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Nursing and Health Sciences (2014), 16, 449–453
Research Article
Emergency department nurses’ perceptions and experiences of providing care for older people Robyn Gallagher, RN, PhD, Margaret Fry, RN, PhD, Lynne Chenoweth, RN, PhD, Patrick Gallagher BSocSc, BLaws, and Jane Stein-Parbury RN, PhD Faculty of Health, University of Technology, Sydney, Australia
Abstract
Emergency department nurses are challenged to provide safe, quality care to older people; however, nurses’ perceptions of their role and experiences are seldom investigated. This focus-group study investigated emergency department nurses’ perceptions and experiences of caring for older people, using four focus groups of nurses with a minimum three months’ experience in the emergency department and a demographic survey. Data were thematically analyzed. Two themes emerged. The first was the clash of expectations between nurses and family/carers related to safety and quality of nursing care. Older people were perceived to be vulnerable in the emergency department, and nurses were frustrated that competing priorities decreased their ability to ensure them safe and quality care. Nurses felt family/carers were disappointed with care provided, and might not empathize with or understand their predicament. The second theme concerned nurses’ perception that family/carers could provide a safety net for the older person in the emergency department in times of high workload. Nurses need support to care for older people in the emergency department to ensure safe and optimal care, and a shared understanding of care provision between nurses and family needs development.
Key words
carer, emergency department, family, older person, quality, safety.
INTRODUCTION The quality and safety of care for older people in the emergency department (ED) are important concerns for nurses (Shanley et al., 2008; Kelley et al., 2011). However, they are challenged in addressing this concern, because the ED environment and processes of care focus on assessing and treating acute illness, which is only one aspect of the overall health needs of older people (Shanley et al., 2008). In addition, the often busy, crowded, and noisy ED environment, and the periods of waiting for various services in the ED, can increase discomfort and distress for older people. Patients over the age of 70 years are more likely to have comorbid conditions, varying levels of functional decline, and some sensory and cognitive deficits, which require additional evaluation time in the ED. Attending to these multiple health needs requires ED nurses to provide these patients with more essential nursing care than routinely provided to younger ED patients (Hayes, 2000, Shanley et al., 2008).
Literature review ED nurses have identified many barriers to providing this level of care for older people.While some issues clearly relate Correspondence address: Robyn Gallagher, Faculty of Nursing, Midwifery and Health, The University of Technology, Jones Street, Ultimo, Sydney, NSW 2007, Australia. Email: [email protected] Received 18 July 2013; revision received 20 January 2014; accepted 22 January 2014
© 2014 Wiley Publishing Asia Pty Ltd.
to lack of time and staff, others are related to the priority of having to assess and treat a single acute illness and the routine assembly of information regarding the presenting illness (Boltz et al., 2013). Consequently, ED nurses often have to give lower priority to the older patient’s other illnesses/conditions and some fundamental nursing care requirements, such as frequent toileting, repositioning, and oral care (Kihlgren et al., 2005). The effects of nurses’ inability to meet their own expectations of care for older people in the ED on nurses has not been described in the literature, but it is likely to contribute to frustration and lessened job satisfaction (Forsyth & McKenzie, 2006). This might be heightened when nurses perceive that other participants in the care process, such as family, also feel that care does not meet expectations. Families and carers are an important resource for older people, and often accompany and transport older people into the ED. A study of the profile of ED attendees found that more than 64% of patients were accompanied by people they knew, half of whom were family (Fealy et al., 2012). Older patients consider the family’s presence important in the ED, as they are often able to provide information or detail when older people themselves cannot because of illness or disability (Shanley et al., 2008, Nikki et al., 2012). Family members can communicate to healthcare professionals, provide support to the patient, and be involved in decision-making about treatment (Boltz et al., 2013). However, an integral part of this communication might include family or carer doi: 10.1111/nhs.12137
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feedback on care standards to nursing staff, and this is likely to impact on nurses’ experiences. There is little information available on ED nurses’ perspectives of providing care for older people in the ED. A study conducted by the authors on this topic involved multiple aspects of the care of older people in the ED. One aspect investigated nurses’ experiences and expectations of the family or carers of older people in the ED (Fry et al., 2013). Nurses evaluated family and carers according to time; the time they invested in their family member, the time nurses had to invest to manage family needs, and the time family could save nurses by providing information on older people. Another aspect of this study investigated nurses’ perceptions and experiences of providing care for older people, and this aspect is the focus of this paper. ED nurses’ perceptions and experiences of providing care for older people were investigated in this study.
Data collection
METHODS
Procedure
Design This study used a qualitative design. The study method has been published previously, but is summarized here (Fry et al., 2013).
Participants The study setting was a tertiary referral hospital in metropolitan Sydney, Australia. More than one-third of the 60,000 hospital presentations annually at the study site are for people aged 60 years or over. In this setting, older people undergo the same triage, assessment, and treatment model of care and team allocation as other adults presenting in all respects, with two exceptions. If the older person is discharged directly from the ED and has nil or limited support at home, then they are identified to a nursing team that provides one home visit following discharge. If the person is aged 75 years or older is to be admitted and has had two hospital admissions in the previous three months, then they are screened by a specialist aged care assessment team to begin the discharge planning process as early as possible. Neither of these services is designed to directly modify care in the ED; however, the specialist staff involved are more available for advice and might flag issues needing attention specific to the older person. The ED staff includes 60 nurses. To be eligible for the study, nurses had to be employed either part time or full time for at least three months within the ED.
Four focus groups of between six and 12 participants were used to collect data. The focus groups were guided by a semistructured interview schedule, which consisted of 10 open-ended questions that directed the nurses’ thoughts toward their perceptions and experiences of providing care for older people. An experienced facilitator, independent of the ED, led each focus group (JSP, RG). Each focus group began with an introduction, where confidentiality principles and processes for the group were outlined. All participants were encouraged to contribute, and sufficient time was allowed for participants to express themselves and discuss points raised in the care of older people presenting to the ED. Focus groups were audio-taped. A confidential checklist was used to collect data on participants’ sex, age, education, and experience in ED.
Several information sessions were conducted, and posters were placed in the ED to inform staff of the study and inviting them to join. Focus groups were conducted during staff changeover in the ED tutorial room once per week for four weeks. Staff were reminded of the focus groups on the day. Participants completed consent procedures, and the sociodemographic checklist before focus groups began. Focus groups took place between September and November 2011, and lasted approximately 60 min.
Data analysis Audio-taped data were transcribed verbatim and stored and managed using NVivo (version 9.2; Burlington, MA, USA). Codes were used to identify the focus groups, and all other data were de-identified. Data were analyzed and organized thematically and guided by Gibbs’s (2012) framework, which included: (i) transcription and familiarization; (ii) code building; (iii) dis/confirmatory theme development; and (iv) data consolidation and interpretation. Two of the investigators (RG and MF) coded, and then met regularly to discuss the codes as they emerged, and then developed and reviewed the themes that developed for the data. The analysis framework provided a systematic approach for interpretation (Lichtman, 2010). There were two distinct and connected themes, which were intertwined with nurses’ perceptions of quality and safety of nursing care for older people in the ED, and these themes form the basis for this paper.
Ethical considerations
RESULTS
The study received human research ethics approval from the study site and the university’s human research ethics committee. Data collected on participants were collected confidentially, and all responses during the focus groups were de-identified in transcription. The research processes were congruent with the statement on the ethical conduct of human research outlined in the Declaration of Helsinki.
Focus groups were attended by 27 nurses, representing 45% of the total nursing staff. Participants were predominantly female (89%) and aged over 30 years (72%). The average length of experience in the ED was five years (range: from three months to 25 years); 10 nurses (37%) had postgraduate qualifications, the highest of which were postgraduate diploma (3) and master degrees (7).
© 2014 Wiley Publishing Asia Pty Ltd.
Emergency nurses’ care for older people
Two main themes were evident: the clash of expectations related to safety and quality nursing care, and the family or carers as a potential safety net. Both themes reflected the underlying perception that older people were vulnerable in the ED. The themes were related to the need to ensure safety and provide quality care for older people in the ED, and resonated frustration due to a clash of expectations. In the first theme, this frustration arose from nurses’ perception that the tailored care that older people needed in the ED could not be met, due to lack of time and competing acute care priorities. This frustration was enhanced and despair ensued when nurses felt that family or carers were also disappointed with the lack of individualized care provided and did not understand the nurses’ predicament. The second theme identified the potential contribution that nurses felt that family or carers could make to provide a safety net for older people in the ED.
Clash of expectations related to safety and quality nursing care Nurses expressed their frustrations with their inability to provide appropriate and quality care for older patients due to lack of time and other priorities. If you have multiple patients and they’re all calling out to you, I think it’s frustrating not being able to give that care and that time to really know what they need. (Focus group [FG]1) The participants particularly emphasized that their frustration arose from their inability to provide care related to essential nursing, such as hydration and continence care and comfort measures. Nurses agreed that “basic nursing care was long gone” (FG1) and that the provision of comfort was often abandoned in the effort to address assessment and treatment of acute illness: Our main priority is the acute illness all the time and keeping them alive. . . . There’s just not a lot of time to do the basic tasks that are really important to everyone. (FG1) Nurses expressed that family or carers did not recognize their skillful management of workload and prioritization of care activities, including addressing urgent health needs: The family members and the patient get really frustrated if you can’t get them the pan or bottle . . . because you’re dealing with someone with chest pain or something else; it’s like, that’s sort of more critical. They forget about the medical side, the acute problems that we’re dealing with. (FG4) Not only did nurses fail to meet their own and families’ or carers’ expectations of care, but they perceived that they were misunderstood and judged harshly by family members during periods of high workload: And you go, “Look, I’ll get to the pan in a minute”, but they get really agitated and angry, and then you get the pan and they say, “Well, it’s too late now”, and they’ve
451
wet the bed, and you’re like, “I’m really sorry, but I physically couldn’t get there”. (FG4) Nurses experienced personal frustration and disappointment in not meeting their own care standards and sympathized with patients’ humiliation. However, these emotions were heightened when families or carers conveyed their disappointment in the nurse, as in the following excerpt which was met by agreement by many participants in the discussion in FG4: And the family’s so adamant that you’re not caring for them appropriately because you just couldn’t get there on time. And sometimes it’s hard . . . it’s just hard . . . it’s not how I was taught to care for patients either. (FG4) However, frustrations were greatly reduced when nurses perceived that families not only understood their efforts, but also worked with them to support older people in the ED, thereby improving safety and quality of care: Other carers who are with the patient most of the time, they know exactly how to treat the patient, they understand what you are trying to do . . . they do tend to help you. When you try to help them, they help you. (FG3) Nurses made the assumption that family/carers would understand and participate in ensuring the older person’s safety. However, family/carers were not always aware of nurses’ expectations of their involvement, or their willingness or ability to participate. In these situations, nurses described being told by family/carers: “It’s your job” (FG3), and the clash of expectations contributed to frustration.
Family or carers as a potential safety net Nurses particularly identified the potential for family or carers to provide a safety net for the vulnerable older person. Family or carers were vital resources that many ED nurses used for support when they were experiencing episodes of high workload and were concerned that they could not ensure older people’s safety: That’s why we need to rely on the family. You know when they (radiology staff) say this patient is (disoriented) and can’t identify themselves, so I’ll say to the son: “Do you mind going down to X-ray with them and telling them who they are?”. That means I can stay with my other patients. (FG1) Nurses perceived older people to be particularly vulnerable when they were busiest. At these times, nurses valued the presence of family or carers and their specific knowledge of the patient to help provide a broader safety net for them: Small behavior problems can tend to become quite large in an unlocked, unsecure environment, and it can become quite risky for the patient. They (the family) sort of provide . . . a good guideline of how to manage the person, whether it be physically, emotionally, medically. (FG3) © 2014 Wiley Publishing Asia Pty Ltd.
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Because family or carers were skillful in noticing, responding to, and understanding changes in the patient, family or carers could alert nurses to deterioration or change and contribute to the nurses’ assessment and judgement of the patient’s condition. This was particularly the case when older people did not communicate their discomfort or needs: Because they (the patient) just sit there and say nothing, and if they don’t have a family member there to tell you that something’s wrong, you don’t know, because they’re not screaming out to you like the other 10 people are. (FG2) Furthermore, family or carers could distract and engage patients from unsafe behaviors that could potentially cause harm. The most vulnerable people in this case were older people who were confused, delirious, or disoriented: Like if they’re (the patient) trying to climb out of the bed, to be able to just sit with them and talk to them. (FG2)
DISCUSSION In the ED, nurses experience multiple challenges in providing quality nursing care for older people and ensuring their safety. The findings of our study clearly identify that the standards of care for older people that ED nurses value are often unable to be met. Nurses expressed strong emotional responses when they judged themselves as being unable to meet standards of care, consistent with international findings (Lim et al., 2010). This judgement was reinforced by criticisms from patients and their family or carers, and nurses experienced additional frustration when the family or carers did not acknowledge the extraordinary efforts nurses made to try to achieve care standards. Our study results contribute to a mounting body of evidence that nurses, families, and carers are increasingly frustrated with their perception that the level and quality of care able to be provided to older people in the ED is not adequate (Hayes, 2000; Kihlgren et al., 2005; Shanley et al., 2008). For nurses, much of the frustration experienced is due to their difficulty managing shortcomings created by a system in which acute health assessment and treatments are prioritized above what nurses perceive to be basic care. In particular, this distress arose from the lack of time nurses had available for the provision of direct personal care and information. This discontent may not be limited to the ED, but needs to be addressed, because it can be an important indicator of intention to leave the workforce by nurses (Forsyth & McKenzie, 2006). The consensus between nurses, family, or carers and patients themselves that care is not optimal is also a good indicator that the care of older people in the ED needs urgent attention (Grief, 2003; Muntlin et al., 2006). Interventions and policy recommendations that address these shortcomings have been published, but in reality, might not be translated into practice (Parke & McCusker, 2008; Joanna Briggs Institute, 2012). This study contributes to the body of literature aiming to improve quality of care in the ED by identifying the potential © 2014 Wiley Publishing Asia Pty Ltd.
R. Gallagher et al.
for family or carers to contribute to a safety net for older people. Previous studies have reported the importance of caregiving roles that family or carers can play in addressing shortcomings in the quality of care for older people in the ED (Shanley et al., 2008; Nikki et al., 2012; Boltz et al., 2013). However, these contributions tended to be limited to providing timely information (Shanley et al., 2008; Nikki et al., 2012; Fry et al., 2013), giving emotional support (Nikki et al., 2012; Boltz et al., 2013), assisting with nutrition and hydration, toileting, and providing support during transfers and tests (Nikki et al., 2012). This study goes further to report that nurses perceive it is necessary to harness and further develop an interdependence between nurses and family or carers to ensure the safety of older people. Nurses could garner the family’s or carer’s specific patient knowledge and bedside presence to encourage monitoring and reporting of subtle changes in the patient’s attention, mood, and behavior, which might warn of deteriorating health. Family could provide emotional support and distraction to the distressed older person to reduce escalating confusion and the potential for falls (Close et al., 2007). However, nurses cannot presume that all family or carers can participate in the safety net described, especially if the carer is old, unwell, or unaccustomed to providing care (Levine & Zuckerman, 2000; Bookman & Harrington, 2007). Furthermore, while the family’s or carer’s contribution has the potential to be valuable in the ED, this contribution might be accompanied by increased criticism of nursing services. Criticism by family or carers heightened nurses’ frustration and distress, especially when extraordinary efforts were being made to juggle competing treatment and care demands for a large number of patients. Such distress arising from conflict between nurses and family or carers has been identified as a source of nurse burnout and dissatisfaction in other contexts, and is important to treat, at the least to promote staff retention (Abrahamson et al., 2009).
Implications for clinical practice Concerns with standards of care quality and safety are directly relevant to ED nurses’ clinical practice. A recent systematic review of the evidence on age-friendly nursing interventions reported seven areas where nursing care could be developed, many of which included fundamental care such as toileting and nutrition (Joanna Briggs Institute, 2012). Specialist geriatric nursing knowledge is also needed, particularly in differentiating acute illness symptoms from other symptoms that older people might be experiencing (Parke & McCusker, 2008). The addition of specialized geriatric assessment teams and emergency units have shown promise in initial evaluations (Baumbusch & Shaw, 2011; Conroy et al., 2013).
Limitations Study participants were recruited from one ED only, so the results might represent site-specific issues. While efforts were made for all focus-group participants to express their views, it is possible that some voices were not heard equally. The focus
Emergency nurses’ care for older people
in this paper was on two major themes, which were related to perceptions of nursing care of the older person, and other latent themes might have been present. Further research is needed into families’ and carers’ perceptions of the quality of care of older people in the ED, and whether there are shared perceptions of care level, as this paper reflects only nurses’ perceptions.
Conclusion As an increasing number of older people are being cared for in the ED, ED nurses need support to provide quality care and ensure their safety. The frustration that nurses experience in relation to mismatched expectations with both their own standards of care and those of older people’s family or carers could be mitigated by more clarity and communication with family or carers and support from specialist geriatric services.
ACKNOWLEDGMENTS We acknowledge the contribution of the Centre for the Advancement of Gerontological Nursing Science at the University of California Los Angeles.
CONTRIBUTIONS Study Design: RG, MF, LC. Data Collection and Analysis: MF, JSP, RG, PG. Manuscript Writing: RG, MF, LC, JSP, PG.
REFERENCES Abrahamson K, Suitor JJ, Pillemer K. Conflict between nursing home staff and residents’ families: does it increase burnout? J. Aging Health 2009; 21: 895–912. Baumbusch J, Shaw M. Geriatric emergency nurses: addressing the needs of an aging population. J. Emerg. Nurs. 2011; 37: 321–327. Boltz M, Parke B, Shuluk J, Capetuzi E, Galvin JE. Care of the older adult in the emergency department: nurses views of the pressing issues. Geront 2013; 43: 109–114. Bookman A, Harrington M. Family caregivers: a shadow workforce in the geriatric health care system? J. Health Polit. Polic. Law 2007; 32: 1005–1041.
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Close JC, Lord SR, Antonova EJ et al. Older people presenting to the emergency department after a fall: a population with substantial recurrent healthcare use. Emerg. Med. J. 2007; 29: 742–747. Conroy SP, Ansari K, Williams M et al. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the “Emergency Frailty Unit. Age. Ageing 2013; 43: 109–114. Fealy GM, Treacy M, Drennan J, Naughton C, Butler M, Lyons I. A profile of older emergency department attendees: findings from an Irish study. J. Adv. Nurs. 2012; 68: 1003–1013. Forsyth S, McKenzie H. A comparative analysis of contemporary nurses’ discontents. J. Adv. Nurs. 2006; 56: 209–216. Fry M, Gallagher R, Chenoweth L, Stein-Parbury J. Nurses’ experiences and expectations of family and carers of older patients in the emergency department. Int. Emerg. Nurs. 2013; 22: 31–36. Gibbs GR. Analysing Qualitative Data. Sage Publications: London, 2012. Grief C. Patterns of ED use and perceptions of the elderly regarding their emergency care: a synthesis of recent research. J. Emerg. Nurs. 2003; 29: 122–126. Hayes KS. Geriatric assessment in the emergency department. J. Emerg. Nurs. 2000; 26: 430–435. Joanna Briggs Institute. Best practice information sheet: age-friendly nursing interventions in the management of older people in emergency departments. Nurs. Health Sci. 2012; 14: 272–274. Kelley ML, Parke B, Jokinen N, Stones M, Renaud D. Senior-friendly emergency department care: an environmental assessment. J. Health Serv. Res. Policy 2011; 16: 6–12. Kihlgren AL, Nilsson M, Sorlie V. Caring for older patients at an emergency department-emergency nurses’ reasoning. J. Clin. Nurs. 2005; 14: 601–608. Levine C, Zuckerman C. Hands on/hands off: why health care professionals depend on families but keep them at arm’s length. J. Law Med. Ethics 2000; 28: 5–18. Lichtman M. Qualitative Research in Education: A Users Guide (2nd edn). Thousand Oaks, California: Sage, 2010. Lim J, Bogossian F, Ahern K. Stress and coping in Singaporean nurses: a literature review. Nurs. Health Sci. 2010; 12: 251–258. Muntlin A, Gunningberg L, Carlsson M. Patients’ perceptions of quality of care at an emergency department and identification of areas for quality improvement. J. Clin. Nurs. 2006; 15: 1045–1056. Nikki L, Lepisto S, Paavilainen E. Experiences of family members in the emergency department: a qualitative study. Int. Emerg. Nurs. 2012; 20: 193–200. Parke B, McCusker J. Consensus-based policy recommendations for geriatric emergency care. Int. J. Health Care 2008; 21: 385–395. Shanley C, Sutherland S, Stott K, Tumeth R, Whitmore E. Increasing the profile of the care of older people in the ED: a contemporary nursing challenge. Int. Emerg. Nurs. 2008; 6: 152–158.
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Nursing and Health Sciences (2014), 16, 449–453
Research Article
Emergency department nurses’ perceptions and experiences of providing care for older people Robyn Gallagher, RN, PhD, Margaret Fry, RN, PhD, Lynne Chenoweth, RN, PhD, Patrick Gallagher BSocSc, BLaws, and Jane Stein-Parbury RN, PhD Faculty of Health, University of Technology, Sydney, Australia
Abstract
Emergency department nurses are challenged to provide safe, quality care to older people; however, nurses’ perceptions of their role and experiences are seldom investigated. This focus-group study investigated emergency department nurses’ perceptions and experiences of caring for older people, using four focus groups of nurses with a minimum three months’ experience in the emergency department and a demographic survey. Data were thematically analyzed. Two themes emerged. The first was the clash of expectations between nurses and family/carers related to safety and quality of nursing care. Older people were perceived to be vulnerable in the emergency department, and nurses were frustrated that competing priorities decreased their ability to ensure them safe and quality care. Nurses felt family/carers were disappointed with care provided, and might not empathize with or understand their predicament. The second theme concerned nurses’ perception that family/carers could provide a safety net for the older person in the emergency department in times of high workload. Nurses need support to care for older people in the emergency department to ensure safe and optimal care, and a shared understanding of care provision between nurses and family needs development.
Key words
carer, emergency department, family, older person, quality, safety.
INTRODUCTION The quality and safety of care for older people in the emergency department (ED) are important concerns for nurses (Shanley et al., 2008; Kelley et al., 2011). However, they are challenged in addressing this concern, because the ED environment and processes of care focus on assessing and treating acute illness, which is only one aspect of the overall health needs of older people (Shanley et al., 2008). In addition, the often busy, crowded, and noisy ED environment, and the periods of waiting for various services in the ED, can increase discomfort and distress for older people. Patients over the age of 70 years are more likely to have comorbid conditions, varying levels of functional decline, and some sensory and cognitive deficits, which require additional evaluation time in the ED. Attending to these multiple health needs requires ED nurses to provide these patients with more essential nursing care than routinely provided to younger ED patients (Hayes, 2000, Shanley et al., 2008).
Literature review ED nurses have identified many barriers to providing this level of care for older people.While some issues clearly relate Correspondence address: Robyn Gallagher, Faculty of Nursing, Midwifery and Health, The University of Technology, Jones Street, Ultimo, Sydney, NSW 2007, Australia. Email: [email protected] Received 18 July 2013; revision received 20 January 2014; accepted 22 January 2014
© 2014 Wiley Publishing Asia Pty Ltd.
to lack of time and staff, others are related to the priority of having to assess and treat a single acute illness and the routine assembly of information regarding the presenting illness (Boltz et al., 2013). Consequently, ED nurses often have to give lower priority to the older patient’s other illnesses/conditions and some fundamental nursing care requirements, such as frequent toileting, repositioning, and oral care (Kihlgren et al., 2005). The effects of nurses’ inability to meet their own expectations of care for older people in the ED on nurses has not been described in the literature, but it is likely to contribute to frustration and lessened job satisfaction (Forsyth & McKenzie, 2006). This might be heightened when nurses perceive that other participants in the care process, such as family, also feel that care does not meet expectations. Families and carers are an important resource for older people, and often accompany and transport older people into the ED. A study of the profile of ED attendees found that more than 64% of patients were accompanied by people they knew, half of whom were family (Fealy et al., 2012). Older patients consider the family’s presence important in the ED, as they are often able to provide information or detail when older people themselves cannot because of illness or disability (Shanley et al., 2008, Nikki et al., 2012). Family members can communicate to healthcare professionals, provide support to the patient, and be involved in decision-making about treatment (Boltz et al., 2013). However, an integral part of this communication might include family or carer doi: 10.1111/nhs.12137
450
R. Gallagher et al.
feedback on care standards to nursing staff, and this is likely to impact on nurses’ experiences. There is little information available on ED nurses’ perspectives of providing care for older people in the ED. A study conducted by the authors on this topic involved multiple aspects of the care of older people in the ED. One aspect investigated nurses’ experiences and expectations of the family or carers of older people in the ED (Fry et al., 2013). Nurses evaluated family and carers according to time; the time they invested in their family member, the time nurses had to invest to manage family needs, and the time family could save nurses by providing information on older people. Another aspect of this study investigated nurses’ perceptions and experiences of providing care for older people, and this aspect is the focus of this paper. ED nurses’ perceptions and experiences of providing care for older people were investigated in this study.
Data collection
METHODS
Procedure
Design This study used a qualitative design. The study method has been published previously, but is summarized here (Fry et al., 2013).
Participants The study setting was a tertiary referral hospital in metropolitan Sydney, Australia. More than one-third of the 60,000 hospital presentations annually at the study site are for people aged 60 years or over. In this setting, older people undergo the same triage, assessment, and treatment model of care and team allocation as other adults presenting in all respects, with two exceptions. If the older person is discharged directly from the ED and has nil or limited support at home, then they are identified to a nursing team that provides one home visit following discharge. If the person is aged 75 years or older is to be admitted and has had two hospital admissions in the previous three months, then they are screened by a specialist aged care assessment team to begin the discharge planning process as early as possible. Neither of these services is designed to directly modify care in the ED; however, the specialist staff involved are more available for advice and might flag issues needing attention specific to the older person. The ED staff includes 60 nurses. To be eligible for the study, nurses had to be employed either part time or full time for at least three months within the ED.
Four focus groups of between six and 12 participants were used to collect data. The focus groups were guided by a semistructured interview schedule, which consisted of 10 open-ended questions that directed the nurses’ thoughts toward their perceptions and experiences of providing care for older people. An experienced facilitator, independent of the ED, led each focus group (JSP, RG). Each focus group began with an introduction, where confidentiality principles and processes for the group were outlined. All participants were encouraged to contribute, and sufficient time was allowed for participants to express themselves and discuss points raised in the care of older people presenting to the ED. Focus groups were audio-taped. A confidential checklist was used to collect data on participants’ sex, age, education, and experience in ED.
Several information sessions were conducted, and posters were placed in the ED to inform staff of the study and inviting them to join. Focus groups were conducted during staff changeover in the ED tutorial room once per week for four weeks. Staff were reminded of the focus groups on the day. Participants completed consent procedures, and the sociodemographic checklist before focus groups began. Focus groups took place between September and November 2011, and lasted approximately 60 min.
Data analysis Audio-taped data were transcribed verbatim and stored and managed using NVivo (version 9.2; Burlington, MA, USA). Codes were used to identify the focus groups, and all other data were de-identified. Data were analyzed and organized thematically and guided by Gibbs’s (2012) framework, which included: (i) transcription and familiarization; (ii) code building; (iii) dis/confirmatory theme development; and (iv) data consolidation and interpretation. Two of the investigators (RG and MF) coded, and then met regularly to discuss the codes as they emerged, and then developed and reviewed the themes that developed for the data. The analysis framework provided a systematic approach for interpretation (Lichtman, 2010). There were two distinct and connected themes, which were intertwined with nurses’ perceptions of quality and safety of nursing care for older people in the ED, and these themes form the basis for this paper.
Ethical considerations
RESULTS
The study received human research ethics approval from the study site and the university’s human research ethics committee. Data collected on participants were collected confidentially, and all responses during the focus groups were de-identified in transcription. The research processes were congruent with the statement on the ethical conduct of human research outlined in the Declaration of Helsinki.
Focus groups were attended by 27 nurses, representing 45% of the total nursing staff. Participants were predominantly female (89%) and aged over 30 years (72%). The average length of experience in the ED was five years (range: from three months to 25 years); 10 nurses (37%) had postgraduate qualifications, the highest of which were postgraduate diploma (3) and master degrees (7).
© 2014 Wiley Publishing Asia Pty Ltd.
Emergency nurses’ care for older people
Two main themes were evident: the clash of expectations related to safety and quality nursing care, and the family or carers as a potential safety net. Both themes reflected the underlying perception that older people were vulnerable in the ED. The themes were related to the need to ensure safety and provide quality care for older people in the ED, and resonated frustration due to a clash of expectations. In the first theme, this frustration arose from nurses’ perception that the tailored care that older people needed in the ED could not be met, due to lack of time and competing acute care priorities. This frustration was enhanced and despair ensued when nurses felt that family or carers were also disappointed with the lack of individualized care provided and did not understand the nurses’ predicament. The second theme identified the potential contribution that nurses felt that family or carers could make to provide a safety net for older people in the ED.
Clash of expectations related to safety and quality nursing care Nurses expressed their frustrations with their inability to provide appropriate and quality care for older patients due to lack of time and other priorities. If you have multiple patients and they’re all calling out to you, I think it’s frustrating not being able to give that care and that time to really know what they need. (Focus group [FG]1) The participants particularly emphasized that their frustration arose from their inability to provide care related to essential nursing, such as hydration and continence care and comfort measures. Nurses agreed that “basic nursing care was long gone” (FG1) and that the provision of comfort was often abandoned in the effort to address assessment and treatment of acute illness: Our main priority is the acute illness all the time and keeping them alive. . . . There’s just not a lot of time to do the basic tasks that are really important to everyone. (FG1) Nurses expressed that family or carers did not recognize their skillful management of workload and prioritization of care activities, including addressing urgent health needs: The family members and the patient get really frustrated if you can’t get them the pan or bottle . . . because you’re dealing with someone with chest pain or something else; it’s like, that’s sort of more critical. They forget about the medical side, the acute problems that we’re dealing with. (FG4) Not only did nurses fail to meet their own and families’ or carers’ expectations of care, but they perceived that they were misunderstood and judged harshly by family members during periods of high workload: And you go, “Look, I’ll get to the pan in a minute”, but they get really agitated and angry, and then you get the pan and they say, “Well, it’s too late now”, and they’ve
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wet the bed, and you’re like, “I’m really sorry, but I physically couldn’t get there”. (FG4) Nurses experienced personal frustration and disappointment in not meeting their own care standards and sympathized with patients’ humiliation. However, these emotions were heightened when families or carers conveyed their disappointment in the nurse, as in the following excerpt which was met by agreement by many participants in the discussion in FG4: And the family’s so adamant that you’re not caring for them appropriately because you just couldn’t get there on time. And sometimes it’s hard . . . it’s just hard . . . it’s not how I was taught to care for patients either. (FG4) However, frustrations were greatly reduced when nurses perceived that families not only understood their efforts, but also worked with them to support older people in the ED, thereby improving safety and quality of care: Other carers who are with the patient most of the time, they know exactly how to treat the patient, they understand what you are trying to do . . . they do tend to help you. When you try to help them, they help you. (FG3) Nurses made the assumption that family/carers would understand and participate in ensuring the older person’s safety. However, family/carers were not always aware of nurses’ expectations of their involvement, or their willingness or ability to participate. In these situations, nurses described being told by family/carers: “It’s your job” (FG3), and the clash of expectations contributed to frustration.
Family or carers as a potential safety net Nurses particularly identified the potential for family or carers to provide a safety net for the vulnerable older person. Family or carers were vital resources that many ED nurses used for support when they were experiencing episodes of high workload and were concerned that they could not ensure older people’s safety: That’s why we need to rely on the family. You know when they (radiology staff) say this patient is (disoriented) and can’t identify themselves, so I’ll say to the son: “Do you mind going down to X-ray with them and telling them who they are?”. That means I can stay with my other patients. (FG1) Nurses perceived older people to be particularly vulnerable when they were busiest. At these times, nurses valued the presence of family or carers and their specific knowledge of the patient to help provide a broader safety net for them: Small behavior problems can tend to become quite large in an unlocked, unsecure environment, and it can become quite risky for the patient. They (the family) sort of provide . . . a good guideline of how to manage the person, whether it be physically, emotionally, medically. (FG3) © 2014 Wiley Publishing Asia Pty Ltd.
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Because family or carers were skillful in noticing, responding to, and understanding changes in the patient, family or carers could alert nurses to deterioration or change and contribute to the nurses’ assessment and judgement of the patient’s condition. This was particularly the case when older people did not communicate their discomfort or needs: Because they (the patient) just sit there and say nothing, and if they don’t have a family member there to tell you that something’s wrong, you don’t know, because they’re not screaming out to you like the other 10 people are. (FG2) Furthermore, family or carers could distract and engage patients from unsafe behaviors that could potentially cause harm. The most vulnerable people in this case were older people who were confused, delirious, or disoriented: Like if they’re (the patient) trying to climb out of the bed, to be able to just sit with them and talk to them. (FG2)
DISCUSSION In the ED, nurses experience multiple challenges in providing quality nursing care for older people and ensuring their safety. The findings of our study clearly identify that the standards of care for older people that ED nurses value are often unable to be met. Nurses expressed strong emotional responses when they judged themselves as being unable to meet standards of care, consistent with international findings (Lim et al., 2010). This judgement was reinforced by criticisms from patients and their family or carers, and nurses experienced additional frustration when the family or carers did not acknowledge the extraordinary efforts nurses made to try to achieve care standards. Our study results contribute to a mounting body of evidence that nurses, families, and carers are increasingly frustrated with their perception that the level and quality of care able to be provided to older people in the ED is not adequate (Hayes, 2000; Kihlgren et al., 2005; Shanley et al., 2008). For nurses, much of the frustration experienced is due to their difficulty managing shortcomings created by a system in which acute health assessment and treatments are prioritized above what nurses perceive to be basic care. In particular, this distress arose from the lack of time nurses had available for the provision of direct personal care and information. This discontent may not be limited to the ED, but needs to be addressed, because it can be an important indicator of intention to leave the workforce by nurses (Forsyth & McKenzie, 2006). The consensus between nurses, family, or carers and patients themselves that care is not optimal is also a good indicator that the care of older people in the ED needs urgent attention (Grief, 2003; Muntlin et al., 2006). Interventions and policy recommendations that address these shortcomings have been published, but in reality, might not be translated into practice (Parke & McCusker, 2008; Joanna Briggs Institute, 2012). This study contributes to the body of literature aiming to improve quality of care in the ED by identifying the potential © 2014 Wiley Publishing Asia Pty Ltd.
R. Gallagher et al.
for family or carers to contribute to a safety net for older people. Previous studies have reported the importance of caregiving roles that family or carers can play in addressing shortcomings in the quality of care for older people in the ED (Shanley et al., 2008; Nikki et al., 2012; Boltz et al., 2013). However, these contributions tended to be limited to providing timely information (Shanley et al., 2008; Nikki et al., 2012; Fry et al., 2013), giving emotional support (Nikki et al., 2012; Boltz et al., 2013), assisting with nutrition and hydration, toileting, and providing support during transfers and tests (Nikki et al., 2012). This study goes further to report that nurses perceive it is necessary to harness and further develop an interdependence between nurses and family or carers to ensure the safety of older people. Nurses could garner the family’s or carer’s specific patient knowledge and bedside presence to encourage monitoring and reporting of subtle changes in the patient’s attention, mood, and behavior, which might warn of deteriorating health. Family could provide emotional support and distraction to the distressed older person to reduce escalating confusion and the potential for falls (Close et al., 2007). However, nurses cannot presume that all family or carers can participate in the safety net described, especially if the carer is old, unwell, or unaccustomed to providing care (Levine & Zuckerman, 2000; Bookman & Harrington, 2007). Furthermore, while the family’s or carer’s contribution has the potential to be valuable in the ED, this contribution might be accompanied by increased criticism of nursing services. Criticism by family or carers heightened nurses’ frustration and distress, especially when extraordinary efforts were being made to juggle competing treatment and care demands for a large number of patients. Such distress arising from conflict between nurses and family or carers has been identified as a source of nurse burnout and dissatisfaction in other contexts, and is important to treat, at the least to promote staff retention (Abrahamson et al., 2009).
Implications for clinical practice Concerns with standards of care quality and safety are directly relevant to ED nurses’ clinical practice. A recent systematic review of the evidence on age-friendly nursing interventions reported seven areas where nursing care could be developed, many of which included fundamental care such as toileting and nutrition (Joanna Briggs Institute, 2012). Specialist geriatric nursing knowledge is also needed, particularly in differentiating acute illness symptoms from other symptoms that older people might be experiencing (Parke & McCusker, 2008). The addition of specialized geriatric assessment teams and emergency units have shown promise in initial evaluations (Baumbusch & Shaw, 2011; Conroy et al., 2013).
Limitations Study participants were recruited from one ED only, so the results might represent site-specific issues. While efforts were made for all focus-group participants to express their views, it is possible that some voices were not heard equally. The focus
Emergency nurses’ care for older people
in this paper was on two major themes, which were related to perceptions of nursing care of the older person, and other latent themes might have been present. Further research is needed into families’ and carers’ perceptions of the quality of care of older people in the ED, and whether there are shared perceptions of care level, as this paper reflects only nurses’ perceptions.
Conclusion As an increasing number of older people are being cared for in the ED, ED nurses need support to provide quality care and ensure their safety. The frustration that nurses experience in relation to mismatched expectations with both their own standards of care and those of older people’s family or carers could be mitigated by more clarity and communication with family or carers and support from specialist geriatric services.
ACKNOWLEDGMENTS We acknowledge the contribution of the Centre for the Advancement of Gerontological Nursing Science at the University of California Los Angeles.
CONTRIBUTIONS Study Design: RG, MF, LC. Data Collection and Analysis: MF, JSP, RG, PG. Manuscript Writing: RG, MF, LC, JSP, PG.
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