Int. J. Nurs. Smd., Vol. 28, No. Printed in Great Britain.
I, pp. 55-64,
1991. 0
OOZO-7489/91 $3.oO+O.W 1991 Pergamon Press plc
Nurses’ assessment of elderly patients in hospital JAN REED, R.G.N., Department
B.A.,
Ph.D.
ofHealth and Behavioural Science, Newcastle upon Tyne Polytechnic, Ellison Place, Newcastle upon Tyne, NE1 LIST, U.K.
SENGA BOND,
R.G.N.,
Ph.D.,
F.R.C.N.
Centre for Health Services Research. University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, I/. K.
Abstract-Nurses’ assessment of patients’ mobility in hospital provided the focus for an inductive qualitative study which examined how an everyday aspect of nursing practice was carried out. The study described assessment practices in both long-term care and acute care wards for elderly patients as a situated activity. Interviews with nurses, as well as observation of their activities and records, resulted in explanations of their behaviour as deriving from their conceptions of ward functions. These conceptions arose from their adoption of the values of cure and discharge and so, in the different types of ward, assessment held different meanings and was carried out in different ways. The findings have implications for nursing practice in different settings but also for the care of elderly and chronically ill patients, where cure is an inappropriate end goal of care. This example of developing explanatory theory inductively also has implications for the development of mid-range nursing theory and suggestions are made for its extension.
Introduction
That nursing care should derive from the careful assessment of a patient’s condition was brought to prominence when care planning based on ‘the nursing process’ was introduced into the United Kingdom during the 1970’s. De La Cuesta (1983) argues that it was nurses’ discontent with depersonalized, task-centred care which assisted the ready acceptance of 55
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ideas which oriented care towards the identified needs of individual patients. While there was wide ideological acceptance of proposals for more patient-centred nursing, the organizational constraints of hospital nursing with its emphasis on achieving efficiency through routine procedures severely limited the extent to which individualized care could replace ward routines. As Miller (1985) noted, often documentation suitable for a structured problem-oriented and problem-solving approach to care has been introduced but, “that is as far as it goes”. Miller and more recently Green (1990) note that the underlying beliefs and principles guiding individualized care are often absent. While the nursing process offers a framework with a recognized problem-solving style of assessment-planningimplementation and evaluation of care, Sheehan (1990) found that it was characterized in many different ways. Others have opined that this framework is, “essentially an empty approach to care” (Aggleton and Chalmers, 1986, vii). It does not tell nurses what to assess or how to plan, implement or evaluate care. Whittington and Boore (1988) ask, “If nursing is such a process, then how do nurses in fact set about each stage of it? And how do their approaches to each stage relate to patient and community well-being?” (p. 123). In a longterm care setting Green (1990) observed, “. . . there was little assessing of residents’ abilities occurring at all” (p. 26). A concern with standardization has led to attempts to attract nurses to embed the process of nursing within particular nursing models or theories (e.g. Binnie et al, 1984; Kershaw and Salvage, 1990). Others (e.g. Holden, 1990; Cash, 1990) have pointed to the impossibility of basing nursing care upon what currently pass as generalized theories of nursing while writers like Hardy (1986) have criticized the drive to the unthinking advocacy of untested theoretical schema or models. She encourages nurses to work through their own ideas about the most appropriate conceptual frameworks for the delivery of care. It remains likely that what guides nursing practice will depend on a synthesis of values, concepts, knowledge, routines, the staff and technology available in the particular setting. One such influence will be the extent to which education and nursing practice remain embedded in medically dominated structures. Medical dominance applies even in situations where patients cannot be rehabilitated or discharged from medical care. As Evers remarks, “The ‘humanitarian’ need to provide long-term care for patients who become nondischargeable from hospital is a clear embarrassment not only for the clinical-medical ‘cure’ model of health care, but also for ‘organizational’ objectives of social and health care policy.” (Evers, 1981, pp. 51-52). While continuing care of elderly people with multiple pathology, as well as social and psychological needs, potentially offers a setting in which “nursing comes into its own” (Wells, 1980), studies by Evers (1981), Wells (1980) and Fielding (1986) and more recently Bond and Bond (in preparation) show that the nursing care of long-stay elderly patients in hospital remains a routinized work system within a cure-dominated health care ethos. When cure is not possible it is patients who have ‘failed the system’; it is they who are ‘hopeless’ cases and who ‘block beds’. Rather than nursing becoming dynamic and self-governing it remains subservient both to the prevailing medical ethos as well as to the constraints of hospital organization dominated by “getting through the work” (Baker, 1978; Clarke, 1978; Melia, 1987) and reducing patients to the status of work objects. It is against this depressing picture of hospital nursing of long-term elderly patients, described in successive reports of the Health Advisory Service (1985) that the present study emerged (Reed, 1989). Nurse writers like Wells (1980) and Cormack (1985) have pinned their hopes to the problem-solving procedures of the nursing process removing the
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depersonalization and concentration on routines found in long-term care. It is debatable, however, whether nursing practice can be transformed by the introduction of new procedures if existing ways of identifying and defining patient care needs remain unacknowledged and unexplored. Such a strategy for change assumes that existing practice is without value and that it will be improved by the introduction of obviously ‘better’ approaches. These assumptions require investigation. The central concern of the study was the first stage in the formalized procedures of the nursing process, that of assessing patients for the purpose of providing nursing. The study addressed the basic questions: what is assessed? (i) (ii) how is the assessment of patients carried out? (iii) what are the nurses’ concepts of assessment? (iv) can the methods of assessment used in practice be explained as well as described? Methods
An inductive approach to theory building was adopted. This began with a period of observation in a long-term care ward of a peripheral hospital. It became apparent that the diversity of nursing activities and patient problems threatened an overwhelming degree of complexity. In order to begin theory development, the study focused on the assessment of patients’ mobility. The rationale for this choice was that not only was mobility a prevalent source of difficulty for patients, but also that it generated observable and accessible nursing activities. The range of activities that nurses regarded as encompassed within assessment included information collection though direct observation or from other sources, discussion and decision making about patients’ abilities or disabilities. This range of activities formed the basis of a checklist to guide observations which enabled the recording of the incidence and nature of observable assessment activities. Observation was conducted in two long-term care (LTC) wards in the same hospital. Theory development required theoretical rather than statistical sampling of sites and data collection was subsequently carried out in an acute/rehabilitation (A/R) ward in a second hospital. These wards were part of the same care of the elderly system, in that the A/R ward was the initial point of entry into the hospital system for those patients who subsequently would be admitted to the LTC wards. The wards came under the medical control of the same consultants, although they were situated in different hospitals and consequently had different nursing and hospital management teams. While the ward titles indicate patients with different care requirements, in fact there was some overlap as patients who were unable to be transferred had to wait in the A/R ward until an LTC bed was available. This permitted comparisons of nursing work practices with patients of the same status being cared for in wards which had different objectives of care. Observation was carried out for 14 hours on each of the study wards, covering day duty hours. An initial period of unstructured observation was repeated on each ward in order to identify any necessary modification to the checklist, and also to permit nurses and the researcher to become familiar with each other. This process of mutual habituation appeared successful in reducing the anxieties felt on both sides, and facilitated open discussion of the study. Acknowledgement of nurses’ views about the research topic, grounded the structure of the study in the practitioners’ perspective. In addition, nurses appeared to feel under no obligation to present idealized pictures of nursing. Greater methodological detail is available from Reed (1989).
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Results
I. The LTC wards The context and frequency of assessment Over the period of observation on the two LTC wards a total of 19 assessment activities were observed. An initial analysis of the context in which they occurred revealed that the majority (15) occurred while nurses were engaged in working with patients as opposed to during formal reports or change of shift handovers. The assessments consisted of informal descriptions of patients’ abilities, rather than identified possible activities, such as the experimental use of mobility aids. These descriptions did not result in proposals for change in the way in which the patient was nursed. Changes which were proposed concerned how the existing routine of care could be implemented more effectively. Observed assessment Each assessment was initially coded to reflect the themes they illustrated. This activity generated four categories. These were: (i) Global assessments. Generalized statements about the patients as a group. For example: “They’re all hopeless on here, none of them can do anything for themselves.” (ii) Workload related assessments. Estimates of equipment or staff needed to complete predetermined routines of care, rather than to meet individual patient’s needs. For example: “He’s getting worse, we’ll need two to move him.” (iii) References to patients’personal characteristics. Assessments which attributed mobility problems to the personal characteristics of the patient, and therefore not directly amenable to nursing intervention. The comment from one of two nurses attempting to transfer a patient from a wheelchair to armchair was: “She’s hopeless, she’s just being awkward.” Attributing problems to patient characteristics such as ‘awkwardness’, ‘laziness’, and ‘silliness’, was not met with suggestions for nursing intervention or changes in approach beyond that of increasing the numbers of staff, or changing the equipment used to complete routines of care. (iv) Ward function related assessments. Similar to, and originally included in, the category of global assessments. They were, however, differentiated from global assessments because they included specific reference to the function of the ward as a place to which ‘no hopers’ were sent. This perceived function was used as an indication of patients’ abilities, for example: “Of course he can’t do that, this is long-term care you know, not rehab.” Written assessments In addition to verbal exchanges, expressions of assessments were found in written care plans. Forms on which to record patient information according to the problem-solving format of the nursing process had recently been introduced by nurse managers. The main sections of the nursing records were (i) the patient profile, which contained personal and medical details, as well as a brief functional assessment; (ii) the nursing care plan, which identified patients’ problems using an Activities of Daily Living model (Roper et a/., 1980), and also contained prescriptions for nursing care, and (iii) the daily record of care. The first two sections were the main source of data, but there were variations in the way nurses had organized their entries. An example was one nursing record in which no mention was made anywhere of a mobility problem and this had to be inferred from an entry in the patient profile which recorded a past medical history of “left CVA with contractures and Parkinson’s disease.”
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The most striking feature of the care plan entries was the uniformity of terminology used. In detailing the mobility status of the patient, nurses used a dichotomous classification in both the patient profiles and in the care plans whereby patients were described as either ‘Mobile’ or ‘Immobile’. The descriptor ‘Immobile’ was occasionally supplemented by a functional description. Again the range of terms was limited and only one type of description was found which centred on the number of nurses required to mobilize the patient. These same categories were repeated in the section detailing prescribed nursing care, i.e. a patient described as needing two nurses to stand, was prescribed nursing care which consisted of “two nurses to stand and transfer”. More elaborate prescriptions were found where the mobility problem was classified as a ‘problem’ of ‘maintaining a safe environment’, when there were supplementary instructions, for example to ‘ensure brakes were applied to wheelchairs correctly’. These prescriptions reflected a managerial rather than therapeutic approach to nursing care, i.e. the care did not aim to improve or maintain the current mobility status, but to accommodate immobility within the ward routines. Some attempt was made to introduce a therapeutic component, but these were vaguely worded, for example ‘encourage to stand’. These ‘encouragements’ however were accompanied by a concern for patients’ safety, as in the case of one patient who was prescribed to be encouraged to stand but also have the restraining table across the front of his Buxton chair securely fastened at all times, and to have ‘two nurses to transfer’ when his problem of maintaining a safe environment was discussed. The recorded aims of care were correspondingly vague and on occasion contradictory. Maintaining safety, by immobilizing patients and not putting them at risk of falling then limited the possibility for improving mobility. 2. The acute/rehabilitation ward Observation data consisted of 36 assessment activities, and their qualitative analysis resulted in the development of an additional category, ‘scientific assessment’. All but 10 assessment activities fell into this category. Scientific assessments
These assessments were remarkably similar to the procedures advocated by nursing textbooks, in that they involved undertaking specific activities in order to gauge the extent of the patients’ problem. For example, one nurse approached a patient in bed and said “I’m going to try to get you out of bed myself this morning . . . I want to see if you can do it.” Other activities included the experimental use of mobility aids and discussions with physiotherapy staff about the patients’ mobility status. A striking characteristic of many of these scientific assessments was the explicit concern with discharge and cure. Patients were congratulated on their progress but also reminded that this would bring them closer to discharge. Those patients who were waiting for beds on the LTC wards were also subject to the goal of discharge. One female patient was told “If you keep practising, the world’s your oyster. Even if you stay (on LTC) you’ll be able to get about, and who knows, you might even get home.” The goal of discharge was not abandoned but merely postponed. Scientific assessment with its goal of discharge was linked to the ward function as the nurses portrayed it. Phrases like “you’re here to get better” and “we’re here to get you home”, illustrate this perception of the ward as a place devoted to the restoration of independence.
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Personal characteristics and global assessments The assessments which were classified as being concerned with patients’ personal characteristics also reflected the importance of ward function for nurses. The personal characteristics which were judged to perpetuate poor mobility were described as “poor motivation” and “hopelessness” which were obstructing the goals of the ward. Similarly the one global assessment referred to the patients as believing that “because it’s a geriatric ward they think they’re all here to die”. This belief was regarded as erroneous and incompatible with the nurses’ belief that the patients were there to get better. Written assessments The care plans in the A/R ward were kept at the foot of the patients’ beds. The aetiology of mobility problems was written in some detail, expressed in terms of medical conditions. As one nurse stated, “You see, the diagnosis is the most important thing, you base your nursing care around it.” The descriptions of functional impairment were also detailed, and these served as headings for care prescriptions, rather than routine Activities of Daily Living. Despite this attention to particularizing the problems of individual patients, the prescribed nursing care followed a largely uniform pattern, with goals of care focusing on the same stages on the road to mobility. These stages involved the development of the ability to weight bear, followed by the increase in ability to walk with various aids, until these were finally jettisoned and the patient was walking unaided. Variations between individuals were found in their rate of progress, or lack of progress through these stages.
Interviews
The findings from the observation of nursing activities and analysis of nurses records were extended and further developed by a formal interview study. An interview agenda was developed which was informed by the data collected during observation of the practice of assessment, but which was sufficiently broad and flexible to enable potential unexpected or unknown issues to be explored. I. The L TC wards interviews Analysis of the interview data collected from nurses in the LTC wards revealed three major value systems. These value systems varied in the extent to which the nurses adhered to them or supported them as relevant to their practice, but all had implications for nursing assessment. Being up-to-date. Nurses described themselves initially as being up-to-date, giving as evidence the fact that they had adopted the nursing process. On further exploration, however, being up-to-date (or using the nursing process) presented problems for the nurses. They stated that they had received little help in implementing the nursing process, but perhaps more significantly, saw the recording procedures as irrelevant to their practice, given the setting in which they worked; “Well you just write the same things, they’re (patients) all the same on here, and nothing ever changes, it’s’not like acute care.” Another expressed concern was that the use of a problem-solving approach afforded little satisfaction, as the patients’ problems were never “solved”. Problems, defined as medical conditions, were permanent states which could not be “cured”. The nurses differentiated between “proper problems” which could be eradicated, and “conditions” which could not; “Well you see, they don’t have proper problems, things that you can
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get rid of, they just have conditions really. Apart from pressure sores sometimes, you can cure those.” The imperative of absolute cure was not modified to include amelioration of problems, maintaining current function or prevention of deterioration. Conditions were managed through the ward routines. This made the care plans, espoused as the means of communicating the individualized care of patients, in reality, window dressing. Their content reflected unvarying ward routines, rather than individual patient’s needs or goals of care and nursing action. Beingprofessional. This set of values was concerned with appearing distant and serious in front of visitors and senior nurses. Staff talked about “being caught carrying on” by visitors to the ward, which they said did not “look professional”. As well as portraying a particular demeanour, “being professional” also involved being ready and prepared to cope with any acute medical emergency, however unlikely it was to occur. Therefore nurses engaged in routines like checking resuscitation trolleys weekly even when they had not been or would not be used. As one nurse put it; “What it is, we’re all dressed up with nowhere to go. Here we are in hospital, all the gear, all the equipment, all in uniform, all the rules and regulations, but we don’t do what a hospital does. We’re a half hospital. We look like a hospital, but we don’t get anybody better so we’re not.” Again this value system was overtly supported, but on further exploration was rejected by those nurses who saw the acute care model as embodying high status, and proper nursing, but inappropriate for their work in LTC. They were thus caught up in conflicting value systems. Good geriatric cure. This was the value system most supported by nurses. “Good geriatric care” involved unremitting physical labour attendant on completing the ward routines. The aims of these routines were to “keep the ward clean and tidy” and to “get everything nice”. Nurses stressed their satisfaction with the hard work they did; “You really feel you’ve earned your money here, I like that, I don’t like hanging about.” “Good geriatric care” provided goals which the nurses saw as realizable, in contrast to the other value systems which were largely espoused for the benefit of visitors to the wards. Working hard and “getting everything done” however, precluded encouraging patients to do things for themselves; “it would take too long” and, as the nurses saw it, give them “nothing to do but hang around waiting.” This emphasis on getting through the work also precluded attention to individual assessments of patients, as catering for any but minor variations on the general needs met by the ward routines would impede the progress of nurses’ work. 2.The A/R ward interviews Analysis of the interview data on the acute care ward yielded very different findings. The values of being up-to-date and professional were not discernible. Indeed there was rather a dismissive attitude towards these values, which were acknowledged as being held by nurse managers. The nurses did not feel obliged to present any form of facade to these managers and described themselves as having “no time for all of that rubbish.” They used a nursing process format, but had adapted official presentations of it to their own requirements. Being ready for medical emergencies was a value that they espoused, but this was not part of “looking professional” but part of what they called “good acute care”. Good acute cure. This kind of care was as effective in curing their elderly patients as those in any other type of general acute care ward. Nurses frequently made comparisons with the medical ward within the same operational unit, stating that their work was virtually identical to the work done on this ward. When discussing the low status accorded to geriatric
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care by other staff, the nurses on A/R defended their claims to a higher status by reference to the similarities between their work and that of nurses on other acute wards. This differed from the argument made by the nurses in LTC which was based on the amount of hard physical work they did. As a facilitator of “getting patients better” nursing assessment was seen as a crucial part of nursing “otherwise you’d do the wrong things and stop the patient’s progress”. Assessment was based, in the nurses view, on the medical diagnosis, despite the evidence of the care plans that suggested that whatever the cause of the patient’s mobility problem, the prescriptions for nursing care followed a uniform pattern while varying in content. This reliance on medical classifications and goals to provide direction and meaning for nursing work was apparent throughout the data collected on A/R-from the way in which the care plans were written, to the way in which nurses perceived the ward function and subsequently their own role. Discussion Central to the styles of assessment found in each type of ward was the focus on cure as an ideal aim of nursing activity. The goal of cure, as contained within the medical model of treatment was the fundamental criterion by which nurses evaluated their work. In A/R, cure and subsequent discharge was the raison d’Ctre of the ward and of the nurses, and their efforts were directed towards achieving this. Discussions with nurses revealed that they felt that they achieved this and derived satisfaction from this achievement. As Evers (1981) found, the rapid cure and discharge goal was shared between staff and was therefore unproblematic, unless dealing with patients who were awaiting transfer to LTC, when the goal was postponed. Scientific assessment in line with the policy and objectives for hospital geriatric care was therefore important as a basis for planning nursing care. On the LTC wards the nurses also evaluated their work by the yardstick of cure. This caused many more problems for them than it did for the nurses who worked where cure, or at least discharge from hospital, was a possibility. The seeming inappropriateness of cure as the end point in their work prevented nurses from valuing what they did which was associated with cure. To overcome this they sought satisfaction primarily from giving ‘good geriatric care’ which was achievable within their own terms of reference. This involved investment in the speedy and efficient completion of ward routines, which precluded assessment of individual patients’ problems. Other values, such as professionalism, which were adopted for the benefit of visitors and senior nurses, involved maintaining a facade of acute care concerns. Again this espoused professionalism precluded addressing the needs of individual patients. This central concern with cure could be traced back to nurses’ experiences prior to working in wards in the geriatric sector. Incidents were reported when they had been discouraged from “wasting” themselves and their training, when applying for the posts in which they were employed. This discouragement came from colleagues, friends and nurse educators who regarded care of elderly people as low-status and unstimulating work. Furthermore, the hospital system in which they worked reinforced the primacy of cure, by enforcing uniform policies, which did not acknowledge the differences between wards and their objectives for patients. Similarly, enforcing the use of a universal ‘problem-solving’ approach to care plan writing reinforces the idea that patient problems must be solved by nurses. This, when combined with the endemic definition of problems in medical terms, put the nurses in LTC in a no-win position.
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The nurses of LTC wards therefore faced great problems in attempting to find satisfaction in their work, and the solution they chose, “good geriatric care” was not conducive to patient-centred assessment. This value system does, however, represent a move away from cure-centred values, albeit a clandestine one. Ironically it was the nurses in A/R who demonstrated more direct medical influence on their perceptions than the nurses in LTC, who acknowledged the status and desirability of adopting medical values but also their irrelevance in LTC. Adoption of rehabilitation as a central value of geriatric medicine similarly is of dubious value in LTC settings. These data point to the need for nursing to clarify its values in association with the kind of care regarded as appropriate in different settings. As Faucett et al. (1990) have demonstrated, when care was oriented towards taking account of patients’ abilities and involvement in their own care then nursing assessments and prescriptions for nursing care changed in an LTC setting.
Conclusion
This study represents an attempt to develop nursing theory through an inductive approach. Its focus on an everyday aspect of nursing practice in different settings and its relationship to how nurses regard their work requires to be extended to other aspects of care and to other settings where different value systems hold. While offering a bottom up approach to theory development with explanatory powers, the study also yields findings of practical value. It points to the futility of introducing practices, like completing nursing process documentation which are at odds with nurses’ value systems and levels of functioning. As a consequence such activities become routinized into another administrative task to be completed to meet the decree of managers with no recognizable benefits for patients or staff. It reinforces the inappropriateness of a medical model of care, emphasizing cure or rehabilitation, for continuing care and chronically ill patients, and suggests that so long as there is adherence to such a model, nursing staff will reap little by way of satisfaction from the care they provide while the benefits to patients are limited. It poses the question of what kind of nursing or social welfare models of care might replace it and the extent to which these can exist in hospitals which cater for a range of different types of patients. Acknowledgements-Jan Senga Bond is funded
Reed was funded by the Department
by Newcastle Health Authority while this study was in progress of Health. Freda Bolam kindly typed the manuscript.
and
References Aggleton, P. and Chalmers, H. (1986). Nursing Models and the Nursing Process. Macmillan Education, Hampshire. Bond, S. and Bond, J. (1991). Care of frail elderly people: Case Studies of Hospital Wards and NHS Nursing Homes. (in press). Baker, D. E. (1978). Attitudes of Nurses to the Care of the Elderly. Unpublished PhD thesis, University of Manchester. Binnie, A., Bond, S., Law, G., Lowe, K., Pearson, A., Roberts, R., Tierney, A. and Vaughan, B. (1984). A Systematic Approach to Nursing Care. An Introduction. Open University Press, Milton Keynes. Clarke, M. (1978). Getting through the work. In Readings in the Sociology ofNursing. Dingwall, R. and McIntosh, J. (Eds). Churchill Livingstone, Edinburgh. Cormack, D. S. (1985). The geriatric nursing process. In Geriatric Nursing: A Conceptual Approach. Cormack, D. S. (Ed.). Blackwell Scientific, Oxford.
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Cash, K. (1990). Nursing models and the idea of nursing. ht. J. Nurs. Stud. 21, 249-256. De La Cuesta, C. (1983). The nursing process: from development to implementation. J. udv. Nurs. 8, 365-371. Evers, H. K. (1981). Tender Loving Care ?-Patients and nurses in geriatric wards. In Care of the Elderly. Copp, L. A. (Ed.). Churchill Livingstone, Edinburgh. Faucett, J., Ellis, V., Underwood, P., Naqui, A. and Wilson, D. (1990). The effect of Orem’s self-care model on nursing care in a nursing home setting. J. adv. Nurs. 15, 659-666. Fielding, P. (1986). Attitudes Revisited: An Examination of Student Nurses'Attitudes Towards Old People in Hospital. Royal College of Nursing, London. Green, C. (1990). Have we the skills? Nurs. Pructice 3 (3), 26-28. Hardy, L. K. (1986). Janforum. Identifying the place of theoretical frameworks in an evolving discipline. J. adv. Nurs. 11, 103-107. Holden, R. J. (1990). Models, muddles and medicine. Znt. J. Nurs. Stud. 27, 223-234. Health Advisory Service (1985). Annual Report. Kershaw, B. and Salvage, J. (Eds) (1990). Models for Nursing. Scutari Press, London. Melia, K. (1987). Learning and Working. The Occupational Socialisation of Nurses. Tavistock, London. Miller, A. (1985). The relationship between nursing theory and nursing practice. J. adv. Nurs. 10, 417-424. Reed, J. (1989). All Dressed up and Nowhere to go: Nursing Assessment in Geriatric Care. Unpublished PhD Thesis, Newcastle upon Tyne Polytechnic. Roper, N., Logan, W. W. and Tierney, A. J. (1980). The Elements of Nursing. Churchill Livingstone, Edinburgh. Sheehan, J. (1990). The Nature of the “‘Nursing Process” as a Central Concept in the Current Education of Nurses. Unpublished PhD thesis, School of Education, University of Leeds. Wells, T. J. (1980). Problems of Geriatric Nursing Care: a Study of Nurses’ Problems in Care of Old People in Hospituls. Churchill Livingstone, Edinburgh. Whittington, D. and Boore, J. (1988). Competence in nursing. In Professional Competence and Quality Assurance in the Curing Professions. Ellis, R. (Ed.). Chapman & Hall, New York. (Received 22 August 1990)
I, pp. 55-64,
1991. 0
OOZO-7489/91 $3.oO+O.W 1991 Pergamon Press plc
Nurses’ assessment of elderly patients in hospital JAN REED, R.G.N., Department
B.A.,
Ph.D.
ofHealth and Behavioural Science, Newcastle upon Tyne Polytechnic, Ellison Place, Newcastle upon Tyne, NE1 LIST, U.K.
SENGA BOND,
R.G.N.,
Ph.D.,
F.R.C.N.
Centre for Health Services Research. University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, I/. K.
Abstract-Nurses’ assessment of patients’ mobility in hospital provided the focus for an inductive qualitative study which examined how an everyday aspect of nursing practice was carried out. The study described assessment practices in both long-term care and acute care wards for elderly patients as a situated activity. Interviews with nurses, as well as observation of their activities and records, resulted in explanations of their behaviour as deriving from their conceptions of ward functions. These conceptions arose from their adoption of the values of cure and discharge and so, in the different types of ward, assessment held different meanings and was carried out in different ways. The findings have implications for nursing practice in different settings but also for the care of elderly and chronically ill patients, where cure is an inappropriate end goal of care. This example of developing explanatory theory inductively also has implications for the development of mid-range nursing theory and suggestions are made for its extension.
Introduction
That nursing care should derive from the careful assessment of a patient’s condition was brought to prominence when care planning based on ‘the nursing process’ was introduced into the United Kingdom during the 1970’s. De La Cuesta (1983) argues that it was nurses’ discontent with depersonalized, task-centred care which assisted the ready acceptance of 55
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ideas which oriented care towards the identified needs of individual patients. While there was wide ideological acceptance of proposals for more patient-centred nursing, the organizational constraints of hospital nursing with its emphasis on achieving efficiency through routine procedures severely limited the extent to which individualized care could replace ward routines. As Miller (1985) noted, often documentation suitable for a structured problem-oriented and problem-solving approach to care has been introduced but, “that is as far as it goes”. Miller and more recently Green (1990) note that the underlying beliefs and principles guiding individualized care are often absent. While the nursing process offers a framework with a recognized problem-solving style of assessment-planningimplementation and evaluation of care, Sheehan (1990) found that it was characterized in many different ways. Others have opined that this framework is, “essentially an empty approach to care” (Aggleton and Chalmers, 1986, vii). It does not tell nurses what to assess or how to plan, implement or evaluate care. Whittington and Boore (1988) ask, “If nursing is such a process, then how do nurses in fact set about each stage of it? And how do their approaches to each stage relate to patient and community well-being?” (p. 123). In a longterm care setting Green (1990) observed, “. . . there was little assessing of residents’ abilities occurring at all” (p. 26). A concern with standardization has led to attempts to attract nurses to embed the process of nursing within particular nursing models or theories (e.g. Binnie et al, 1984; Kershaw and Salvage, 1990). Others (e.g. Holden, 1990; Cash, 1990) have pointed to the impossibility of basing nursing care upon what currently pass as generalized theories of nursing while writers like Hardy (1986) have criticized the drive to the unthinking advocacy of untested theoretical schema or models. She encourages nurses to work through their own ideas about the most appropriate conceptual frameworks for the delivery of care. It remains likely that what guides nursing practice will depend on a synthesis of values, concepts, knowledge, routines, the staff and technology available in the particular setting. One such influence will be the extent to which education and nursing practice remain embedded in medically dominated structures. Medical dominance applies even in situations where patients cannot be rehabilitated or discharged from medical care. As Evers remarks, “The ‘humanitarian’ need to provide long-term care for patients who become nondischargeable from hospital is a clear embarrassment not only for the clinical-medical ‘cure’ model of health care, but also for ‘organizational’ objectives of social and health care policy.” (Evers, 1981, pp. 51-52). While continuing care of elderly people with multiple pathology, as well as social and psychological needs, potentially offers a setting in which “nursing comes into its own” (Wells, 1980), studies by Evers (1981), Wells (1980) and Fielding (1986) and more recently Bond and Bond (in preparation) show that the nursing care of long-stay elderly patients in hospital remains a routinized work system within a cure-dominated health care ethos. When cure is not possible it is patients who have ‘failed the system’; it is they who are ‘hopeless’ cases and who ‘block beds’. Rather than nursing becoming dynamic and self-governing it remains subservient both to the prevailing medical ethos as well as to the constraints of hospital organization dominated by “getting through the work” (Baker, 1978; Clarke, 1978; Melia, 1987) and reducing patients to the status of work objects. It is against this depressing picture of hospital nursing of long-term elderly patients, described in successive reports of the Health Advisory Service (1985) that the present study emerged (Reed, 1989). Nurse writers like Wells (1980) and Cormack (1985) have pinned their hopes to the problem-solving procedures of the nursing process removing the
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depersonalization and concentration on routines found in long-term care. It is debatable, however, whether nursing practice can be transformed by the introduction of new procedures if existing ways of identifying and defining patient care needs remain unacknowledged and unexplored. Such a strategy for change assumes that existing practice is without value and that it will be improved by the introduction of obviously ‘better’ approaches. These assumptions require investigation. The central concern of the study was the first stage in the formalized procedures of the nursing process, that of assessing patients for the purpose of providing nursing. The study addressed the basic questions: what is assessed? (i) (ii) how is the assessment of patients carried out? (iii) what are the nurses’ concepts of assessment? (iv) can the methods of assessment used in practice be explained as well as described? Methods
An inductive approach to theory building was adopted. This began with a period of observation in a long-term care ward of a peripheral hospital. It became apparent that the diversity of nursing activities and patient problems threatened an overwhelming degree of complexity. In order to begin theory development, the study focused on the assessment of patients’ mobility. The rationale for this choice was that not only was mobility a prevalent source of difficulty for patients, but also that it generated observable and accessible nursing activities. The range of activities that nurses regarded as encompassed within assessment included information collection though direct observation or from other sources, discussion and decision making about patients’ abilities or disabilities. This range of activities formed the basis of a checklist to guide observations which enabled the recording of the incidence and nature of observable assessment activities. Observation was conducted in two long-term care (LTC) wards in the same hospital. Theory development required theoretical rather than statistical sampling of sites and data collection was subsequently carried out in an acute/rehabilitation (A/R) ward in a second hospital. These wards were part of the same care of the elderly system, in that the A/R ward was the initial point of entry into the hospital system for those patients who subsequently would be admitted to the LTC wards. The wards came under the medical control of the same consultants, although they were situated in different hospitals and consequently had different nursing and hospital management teams. While the ward titles indicate patients with different care requirements, in fact there was some overlap as patients who were unable to be transferred had to wait in the A/R ward until an LTC bed was available. This permitted comparisons of nursing work practices with patients of the same status being cared for in wards which had different objectives of care. Observation was carried out for 14 hours on each of the study wards, covering day duty hours. An initial period of unstructured observation was repeated on each ward in order to identify any necessary modification to the checklist, and also to permit nurses and the researcher to become familiar with each other. This process of mutual habituation appeared successful in reducing the anxieties felt on both sides, and facilitated open discussion of the study. Acknowledgement of nurses’ views about the research topic, grounded the structure of the study in the practitioners’ perspective. In addition, nurses appeared to feel under no obligation to present idealized pictures of nursing. Greater methodological detail is available from Reed (1989).
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Results
I. The LTC wards The context and frequency of assessment Over the period of observation on the two LTC wards a total of 19 assessment activities were observed. An initial analysis of the context in which they occurred revealed that the majority (15) occurred while nurses were engaged in working with patients as opposed to during formal reports or change of shift handovers. The assessments consisted of informal descriptions of patients’ abilities, rather than identified possible activities, such as the experimental use of mobility aids. These descriptions did not result in proposals for change in the way in which the patient was nursed. Changes which were proposed concerned how the existing routine of care could be implemented more effectively. Observed assessment Each assessment was initially coded to reflect the themes they illustrated. This activity generated four categories. These were: (i) Global assessments. Generalized statements about the patients as a group. For example: “They’re all hopeless on here, none of them can do anything for themselves.” (ii) Workload related assessments. Estimates of equipment or staff needed to complete predetermined routines of care, rather than to meet individual patient’s needs. For example: “He’s getting worse, we’ll need two to move him.” (iii) References to patients’personal characteristics. Assessments which attributed mobility problems to the personal characteristics of the patient, and therefore not directly amenable to nursing intervention. The comment from one of two nurses attempting to transfer a patient from a wheelchair to armchair was: “She’s hopeless, she’s just being awkward.” Attributing problems to patient characteristics such as ‘awkwardness’, ‘laziness’, and ‘silliness’, was not met with suggestions for nursing intervention or changes in approach beyond that of increasing the numbers of staff, or changing the equipment used to complete routines of care. (iv) Ward function related assessments. Similar to, and originally included in, the category of global assessments. They were, however, differentiated from global assessments because they included specific reference to the function of the ward as a place to which ‘no hopers’ were sent. This perceived function was used as an indication of patients’ abilities, for example: “Of course he can’t do that, this is long-term care you know, not rehab.” Written assessments In addition to verbal exchanges, expressions of assessments were found in written care plans. Forms on which to record patient information according to the problem-solving format of the nursing process had recently been introduced by nurse managers. The main sections of the nursing records were (i) the patient profile, which contained personal and medical details, as well as a brief functional assessment; (ii) the nursing care plan, which identified patients’ problems using an Activities of Daily Living model (Roper et a/., 1980), and also contained prescriptions for nursing care, and (iii) the daily record of care. The first two sections were the main source of data, but there were variations in the way nurses had organized their entries. An example was one nursing record in which no mention was made anywhere of a mobility problem and this had to be inferred from an entry in the patient profile which recorded a past medical history of “left CVA with contractures and Parkinson’s disease.”
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The most striking feature of the care plan entries was the uniformity of terminology used. In detailing the mobility status of the patient, nurses used a dichotomous classification in both the patient profiles and in the care plans whereby patients were described as either ‘Mobile’ or ‘Immobile’. The descriptor ‘Immobile’ was occasionally supplemented by a functional description. Again the range of terms was limited and only one type of description was found which centred on the number of nurses required to mobilize the patient. These same categories were repeated in the section detailing prescribed nursing care, i.e. a patient described as needing two nurses to stand, was prescribed nursing care which consisted of “two nurses to stand and transfer”. More elaborate prescriptions were found where the mobility problem was classified as a ‘problem’ of ‘maintaining a safe environment’, when there were supplementary instructions, for example to ‘ensure brakes were applied to wheelchairs correctly’. These prescriptions reflected a managerial rather than therapeutic approach to nursing care, i.e. the care did not aim to improve or maintain the current mobility status, but to accommodate immobility within the ward routines. Some attempt was made to introduce a therapeutic component, but these were vaguely worded, for example ‘encourage to stand’. These ‘encouragements’ however were accompanied by a concern for patients’ safety, as in the case of one patient who was prescribed to be encouraged to stand but also have the restraining table across the front of his Buxton chair securely fastened at all times, and to have ‘two nurses to transfer’ when his problem of maintaining a safe environment was discussed. The recorded aims of care were correspondingly vague and on occasion contradictory. Maintaining safety, by immobilizing patients and not putting them at risk of falling then limited the possibility for improving mobility. 2. The acute/rehabilitation ward Observation data consisted of 36 assessment activities, and their qualitative analysis resulted in the development of an additional category, ‘scientific assessment’. All but 10 assessment activities fell into this category. Scientific assessments
These assessments were remarkably similar to the procedures advocated by nursing textbooks, in that they involved undertaking specific activities in order to gauge the extent of the patients’ problem. For example, one nurse approached a patient in bed and said “I’m going to try to get you out of bed myself this morning . . . I want to see if you can do it.” Other activities included the experimental use of mobility aids and discussions with physiotherapy staff about the patients’ mobility status. A striking characteristic of many of these scientific assessments was the explicit concern with discharge and cure. Patients were congratulated on their progress but also reminded that this would bring them closer to discharge. Those patients who were waiting for beds on the LTC wards were also subject to the goal of discharge. One female patient was told “If you keep practising, the world’s your oyster. Even if you stay (on LTC) you’ll be able to get about, and who knows, you might even get home.” The goal of discharge was not abandoned but merely postponed. Scientific assessment with its goal of discharge was linked to the ward function as the nurses portrayed it. Phrases like “you’re here to get better” and “we’re here to get you home”, illustrate this perception of the ward as a place devoted to the restoration of independence.
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Personal characteristics and global assessments The assessments which were classified as being concerned with patients’ personal characteristics also reflected the importance of ward function for nurses. The personal characteristics which were judged to perpetuate poor mobility were described as “poor motivation” and “hopelessness” which were obstructing the goals of the ward. Similarly the one global assessment referred to the patients as believing that “because it’s a geriatric ward they think they’re all here to die”. This belief was regarded as erroneous and incompatible with the nurses’ belief that the patients were there to get better. Written assessments The care plans in the A/R ward were kept at the foot of the patients’ beds. The aetiology of mobility problems was written in some detail, expressed in terms of medical conditions. As one nurse stated, “You see, the diagnosis is the most important thing, you base your nursing care around it.” The descriptions of functional impairment were also detailed, and these served as headings for care prescriptions, rather than routine Activities of Daily Living. Despite this attention to particularizing the problems of individual patients, the prescribed nursing care followed a largely uniform pattern, with goals of care focusing on the same stages on the road to mobility. These stages involved the development of the ability to weight bear, followed by the increase in ability to walk with various aids, until these were finally jettisoned and the patient was walking unaided. Variations between individuals were found in their rate of progress, or lack of progress through these stages.
Interviews
The findings from the observation of nursing activities and analysis of nurses records were extended and further developed by a formal interview study. An interview agenda was developed which was informed by the data collected during observation of the practice of assessment, but which was sufficiently broad and flexible to enable potential unexpected or unknown issues to be explored. I. The L TC wards interviews Analysis of the interview data collected from nurses in the LTC wards revealed three major value systems. These value systems varied in the extent to which the nurses adhered to them or supported them as relevant to their practice, but all had implications for nursing assessment. Being up-to-date. Nurses described themselves initially as being up-to-date, giving as evidence the fact that they had adopted the nursing process. On further exploration, however, being up-to-date (or using the nursing process) presented problems for the nurses. They stated that they had received little help in implementing the nursing process, but perhaps more significantly, saw the recording procedures as irrelevant to their practice, given the setting in which they worked; “Well you just write the same things, they’re (patients) all the same on here, and nothing ever changes, it’s’not like acute care.” Another expressed concern was that the use of a problem-solving approach afforded little satisfaction, as the patients’ problems were never “solved”. Problems, defined as medical conditions, were permanent states which could not be “cured”. The nurses differentiated between “proper problems” which could be eradicated, and “conditions” which could not; “Well you see, they don’t have proper problems, things that you can
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get rid of, they just have conditions really. Apart from pressure sores sometimes, you can cure those.” The imperative of absolute cure was not modified to include amelioration of problems, maintaining current function or prevention of deterioration. Conditions were managed through the ward routines. This made the care plans, espoused as the means of communicating the individualized care of patients, in reality, window dressing. Their content reflected unvarying ward routines, rather than individual patient’s needs or goals of care and nursing action. Beingprofessional. This set of values was concerned with appearing distant and serious in front of visitors and senior nurses. Staff talked about “being caught carrying on” by visitors to the ward, which they said did not “look professional”. As well as portraying a particular demeanour, “being professional” also involved being ready and prepared to cope with any acute medical emergency, however unlikely it was to occur. Therefore nurses engaged in routines like checking resuscitation trolleys weekly even when they had not been or would not be used. As one nurse put it; “What it is, we’re all dressed up with nowhere to go. Here we are in hospital, all the gear, all the equipment, all in uniform, all the rules and regulations, but we don’t do what a hospital does. We’re a half hospital. We look like a hospital, but we don’t get anybody better so we’re not.” Again this value system was overtly supported, but on further exploration was rejected by those nurses who saw the acute care model as embodying high status, and proper nursing, but inappropriate for their work in LTC. They were thus caught up in conflicting value systems. Good geriatric cure. This was the value system most supported by nurses. “Good geriatric care” involved unremitting physical labour attendant on completing the ward routines. The aims of these routines were to “keep the ward clean and tidy” and to “get everything nice”. Nurses stressed their satisfaction with the hard work they did; “You really feel you’ve earned your money here, I like that, I don’t like hanging about.” “Good geriatric care” provided goals which the nurses saw as realizable, in contrast to the other value systems which were largely espoused for the benefit of visitors to the wards. Working hard and “getting everything done” however, precluded encouraging patients to do things for themselves; “it would take too long” and, as the nurses saw it, give them “nothing to do but hang around waiting.” This emphasis on getting through the work also precluded attention to individual assessments of patients, as catering for any but minor variations on the general needs met by the ward routines would impede the progress of nurses’ work. 2.The A/R ward interviews Analysis of the interview data on the acute care ward yielded very different findings. The values of being up-to-date and professional were not discernible. Indeed there was rather a dismissive attitude towards these values, which were acknowledged as being held by nurse managers. The nurses did not feel obliged to present any form of facade to these managers and described themselves as having “no time for all of that rubbish.” They used a nursing process format, but had adapted official presentations of it to their own requirements. Being ready for medical emergencies was a value that they espoused, but this was not part of “looking professional” but part of what they called “good acute care”. Good acute cure. This kind of care was as effective in curing their elderly patients as those in any other type of general acute care ward. Nurses frequently made comparisons with the medical ward within the same operational unit, stating that their work was virtually identical to the work done on this ward. When discussing the low status accorded to geriatric
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care by other staff, the nurses on A/R defended their claims to a higher status by reference to the similarities between their work and that of nurses on other acute wards. This differed from the argument made by the nurses in LTC which was based on the amount of hard physical work they did. As a facilitator of “getting patients better” nursing assessment was seen as a crucial part of nursing “otherwise you’d do the wrong things and stop the patient’s progress”. Assessment was based, in the nurses view, on the medical diagnosis, despite the evidence of the care plans that suggested that whatever the cause of the patient’s mobility problem, the prescriptions for nursing care followed a uniform pattern while varying in content. This reliance on medical classifications and goals to provide direction and meaning for nursing work was apparent throughout the data collected on A/R-from the way in which the care plans were written, to the way in which nurses perceived the ward function and subsequently their own role. Discussion Central to the styles of assessment found in each type of ward was the focus on cure as an ideal aim of nursing activity. The goal of cure, as contained within the medical model of treatment was the fundamental criterion by which nurses evaluated their work. In A/R, cure and subsequent discharge was the raison d’Ctre of the ward and of the nurses, and their efforts were directed towards achieving this. Discussions with nurses revealed that they felt that they achieved this and derived satisfaction from this achievement. As Evers (1981) found, the rapid cure and discharge goal was shared between staff and was therefore unproblematic, unless dealing with patients who were awaiting transfer to LTC, when the goal was postponed. Scientific assessment in line with the policy and objectives for hospital geriatric care was therefore important as a basis for planning nursing care. On the LTC wards the nurses also evaluated their work by the yardstick of cure. This caused many more problems for them than it did for the nurses who worked where cure, or at least discharge from hospital, was a possibility. The seeming inappropriateness of cure as the end point in their work prevented nurses from valuing what they did which was associated with cure. To overcome this they sought satisfaction primarily from giving ‘good geriatric care’ which was achievable within their own terms of reference. This involved investment in the speedy and efficient completion of ward routines, which precluded assessment of individual patients’ problems. Other values, such as professionalism, which were adopted for the benefit of visitors and senior nurses, involved maintaining a facade of acute care concerns. Again this espoused professionalism precluded addressing the needs of individual patients. This central concern with cure could be traced back to nurses’ experiences prior to working in wards in the geriatric sector. Incidents were reported when they had been discouraged from “wasting” themselves and their training, when applying for the posts in which they were employed. This discouragement came from colleagues, friends and nurse educators who regarded care of elderly people as low-status and unstimulating work. Furthermore, the hospital system in which they worked reinforced the primacy of cure, by enforcing uniform policies, which did not acknowledge the differences between wards and their objectives for patients. Similarly, enforcing the use of a universal ‘problem-solving’ approach to care plan writing reinforces the idea that patient problems must be solved by nurses. This, when combined with the endemic definition of problems in medical terms, put the nurses in LTC in a no-win position.
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The nurses of LTC wards therefore faced great problems in attempting to find satisfaction in their work, and the solution they chose, “good geriatric care” was not conducive to patient-centred assessment. This value system does, however, represent a move away from cure-centred values, albeit a clandestine one. Ironically it was the nurses in A/R who demonstrated more direct medical influence on their perceptions than the nurses in LTC, who acknowledged the status and desirability of adopting medical values but also their irrelevance in LTC. Adoption of rehabilitation as a central value of geriatric medicine similarly is of dubious value in LTC settings. These data point to the need for nursing to clarify its values in association with the kind of care regarded as appropriate in different settings. As Faucett et al. (1990) have demonstrated, when care was oriented towards taking account of patients’ abilities and involvement in their own care then nursing assessments and prescriptions for nursing care changed in an LTC setting.
Conclusion
This study represents an attempt to develop nursing theory through an inductive approach. Its focus on an everyday aspect of nursing practice in different settings and its relationship to how nurses regard their work requires to be extended to other aspects of care and to other settings where different value systems hold. While offering a bottom up approach to theory development with explanatory powers, the study also yields findings of practical value. It points to the futility of introducing practices, like completing nursing process documentation which are at odds with nurses’ value systems and levels of functioning. As a consequence such activities become routinized into another administrative task to be completed to meet the decree of managers with no recognizable benefits for patients or staff. It reinforces the inappropriateness of a medical model of care, emphasizing cure or rehabilitation, for continuing care and chronically ill patients, and suggests that so long as there is adherence to such a model, nursing staff will reap little by way of satisfaction from the care they provide while the benefits to patients are limited. It poses the question of what kind of nursing or social welfare models of care might replace it and the extent to which these can exist in hospitals which cater for a range of different types of patients. Acknowledgements-Jan Senga Bond is funded
Reed was funded by the Department
by Newcastle Health Authority while this study was in progress of Health. Freda Bolam kindly typed the manuscript.
and
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