Essential care for older patient specialling in acute care settings : a concurrent mixed methods study

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𝘉𝘢𝘤𝘬𝘨𝘳𝘰𝘶𝘯𝘥: During hospitalisation, older people can quickly become disoriented, confused and agitated. In these instances, ‘specialling’ is often provided and involves close monitoring and observation of the person to prevent accidents, injuries and clinical deterioration. Despite the widespread practice of older patient specialling, there is a lack of conceptual clarity around the scope, purpose and expected outcomes of specialling. There is no evidence of the best model, or any clear guidelines around the essential requirements for this practice in terms of who should be specialled, experience and qualifications of staff who special, the type of care that should be provided when specialling and the type of environment that is appropriate for specialling. 𝘈𝘪𝘮: This study aimed to examine specialling of older people in acute care settings and to inform the development of a set of evidence-based care guidelines for specialling older people in these settings. Two research questions that guided the study were (a) what characterises older person specialling in the acute care setting? and (b) what essential care is required when specialling older people in acute care settings? The central premises are the concerns about the lack of guidelines and procedures for specialling the older person in hospital, the varying expectations of the specialling role and limited suggestions on what constitutes a positive, person-centred experience for older people who are specialled. 𝘔𝘦𝘵𝘩𝘰𝘥: Concurrent mixed methods were used to obtain data on older person specialling experiences. The inquiry was conducted in two phases in four acute aged care wards of a large metropolitan hospital in Sydney, Australia. Phase One comprised a focus group interview with nine registered nurses to obtain data on the characteristics of older person specialling. Phase Two used two validated tools to observe care interactions between staff and their care recipients, and the older person’s care during specialling. A total of 58 observations of specialling were undertaken for 12 patients aged 65 years and older. These data were used to further inform the characteristics of older person specialling and identify the essential care required for specialling older people in acute care. 𝘙𝘦𝘴𝘶𝘭𝘵𝘴: Delirium was the most common reason for older person specialling, and most specialling was undertaken by assistants in nursing. Specialling was influenced by an ethos that did not always support person-centred care; rather adopting a task-focused custodial approach. Acute care administrative practices appeared to lack consideration of the impact of specialling on nurses’ workload, and lacked clear policies or procedures around specialling, including staff most appropriate to special older people and how they should be prepared to undertake the role. However, 45 of the 58 care interactions and responses were recorded as positive. These observations were dependent upon the special’s familiarity with the ward and their care recipients, the overall acuity of patients in the wards, the general ward busy-ness and the presence of personal possessions in the person’s immediate surroundings. 𝘓𝘪𝘮𝘪𝘵𝘢𝘵𝘪𝘰𝘯𝘴: The diverse nature of the literature reviewed for the study precluded the use of a quality appraisal tool and therefore the extent to which findings are useful is difficult to determine. Limitations are also acknowledged in the methodology. One focus group of registered nurses held in one hospital potentially limits the findings in voice, time and location and may not fully represent the characteristics of older person specialling in acute care. The small sample size for the observations, small number of observations and short observation periods are also considered to be a limitation. 𝘊𝘰𝘯𝘤𝘭𝘶𝘴𝘪𝘰𝘯: The use of formal guidelines for decision-making on initiation and cessation of specialling, requirements for workload allocation, staff qualifications, educational preparation for the specialling role and team-based care models are proposed for specialling the older person in the acute hospital setting, along with recommendations on what constitutes person-centred specialling practice. Research that focuses on outcomes for person-centred specialling of older people in acute care settings is suggested.
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