Fast thinking: How unconscious bias and binary language contribute to rationing of care to older persons.

BACKGROUND: Binary or categorical thinking is a way of thinking in which the brain unconsciously sorts the masses of information it receives into categories. This helps us to quickly process information and keeps us safe through pattern recognition of possible threats. However, it can also be influenced by unconscious and conscious biases that inform our judgements of other people and situations. OBJECTIVES: To examine nursing practice with older people through the lens of unconscious bias. METHODS: In this critical analysis, using Kahneman's fast and slow thinking, we argue that nurses working with hospitalised older people often rely on thinking quickly in hectic work environments, which can contribute to unconscious and conscious bias, use of binary language to describe older persons and nursing tasks, and ultimately rationing of care. RESULTS: Binary language describes older persons and their care simplistically as nursing tasks. A person is either heavy or light, continent or incontinent, confused or orientated. Although these descriptions are informed in part by nurses' experiences, they also reflect conscious and unconscious biases that nurses hold towards older patients or nursing tasks. We draw on explanations of fast (intuitive) and slow (analytical) to explain how nurses gravitate to thinking fast as a survival mechanism in environments where they are not supported or encouraged to think slow. CONCLUSIONS: Nurses survival efforts in getting through the shift using fast thinking, which can be influenced by unconscious and conscious biases, can lead to use of shortcuts and the rationing of care. We believe that it is of paramount importance that nurses be encouraged and supported to think slowly and analytically in their clinical practice. IMPLICATIONS FOR PRACTICE: Implications Nurses can engage in journaling and reflecting on their practice with older people to examine possible unconscious bias. Managers can support reflective thinking by supporting nurses through staffing models and encouraging conversations about person-centered care in unit practices.

Nursing practice with hospitalised older people: Safety and harm.

BACKGROUND: Nursing teams work with hospitalised older people in institutions, which prioritise a biomedical model of care. This model does not fit the needs of older people because it emphasises efficacy and a narrow definition of patient safety, but does not prioritise functional needs. Nursing care is provided around the clock within the context of fiscal restraints as well as negative societal and nursing perspectives about ageing and old people. Yet, nursing perceptions of managing safety and potential harms to older patients within these hospital institutions are not well understood. METHODS: An integrative review was conducted to examine nursing perspectives of safety and harm related to hospitalised older people. RESULTS: The majority of included papers focused on restraint use. Findings reveal that nurses are using restraints and limiting mobility as strategies to manage their key priority of keeping older patients safe, reflecting a narrow conceptualisation of safety. Policy, administrative support and individual nurse characteristics influence restraint use. Safety policies that nurses interpret as preventing falls can encourage the use of restraints and limiting mobility, both of which result in functional losses to older people. CONCLUSIONS: This complex issue requires attention from clinical nurses, leaders, policy makers and researchers to shift the focus of care to preservation and restoration of function for older people in hospital as a safety priority. IMPLICATIONS FOR PRACTICE: Clinical leaders and nursing teams should engage in developing processes of care that incorporate maintaining and restoring older people's function.

Orchestrating care: nursing practice with hospitalised older adults.

BACKGROUND: The increased incidence of health challenges with aging means that nurses are increasingly caring for older adults, often in hospital settings. Research about the complexity of nursing practice with this population remains limited. OBJECTIVE: To seek an explanation of nursing practice with hospitalised older adults. METHODS: Design. A grounded theory study guided by symbolic interactionism was used to explore nursing practice with hospitalised older adults from a nursing perspective. Glaserian grounded theory methods were used to develop a mid-range theory after analysis of 375 hours of participant observation, 35 interviews with 24 participants and review of selected documents. RESULTS: The theory of orchestrating care was developed to explain how nurses are continuously trying to manage their work environments by understanding the status of the patients, their unit, mobilising the assistance of others and stretching available resources to resolve their problem of providing their older patients with what they perceived as 'good care' while sustaining themselves as 'good' nurses. They described their practice environments as hard and under-resourced. Orchestrating care is comprised of two subprocesses: building synergy and minimising strain. These two processes both facilitated and constrained each other and nurses' abilities to orchestrate care. CONCLUSIONS: Although system issues presented serious constraints to nursing practice, the ways in which nurses were making meaning of their work environment both aided them in managing their challenges and constrained their agency. IMPLICATIONS FOR PRACTICE: Nurses need to be encouraged to share their important perspective about older adult care. Administrators have a role to play in giving nurses voice in workplace committees and in forums. Further research is needed to better understand how multidisciplinary teams influence care of hospitalized older adults.