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Planning to improve the hospital experience for older inpatients

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VOL: 102, ISSUE: 39, PAGE NO: 29

Caroline Lawson, MA, BSc, RGN, is nurse consultant, acute stroke, East Somerset NHS Trust

It is estimated that by 2031 the number of people aged 65 and over will exceed 15 million and comprise 23% of the w...

It is estimated that by 2031 the number of people aged 65 and over will exceed 15 million and comprise 23% of the whole population (Central Office of Information, 2006). This population shift will have dramatic effects on healthcare provision and it is essential not only that the services are in place to meet this demand but also that nurses have the skills to care for this age group.

Caring for older people involves special expertise for many reasons: physiological ageing and the effects of medication may alter the disease presentation; pre-existing conditions may make self-care more difficult and the incidence of depression, dementia and delirium more common; and arranging social support for successful discharge requires complex organisational skills.

It is essential that all nurses are able to recognise and help address the specialist needs of the older person and this should be viewed as an integral part of nursing and not specific to those interested in caring for older people. Patients at particular risk are likely to be those who are unable to continue their independence and as a result are reliant on the care of others. Stroke and Parkinson's disease are examples of conditions that often result in patients becoming dependent on others and this may be a result of many different difficulties.

Appetite is often significantly altered due to swallowing problems, taste alterations and lethargy, resulting in weight loss. Infections in the acute phase are common due to aspiration risk and positional difficulties. Incontinence, urgency and retention are present in many cases and this may be due to a physical or communication problem. Altered sensory perception results in the patient being at high risk of injury from pressure ulcers and unawareness of deficits results in a high incidence of falls.

These all result in a reliance on others, removing independence and often resulting in negative feelings of self-worth. These difficulties are present not only for those admitted with a new stroke but also for those with a previous stroke and it is estimated that there are currently more than 250,000 people living with a disability caused by a stroke (The Stroke Association, 2006) and more than 120,000 have Parkinson's disease in the UK (Parkinson's Disease Society, 2006).

While a patient may have been admitted with a physical problem, emotional issues are often also present and while depression is common in older people it is not always identified. Despite many older people experiencing depressive feelings only one in six feels so depressed that others notice and only one in 30 people are diagnosed by a doctor as having a 'depressive illness' (Royal College of Psychiatrists, 1998).

Being hospitalised is often linked with memories associated with the death of family members or friends and in addition independence is often lost, even if for a short time. This emotion may be expressed as anger or withdrawal and it is essential that the staff have the skills to interpret this behaviour and offer methods to cope. While medication may be considered to be the treatment of choice often talking about concerns is enough to prevent the low mood getting out of control and empathy and listening skills are essential.


Many of the problems affecting older people in hospital are multifactoral and malnutrition is a good example of how many different elements are responsible for affecting dietary intake. These could be: oral, such as swallowing problems following a stroke or Parkinson's disease; ill-fitting dentures or candida; poor manual dexterity, due to frail skin, arthritis, peripheral vascular disease or weakness; or socioeconomic, due to poverty, bereavement or limited access to shops; malabsorption, resulting in a greater infection risk; altered sensation affecting taste, reducing appetite and altered smell perception; and general health related to drugs and chronic disease and disability (Collier, 2006).

This may in part account for the data that among independent older people 3% of men and 6% of women are underweight, while in nursing and residential homes these figures rise to 16% and 15% respectively (Finch et al, 1998). Early identification of those patients at risk is essential and supplements in the form of fortified drinks or meals, additional hydration via intravenous or subcutaneous fluids or nasogastric feeding should be considered.


Many of the concerns regarding older people in hospital are linked with other national projects or key areas identified for improvement. Falls are a large reason for both admission and extended length of stay and Fuller (2000) found that older people who survive a fall experience significant morbidity.

Hospital stays are almost twice as long for older patients hospitalised after a fall as for older patients who are admitted for other reasons (Dunn et al, 1992). Compared with older people who do not fall, those who fall experience greater functional decline in activities of daily living and in physical and social activities and they are at greater risk of subsequent institutionalisation.

It is essential that a holistic review is given while the older person is in hospital and although this may result in an extended stay, the readmission rate for these patients would reduce and requirements on the service would reduce in the long term. A recent report stated that '80% of women surveyed would rather be dead than experience the loss of independence and quality of life that results from a bad hip fracture and subsequent admission to a nursing home' (Salkeld et al, 2000).

It is essential that nurses and other healthcare professionals concentrate on reducing the negative impact of hospitalisation, promote independence and also work together to prevent readmission.

A practical approach

In 2003 the Department of Health provided funding to 40 projects to support the implementation of the recommendations set out in standard four of the NSF. Many of these projects resulted in training programmes with the aim of changing the whole culture of NHS hospitals (DH, 2005).

Getting the basics right was at the heart of the project instituted at East Somerset NHS Trust, with the focus being on raising staff awareness and improving their knowledge of older people's issues using a simple, practical approach. A skills profile of staff identified gaps in knowledge and these were addressed by providing 'bite-sized' education sessions, lasting 10 minutes, and delivered at ward handovers and departmental meetings.

These sessions included topics such as managing hearing loss, spiritual needs, communication, continence, cognitive impairment and walking aids, and were led by in-house experts. The teaching was supported by pocket-sized fact cards, which reiterated the information and provided useful telephone numbers and advice on subjects such as how a hearing aid could be cleaned.

Offering training sessions to all staff enabled a multidisciplinary approach to improve the service. This was reinforced by the championship programme with staff from a variety of backgrounds meeting regularly and being responsible for disseminating information locally and acting as the patient's advocate in a variety of different settings.

Enlisting the support of the porters and support staff has resulted in the additional benefit of a team approach to the provision of a good level of care, especially when the patient is being transferred from the ward to other departments.

One of the concerns from the patients themselves was a lack of social contact, especially in an area where relatives often live far away and the local transport system is such that patients spend much of the day without companionship.

The Time 4 U project was established by a small group of volunteers who regularly visit the wards to talk to patients who the staff have identified as having a need. By developing a rapport with the ward staff, the volunteers have been able to become part of the ward team and offer support to patients. This in turn frees up the nursing staff. While there may be concerns regarding infection control and breach of confidentiality, commencement of this project was a direct result of a survey of patients who felt lonely in hospital. It is easy to become confused between actual and perceived benefits to patients and often health professionals forget to ask patients themselves what is important to them.

The project concentrates on the ability to improve the hospital stay of older patients by treating them with dignity and respecting their preferences. Restricting a patient to bedrest due to not being able to provide a walking frame results in a lack of independence and they will be more likely to try and walk unaided, resulting in a fall.

Completing the menu card for a patient may seem helpful but it is more important that patients see the choices themselves so the menu card should be clear and easy to follow. It is also important to empower older patients to wash themselves by placing the water bowl within easy reach. Variable-height tables are available and inexpensive.Learning objectives

- Understand the impact of the NSF for older people in clinical practice

- Know the disease processes that can affect physical independence

- Know the disease processes that can affect emotional independence

- Understand that improving the hospital experience for a patient requires a multiprofessional approach to careGuided reflection

- Discuss where you work and why this article is relevant

- Discuss the last time you came across an older person in hospital who needed an extra level of care

- Detail a piece of information from this article that could have helped you with that person

- Explain how you intend to disseminate this information among your colleagues

This article has been double-blind peer-reviewed

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