VOL: 97, ISSUE: 03, PAGE NO: 33
Jackie Bridges, BNurs, MSN, RN, RHV, is lead research and development nurse, care for older people, Barts and the London NHS Trust
Jasmine Smith, RGN, is ward manager, Homerton Hospital, London;Julienne Meyer, PhD, RN, RNT, is professor of adult nursing andChristine Carter, MSc, BSc, RMN, is a lecturer, St Bartholomew's and the London NHS TrustStudies of the nursing care of older people in rehabilitation settings have highlighted a gap between what is known to be best practice and what is actually happening on the ground. Relatively little, however, is known about the factors that mediate change in practice settings or how nurses inform their decisions about patient care.
Studies of the nursing care of older people in rehabilitation settings have highlighted a gap between what is known to be best practice and what is actually happening on the ground. Relatively little, however, is known about the factors that mediate change in practice settings or how nurses inform their decisions about patient care.
The ward where this study took place was a 22-bed, mixed-sex rehabilitation unit for older people. Our action research study used patients' accounts of their experiences to prompt reflection and care changes by nurses (see last week's Nursing Times for the study background and methods).
Three main data sets emerged:
- Nurses' accuracy in referral;
- Unmet psychological needs;
- Barriers to the provision of psychological care.
Nurses' accuracy in referral
The nurses on the ward were invited to refer patients whose care they found problematic in some way. Very few referrals were for physical rehabilitation issues. Most reflected a desire by the nurse to know more about the patient as a person. The referral was often a response to the nurse's observation of psychological distress or a result of the nurse sensing that there was more to be known about this patient. Some of the documented reasons for referral illustrate this:
- 'I've had difficulty getting to know him.'
- 'She's very tearful and weepy. We need help getting to the bottom of what is upsetting her.'
- 'It's important to see how he's feeling so that we can take that into account when we look after him.'
- 'Sometimes she cries but you can't get through to her.'
- 'I never know what's going on with him.'
- 'There's more to her than she's letting through.'
The second main reason for referral was a perceived mismatch between the patient's expectations of their own potential and the nursing goals for delivering a rehabilitation service. For example:
- 'He is uncooperative in every aspect of care.'
- 'She claims not to be in pain, but she is not standing up.'
- 'He says he is willing to walk but his priority is to smoke. His actions don't reflect him wanting to rehabilitate.'
- 'She has lots of potential to get going but is holding back on being independent and is not communicating what help she needs.'
Nurses tended to refer patients for whom they could not care properly because of a lack of resources, hoping that the project might benefit them. The impression was that of a barrier to communication with the 'real person'.
During interviews, patients included in the study often showed signs that they did not fully understand what was happening to them and that they felt separate from the decision-making process, thus confirming the nurses' decision to include them in the study. A subproject within the main study involved interviewing patients who were not selected for inclusion. Findings suggested that patients who were not selected were positive about their experience of being on the ward and highly satisfied with the nursing care they were receiving.
In effect, the nurses referred the patients they thought would benefit most from taking part in the study. This confirmed that nurses were capable of identifying the patients in greatest need.
Unmet psychological needs
The second set of study findings highlighted a group of patients whose psychological needs were not being met. The patients referred to the study reflected a broad range of experiences on the ward, but a key theme of 'loss' emerged. The experiences they described suggested these patients viewed themselves as being isolated in dealing with these losses (see Case Study 1).
These findings confirm those of other studies, namely that patients' psychological needs in these settings can be significant and associated with losses in a number of areas, including loss of function, home and social role (Diamond et al, 1995; Lewinter and Mikkelsen, 1995; Brillhart and Johnson, 1997).
Older patients in a rehabilitation setting are usually there following the onset or exacerbation of a physical disability or illness. Even if the disability is temporary, hospitalisation can result in significant life changes. It is not surprising that these changes lead to feelings of loss, grief and bereavement.
In some cases, patients' situations were exacerbated by the presence of clinical depression and/or cognitive impairment. A snapshot prevalence survey of patients' medical and nursing notes revealed that 17 out of the 22 patients on the ward (77%) had cognitive impairment documented on admission, ranging from mild to severe and from acute to chronic. Staff reckoned that the 77% figure remained more or less constant, despite the high turnover of patients.
The patient case studies reflected that states of depression/cognitive impairment made it harder for patients to understand their care and the likely outcomes of their hospitalisation. Poor psychological states also prevented people from developing suitable coping strategies. The reasons behind the nursing referral of Mrs Smith to the study (see Case Study 2) reflect someone unable to access the help she needed in a life stage of major transition.
Some patients on the ward experienced significant losses associated with their illness, along with a sense of isolation in dealing with them. Cognitive impairment and/or depression heightened their vulnerability to the effects of these losses. Nurses on the ward were skilled in knowing which patients would benefit from further intervention.
The findings here are consistent with other literature which calls for a development of the rehabilitation nurse's role in meeting the psychosocial needs of patients (Nolan and Nolan, 1997; Cotter, 1998). The study findings also enabled an exploration of the reasons for the gap between patient need and nursing care. These are reported in the next article in the series.
- The first article in this series appeared on January 11. Next week: barriers to meeting the psychological needs of this patient group.