Caring for older patients at an emergency department -- emergency nurses' reasoning.

AIM: The aim of the study was to use the experiences of emergency nurses to illuminate what constitutes good nursing care for patients 75 years or older transferred to emergency departments. BACKGROUND: Emergency departments have a medical technical character and the number of visits there increases dramatically as people age. Older patients require increased healthcare services in terms of nursing care, interventions and hospitalizations due to an increased complexity of their problems. For these reasons it is important to study what good nursing care of the older patients consists of at an emergency department from the emergency nurses' point of view. METHOD: Ten emergency nurses from a university hospital emergency department in Sweden were interviewed. A thematic content analysis was performed. RESULTS: The study showed that it was necessary to be knowledgeable, to be understanding of the older patients' situation and to take responsibility for them in order to be able to provide good nursing care. The emergency nurses shifted focus from describing the central aspect of good nursing care to describing what hinders the provision of it. Their experience was that prioritizing medical procedures, everyday tasks and routines threatens good nursing care of older patients in emergency departments. The emergency nurses held that the older patient is often sent to an emergency department where the level of care is not appropriate to their needs. CONCLUSIONS: The result can be seen as a challenge for the organization and the nurses in the future; to prioritize differently, thereby maintaining a balance between good nursing and medical/technical tasks when treating older patients. RELEVANCE TO CLINICAL PRACTICE: The present day healthcare system is not organized to appropriately meet the needs of the older patients. Nurses themselves hold they can better serve the older patient. By sharing their experiences, both can be accomplished.

Older patients awaiting emergency department treatment.

The aim of this study was to describe, through observations and interviews with patients >/=75 years old and the relatives who accompanied them to the hospital, the conditions at the emergency department (ED) and the events that took place during the waiting period. Twenty older patients were studied, together with their relatives. A modification of a comparative design, the interpretative method 'grounded theory', was utilized. Open, nonparticipant observations were carried out; from the time patients were admitted until the time they were discharged. Patients were observed through all stages, for example, in the reception area, in the examination room, and in the X-ray department. The observations were supplemented with field notes and interviews with the older patients as they left the ED. The selective coding developed into six core-variables that were the focus of the material. These were: unpleasant waiting, unnecessary waiting, lack of good routines during the waiting stage, suffering during the waiting stage, bad feelings during the waiting stage and nursing care during the waiting stage. The way, in which nursing care was carried out, which in this context is discussed in terms of praxis and poieses, appeared to be of major importance for the older peoples' experiences when visiting the ED.

Dementia and aggressiveness: stimulated recall interviews with caregivers after video-recorded interactions.

BACKGROUND: In a previous study, nine caregivers and two residents with dementia showing aggressive behaviour, were video recorded. Caregivers who reported problems when dealing with such behaviour and caregivers, who did not, were included in this study. AIM: The aim of the present study was to obtain insight into the reasoning of the caregivers who had reported problems when dealing with older people with dementia and aggressiveness and those who did not relative to their respective video-recorded interactions with these residents. A further aim was to gain insight by discussing their reasoning in relation to each other. METHOD: Stimulated recall interviews were carried out with all the caregivers who had been video taped in the previous study. The text was analysed by thematic content analysis. FINDINGS: Two main ways of thinking and discussing the care situations emerged. The caregivers, who had reported problems in handling behavioural and psychiatric symptoms in dementia earlier, reasoned that they were more focused on their duties, this included being responsible for the resident receiving her weekly shower. For this group of caregivers, the well being of the resident was in focus, but their attention was concentrated on the resident's well being and comfort after their shower. However, these caregivers seemed therefore unwittingly to prevent a positive interaction with the resident. The other caregivers were able to reflect spontaneously and appeared to be self-critical. This caregiver group seemed to sustain a positive interaction with the resident both during and after the shower. RELEVANCE TO CLINICAL PRACTICE: In this study a nurturing and supportive climate and competence seemed to be the conditions necessary to facilitate reflections and promote creativity in the caregivers such that they are able to develop possible ways of handling difficult situations like aggressiveness in residents with dementia.

Meeting ethical challenges in acute care work as narrated by enrolled nurses.

Five enrolled nurses (ENs) were interviewed as part of a comprehensive investigation into the narratives of registered nurses, ENs and patients about their experiences in an acute care ward. The ward opened in 1997 and provides patient care for a period of up to three days, during which time a decision has to be made regarding further care elsewhere or a return home. The ENs were interviewed concerning their experience of being in ethically difficult care situations and of acute care work. The method of phenomenological-hermeneutic interpretation inspired by the French philosopher Paul Ricoeur was used. The most prominent feature was the focus on relationships, as expressed in concern for society's and administrators' responsibility for health care and the care of older people. Other themes focus on how nurse managers respond to the ENs' work as well as their relationships with fellow ENs, in both work situations and shared social and sports activities. Their reflections seem to show an expectation of care as expressed in their lived experiences and their desire for a particular level and quality of care for their own family members. A lack of time could lead to a bad conscience over the 'little bit extra' being omitted. This lack of time could also lead to tiredness and even burnout, but the system did not allow for more time.

Dementia and aggressiveness: video recorded morning care from different care units.

The aim of the study was to illuminate, from video recorded sequences, interactions between individuals with dementia and aggressive behaviour and caregivers who reported problems dealing with such behaviour and caregivers who did not. Nine caregivers and two residents participated. The video recordings were later transcribed into text and analysed by using a phenomenological hermeneutic approach, inspired by Ricoeur's philosophy. The main themes that emerged from the analysis were 'Being involved and developing a positive interaction' and 'Being confined to routines and remaining in negative interaction'. The findings indicated the interactions either to be in a positive or negative spiral. Caregivers who had reported problems dealing with behavioural and psychiatric symptoms in dementia focused on accomplishing the task, where the main focus was on 'the goal itself'. In other sequences with caregivers who had been satisfied with their capability the focus was placed on 'how' the caregivers could reach their goal. Power was central in the material, in different ways, either as a possible way to handle the situation or as a possible way of defending oneself. Parts of Kitwood's framework and Fromm's theory about power 'over' and power 'to', has been used in the comprehensive understanding. Our conclusion is that caregivers should use power 'to' when they have to help persons with dementia and aggressive behaviour, as a part of behavioural and psychiatric symptoms of dementia, for being able to give help in the best possible way. They should also act in a sensitive and reflective manner, with the individual in focus.

Referrals from home care to emergency hospital care: basis for decisions.

The Swedish government implemented a reform, the Adel reform, in the care of older citizens in 1992, so that the communities where older people live became responsible for their care and housing. Nurses were appointed to make sure that older people were given accurate care and to act as supervisors for nurses' aides. In this study, 10 Registered Nurses from community home care services and four consultant head physicians in primary care were interviewed in order to illuminate what they thought influenced nurses' decisions to refer patients for emergency treatment and what support they requested to facilitate the decision. Content analysis showed the necessity of feeling secure in one's role as a community nurse. The categories that developed were: own competence, knowledge about the patient and a supportive working environment. The main theme was To feel safe in one's role - a basis for decision-making. High demands were put on the nurses' competence and their burden of responsibility became too great. This influenced decision-making negatively, if nurses felt that they were lacking in their own personal competence. Training in documentation for the nurses was required, as well as the need for organizations to provide staff with sufficient time for accurate documentation. A greater input of nursing and medical care was required to make it possible for patients to be cared for at home if they so wished. Respondents described considerable deficiencies in their working environment and in co-workers' competence, and nurses' professional roles within the community were not made clear. If these problems were remedied, this would improve working conditions, increase understanding, and reduce feelings of uncertainty among decision-makers.