “geriatrics” has been used, resulting in 221 matches. However, out of the acquired list of resources, 136 pieces were books, out of which 83 were e-books. Out of the 83 sources available almost half was published over a decade ago. Out of the 43 e-books left to gather information from, some were not related to the topic of the thesis, so they were not used. As a result, from this search the sources as “Evidence-Based Geriatric Medicine” (2012) by Holroyd- Leduc and Reddy and “Geriatrics” (2013) by Means and Kortebein have been picked. If a topic of the search is to be narrowed down, then multiple search-words have been used.

Both English and Finnish language-based sources have been used. As some of the information provided in the thesis is limited to the Finnish realities, numerous official govern- mental portals have been accessed with the purpose of gaining reliable statistical and le- gitimate data (National Institute for Health and Welfare – THL, Administrative sector of the Ministry of Social Affairs and Health - Sosiaali- ja terveysministeriö, legislations published by the Finnish Ministry of Justice). Research data that is less than 10 years old is mainly used in this document. However, the use of older resources has been also considered ir- respective of the study year if the data is still relevant and does not contradict with the data published within the last 10 years, an example of this would be an article of Tilvis Reijo (1999) published for the Finnish Medical Society Duodecim journal, as it points out the importance of the geriatric medicine, which is relevant to this day.

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9 DISCUSSION

Writing this thesis has provided its authors with an opportunity of an extensive learning experience, where understanding of the subject has been strengthened throughout the writing process.

9.1 Discussion in regard to the thesis

During our search for evidence-based sources to justify the information provided in this thesis, it has been discovered that the amount of research and data on the topic of geriatric medicine is quite extensive in both English and Finnish databases. While gathering data for the thesis’ theoretical part, we often had to wonder what parts of the gathered information should be included into the brochure. While choosing the topic for the thesis as well as while progressing with the thesis process, the importance of the topic of geriatric medicine has been felt, as the elderly population has been increasing globally along with the health care services aimed at meeting the growing demand (WHO 2019a). We con- sider it important that, at a global level, awareness of the need of investing into elderly care be brought up. The simultaneous increase of the ageing population and decrease of working-age population makes it natural to wonder about the ways of promoting the well- being of elderly and securing quality services for them.

We, the authors of the thesis, have felt like the topics included into the theoretical parts of the thesis are essential in order to gain full understanding of the work done at the Acute geriatric emergency ward. The topic of geriatric medicine and effects of ageing have been chosen to be researched in order to explain the very medical specialty of AKKUNA. As- sessment tools used in elderly care have been looked into, as they are part of the comprehensive geriatric assessment that is routinely done at AKKUNA. Closer look has also been taken at the state of the elderly population of Finland in order to understand what the national challenges and goals are. The specifics of work performed at AKKUNA and, in less detailed way, other geriatric health care units have been described. Theoretical part has been concluded by the importance of family’s involvement into lives of elderly people, as the product of this thesis is meant to guide family members of patients admitted to AK- KUNA.

When finalizing and combining our theoretical findings, we have come to a conclusion that all the chosen topics are essential in order to understand the work done at AKKUNA.

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9.2 Discussion in regard to the educational brochure

Linking the theoretical and practical information in the educational brochure has proven to not be an easy task. Naturally, not all the data outlined in the theoretical part of the thesis has been included into the educational brochure in order to keep it succinct and practical at the same time. The brochure greatly consists of the practical information that is not supported by theoretical knowledge that can be justified with evidence-based sources but rather is supported by authors’ own working experiences. The final product of this thesis can be used as a communicating tool for patients’ relatives and medical professionals of AK- KUNA but does not provide a more extensive insight into geriatric medicine and correlated concepts. In the English and Russian versions of the brochures the term “geriatric medicine” has been outlined and explained, while in the Finnish version it has been explained as a part of describing what patients are normally admitted to AKKUNA. In all of the versions of brochure it is mentioned that comprehensive geriatric assessment (CGA) is done at the ward with involvement of a multidisciplinary team of health care professionals. Im- portance of family’s involvement is outlined in all languages under a separate title.

As a result, theoretical and practical knowledge has been implemented into the educational brochure in a laconic manner.

9.3 Reliability and validity

The sources used in the thesis plan and thesis are critically evaluated by taking into con- sideration whether their objectivity is clear, publisher’s credentials are trustworthy and the contents cannot be classified as questionable and instead are supported by other evidence-based scientific materials. Masto-Finna portal has been used as the database. The sources used in the thesis are traceable, which proves the reliability of the study. The references have been used to support the information provided in the thesis appropriately.

Own opinions are not stated, however, when describing the specifics behind the work of the Emergency department, the Emergency ward and the Acute geriatric emergency ward of the Päijät-Häme central hospital, knowledge gained as an employee is being used in order to provide a better understanding of the organizations’ structures. It is distinguisha- ble in the written text what is points are supported by other source and what isn’t, which increases the thesis’s reliability. The informative brochure that is to be given out to the relatives of the patients treated in AKKUNA has been created using both the material already available on the web-site of the Päijät-Häme central hospital and the information that the staff of AKKUNA deemed essential to be shared. The thesis and its outcome have not been affected by any parties outside of the commissioning agreement that has been

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signed by the writers of the thesis, their supervising teacher and the representative of the commissioning party.

As with any Bachelor thesis project at Lahti University of Applied Sciences, along with constant supervision of the ongoing work by done by the supervising teacher, upon its completion, the thesis is to be peer reviewed and language checked (Lahti University of Applied Sciences Ltd 2018, 11). The preliminary contents of the thesis have also been discussed and approved with the commissioning organization, who will also be presented with the thesis work upon its completion. Additionally, the final product of the thesis, the informative leaflet about the work done at AKKUNA, is to be first presented to the commissioner and be asked whether any changes need to be done before putting it into use. As the thesis is completed along with the brochure, the staff of the commissioning organization has been asked to give feedback on its practicality and reliability.

9.4 Ethical considerations

The limitations of the information regarding the work of the Emergency department, the Emergency ward and the Acute geriatric emergency ward of the Päijät-Häme central hospital that can be published along with the thesis have been discussed with the commissioner. A commissioning contract has been signed by the commissioning party, thesis authors and its supervisor prior to starting thesis process. Permission for feedback gathering has been obtained.

The final version of the thesis is to be screened in a plagiarism identification system. In accordance with The Rectors’ Conference of Finnish Universities of Applied Sciences Arene’s (2018) ethical recommendations for thesis writing at universities of applied sciences, this thesis is considered ethically appropriate.

9.5 Implications for further studies

During our thesis process, the structure of the theoretical part has been reviewed multiple times. Initially it has been planned that the theoretical part of this thesis will not only include information about the health care units specialized in geriatric medicine located in Finland, but in addition to that also the ones outside of Finland. However, we were not able to obtain enough evidence-based information on the global units specialized in geriatric medicine. It is possible that the information can be obtained by researching interna- tional sources more thoroughly, making it relevant to become a thesis research of its own.

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https://julkiset.lapinamk.fi/DropOffLibrary/Lapin%20AMK%20YAMK%20opinnäytetyöopas.

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Larivaara, P., Lindroos, S., Heikkilä, T. & Aaltonen, J. 2009. Potilas, perhe ja perusterveydenhuolto. Helsinki: Duodecim.

Larivaara, P., Lindroos, S., Heikkilä, T. 2009a. Perhekeskeisen työn teoreettiset perusteet - johdanto in Potilas, perhe ja perusterveydenhuolto available at Oppiporti, Duodecim.

Larivaara, P., Lindroos, S., Heikkilä, T. 2009a. Systeeminen tieteenteoria ja perhekeskeisyys in Potilas, perhe ja perusterveydenhuolto available at Oppiporti, Duodecim.

Legramante, JM., Morciano, L., Lucaroni, F., Gilardi, F., Caredda, E., Pesaresi, A., Coscia, M., Orlando, S., Brandi, A., Giovagnoli, G., Di Lecce, VN., Visconti, G., Palombi, L. 2016. Frequent Use of Emergency Departments by the Elderly Population When