The profile and follow-up of patients who attend the Emergency Department following a fall.

UNLABELLED: Falls in the older population are associated with increased morbidity and mortality especially in the absence of risk reduction measures. The study aims were to compare the characteristics of older people who present to the Emergency Department (ED) following a fall with the general older ED population and examine referral patterns following ED discharge. Face-to-face interviews were carried out with 306 people aged 65 years or older. Data was collected on demographic, socio-economic, health and social support factors. Descriptive and inferential statistics (Pearson chi-square test or independent t-test) were used to compare the falls and non-falls group. Falls occurred in 17% (53/306) of the study population and 43% sustained an injury requiring medical intervention. Patients in the falls group were significantly more likely to be female (68%), older (79 years (SD 6.6)) and living alone (59%). The physical and mental health profile of the falls and non-falls group was similar with 30-40% of people in both groups experiencing moderate to severe physical health impairment. A third of the falls group was discharged from the ED without evidence of referrals. CONCLUSION: The older population that present to the ED following a fall requires comprehensive risk factor assessment especially physical function and referrals that include falls prevention. Implications for staff: ED staff need to examine current practice within their ED in relation to falls assessment, management and referral pathways.

Boundary matters: clinical leadership and the distinctive disciplinary contribution of nursing to multidisciplinary care.

AIMS: To describe Irish nurses' views of clinical leadership and to describe their clinical leadership development needs. BACKGROUND: Nurses are often unclear about the precise nature of clinical leadership and its impact on the processes and outcomes of care and little is known about their self-perceived clinical leadership development needs. DESIGN: Seventeen focus group interviews were conducted with a purposive sample of 144 nurses from 13 practice settings. A conceptual lens was provided by the work of Bernstein and Young who emphasise the epistemological, practical and relational significance of boundaries and how they relate in fundamental ways to professionals' sense of their distinctive disciplinary identities and membership of specialised communities of practice. METHODS: Focus group data were collected using semi-structured topic guides. Analysis was facilitated by NVivo 7© and interpretation was informed by a conceptual framework arising from the interplay of emerging themes and the literature review. RESULTS: The implications for clinical leadership development of two critical concepts, 'representing nursing' and 'compensatory action', are discussed in detail. CONCLUSIONS: Clinical leadership development should emphasise the development of all nurses as clinical leaders in the context of the delineation, clarification and articulation of their distinctive contribution in multidisciplinary care settings. RELEVANCE TO CLINICAL PRACTICE: Clinical leaders are recognised as practice experts and as leaders in their particular fields. Recognition and influence in and beyond the immediate context of care depends greatly on their ability to articulate the distinct nursing contribution to patient care. This ability provides an essential resource to resist the ongoing blurring, effacement and dilution of nurses' roles.

How different are older people discharged from emergency departments compared with those admitted to hospital?

OBJECTIVE: To compare the characteristics of older people presenting to the emergency department (ED) and admitted to hospital with those discharged directly from the ED and identify factors independently associated with hospital admission. DESIGN: This is a cross-sectional survey of 306 community dwelling people aged 65 years or older presenting to two hospital EDs. A structured questionnaire and ED records were used to collect patient demographics, socioeconomic, physical, cognitive and social network information. STATISTICS: The profile of admitted and discharged patients was compared using the χ statistic. Logistic regression was used to identify factors independently associated with hospital admission. Odds ratios (OR) and 95% confidence intervals (CI) are presented. RESULTS: The analysis involved 306 patients, 158 admitted and 148 discharged home. There was no significant difference in demographic, socioeconomic, cognitive and social networks between the groups. Factors independently associated with hospital admission in the multivariate model were as follows: prior hospital admission OR 6.16 (95% CI 2.61, 14.50), Manchester Triage category 1-2 OR 5.01 (95% CI 1.19, 21.10), low-energy levels OR 3.97 (95% CI 1.32, 11.9) and presenting with cardiac OR 3.59 (95% CI 1.05, 12.3), neurological OR 4.47 (95% CI 1.21, 16.5) or respiratory-related conditions OR 11.2 (95% CI 2.41, 51.9). Among the cohort of discharged patients, 20-30% shared similar physical and mental health characteristics to admitted patients. CONCLUSION: In this elderly population, health-related variables were the only independent factors associated with hospital admission. Approximately 30% of patients discharged home from ED had similar risk profiles to admitted patients.

The role of health and non-health-related factors in repeat emergency department visits in an elderly urban population.

INTRODUCTION: Patients aged 65 years or older account for a growing proportion of emergency department (ED) repeat attendances. This study aimed to identify health and non-health factors associated with repeat ED attendance, defined as one or more visits in the previous 6 months in patients aged 65 years or older, and to examine the interaction between social and health factors. METHODS: 306 patients were interviewed. Demographic, socioeconomic, physical, mental health and post-ED referrals were examined. Logistic regression was used to identify factors independently associated with a repeat ED visit, OR and 95% CI are presented. Log likelihood ratio tests were used to test for interactions. RESULTS: ED revisits were reported by 37% of this elderly population. Independent risk factors for a repeat ED visit were previous hospital admission OR 3.78 (95% CI 2.53 to 5.65), anxiety OR 1.13 (95% CI 1.04 to 1.22), being part of a vulnerable social network OR 2.32 (95% CI 1.12 to 4.81), whereas a unit increase in physical inability as measured by the Nottingham Health Profile had a week association OR 1.01 (95% CI 1.00 to 1.02). There were no significant interactions between social networks and the other health-related variables (p>0.05). In patients directly discharged from ED, 48% (71/148) had no documented referrals made to community services, of which 18% (27/148) were repeat ED attendees. CONCLUSION: ED act as an important safety net for older people regardless of economic or demographic backgrounds. Appropriate assessment and referral are an essential part of this safety role.

In the know: cognitive and social factors in mental health nursing assessment.

AIMS AND OBJECTIVES: To develop an integrated cognitive and social understanding of assessment in mental health nursing. BACKGROUND: Assessment is a vital component of nursing care for mental health service users, largely driven by a tacit, experiential model of assessment; this approach is at variance with an evidence-based approach to assessment. DESIGN: A qualitative design was employed in the study, with a thematic analysis carried out on transcripts of focus groups with mental health nurses. METHOD: Ten focus groups were carried out, guided by questions on nurses' contribution to care and the problems patients present with. Fifty-nine registered mental health nurses were sampled from eight acute and community mental health services across urban and rural regions in Ireland. RESULTS: References to assessment were identified (how nurses acquired information, how it was made sense of and used in the system of care). Assessment talk was characterised by reliance on a experientially based clinical schema and recognition of the task environment's shaping influence. Nurses' clinical knowledge was a pragmatic tool that permitted nurses to assess risk, promote patient engagement and work with doctors. CONCLUSIONS: Nurses strived to 'know the patient', while having to 'work the system', with implications for patient care and decision-making quality. Reliance on experiential knowledge is a professional trait, but one that renders nursing assessment 'invisible' in significant ways. RELEVANCE TO CLINICAL PRACTICE: Cognitive and social aspects of nursing decision-making have been considered apart from one another, whereas cognitions about mental health conditions are, in fact, applied in a pragmatic, task-oriented organisational system. Nurses believed that spending time with the service user led to a privileged position of knowledge in comparison with doctors ('knowing the person'), but this knowledge is frequently applied to the task of 'knowing the patient', assessing the person as a source of risk and danger.

Psychosocial care in mental health nursing: a think aloud study.

AIM: This paper is a report of a study identifying psychosocial interventions relevant to routine care and exploring their content critically and analysing patterns in the use of these interventions. BACKGROUND: People experiencing enduring and serious mental disorders value psychosocial engagement as a means of achieving recovery and rehabilitation. However, mental health nurses' use of person-centred and directive psychosocial engagement in routine care is unclear, with the potential arising for benevolence and paternalism. METHOD: A think aloud study was carried out with 37 mental health nurses responding to a simulated case depicting a person with an enduring mental health problem. Participants were recruited from community and acute hospital facilities across Ireland and responded to two tasks: identifying the nature of the person's problems and recommending what to do next. Transcripts were coded using judgement and intervention themes designed for the purpose. Patterns in the use of psychosocial intervention themes were described and further analysed by level of experience (highly experienced or not) and practice setting (acute/community setting). FINDINGS: A task-oriented psychosocial intervention labelled structured engagement was used extensively, followed by reassurance and encouragement based on pragmatic communication. A minority of nurses used dialogue, representing person-centred care. Highly experienced community mental health nurses were the most likely to talk in terms of intensive psychosocial engagement. CONCLUSION: Relying on pragmatic problem-solving is problematic in terms of decision-making transparency and service user involvement. The use of informal knowledge in practice should be negotiated through more open discussion by nurses, including adoption of a consensus on the components of psychosocial care.

Ambiguities and conflicting results: the limitations of the kappa statistic in establishing the interrater reliability of the Irish nursing minimum data set for mental health: a discussion paper.

BACKGROUND: In a study to establish the interrater reliability of the Irish Nursing Minimum Data Set (I-NMDS) for mental health difficulties relating to the choice of reliability test statistic were encountered. OBJECTIVES: The objective of this paper is to highlight the difficulties associated with testing interrater reliability for an ordinal scale using a relatively homogenous sample and the recommended kw statistic. METHOD: One pair of mental health nurses completed the I-NMDS for mental health for a total of 30 clients attending a mental health day centre over a two-week period. Data was analysed using the kw and percentage agreement statistics. RESULTS: A total of 34 of the 38 I-NMDS for mental health variables with lower than acceptable levels of kw reliability scores achieved acceptable levels of reliability according to their percentage agreement scores. CONCLUSION: The study findings implied that, due to the homogeneity of the sample, low variability within the data resulted in the 'base rate problem' associated with the use of kw statistic. Conclusions point to the interpretation of kw in tandem with percentage agreement scores. Suggestions that kw scores were low due to chance agreement and that one should strive to use a study sample with known variability are queried.

Reconsidering the conceptualization of nursing workload: literature review.

AIM: This paper reports a literature review that aimed to analyse the way in which nursing intensity and patient dependency have been considered to be conceptually similar to nursing workload, and to propose a model to show how these concepts actually differ in both theoretical and practical terms. BACKGROUND: The literature on nursing workload considers the concepts of patient 'dependency' and nursing 'intensity' in the realm of nursing workload. These concepts differ by definition but are used to measure the same phenomenon, i.e. nursing workload. METHOD: The literature search was undertaken in 2004 using electronic databases, reference lists and other available literature. Papers were sourced from the Medline, Psychlit, CINAHL and Cochrane databases and through the general search engine Google. The keywords focussed on nursing workload, nursing intensity and patient dependency. FINDINGS: Nursing work and workload concepts and labels are defined and measured in different and often contradictory ways. It is vitally important to understand these differences when using such conceptualizations to measure nursing workload. A preliminary model is put forward to clarify the relationships between nursing workload concepts. CONCLUSION: In presenting a preliminary model of nursing workload, it is hoped that nursing workload might be better understood so that it becomes more visible and recognizable. Increasing the visibility of nursing workload should have a positive impact on nursing workload management and on the provision of patient care.

Developing a data dictionary for the irish nursing minimum dataset.

One of the challenges in health care in Ireland is the relatively slow acceptance of standardised clinical information systems. Yet the national Irish health reform programme indicates that an Electronic Health Care Record (EHCR) will be implemented on a phased basis. [3-5]. While nursing has a key role in ensuring the quality and comparability of health information, the so- called 'invisibility' of some nursing activities makes this a challenging aim to achieve [3-5]. Any integrated health care system requires the adoption of uniform standards for electronic data exchange [1-2]. One of the pre-requisites for uniform standards is the composition of a data dictionary. Inadequate definition of data elements in a particular dataset hinders the development of an integrated data depository or electronic health care record (EHCR). This paper outlines how work on the data dictionary for the Irish Nursing Minimum Dataset (INMDS) has addressed this issue. Data set elements were devised on the basis of a large scale empirical research programme. ISO 18104, the reference terminology for nursing [6], was used to cross-map the data set elements with semantic domains, categories and links and data set items were dissected.