Older patients in transition : from home care towards emergency care

Abstract

The overall aim of the thesis was to study the praxis of referrals to the emergency department (ED) from different community health care settings and the caring process of older adults in the ED (I-V). With this knowledge, the prerequisites needed to provide older adults with better care can be attained. The thesis focuses on the older adults and the nurses' involvement in the referrals and the caring process.

Study I focused on the extent and reasons that 719 patients > 75 years old, residing in sheltered housing, utilized the emergency department during one year. Observations of and interviews with 20 patients > 75 years old and relatives were conducted to study the conditions and the events that took place during their stay at the ED (II). Ten ED nurses' narrated experiences were analysed to illuminate what constitutes good nursing care for older patients (III). The factors and aspects that influence the community RNs' decisions when referring older patients to the ED and what kind of support may be required to facilitate this decision-making process was studied in narratives from 10 nurses (IV) and 30 persons in management that were nurses, physicians or home care assistants( V).

The inclusion area encompassed two counties with 24 sheltered housing units from one county and a university hospital, two smaller hospitals and 30 Primary Health Care Centres from the other county. Four methodological approaches were utilized in the studies: descriptive statistics (I), grounded theory (II), thematic content analysis (III, V) and latent content analysis (IV).

The main results in this thesis showed that a group of older adults (I) have in one year visited EDs to a great extent and the main reasons for referrals were falls, cardiovascular and cerebrovascular problems, infections and gastrointestinal disorders. Waiting at an ED (II) was a long and unpleasant experience in many different ways. For them, not only was it important that they were cared for, but also the manner in which the care was given. Many patients did however express feelings of trust in the staff s medical expertise and had a positive attitude towards them. For ED nurses (III), it was necessary to be knowledgeable, have an understanding of the older person's situation and be willing to take responsibility for them.

Prioritisation of medical procedures, everyday chores and routines impeded good nursing care and the nurses expressed their sentiments that the ED is not always the appropriate place to meet the needs of these patients. Study IV and V showed that the community nurses needed to feel secure in their professional role since several aspects influenced their referral decision. The nurses needed faith in their own competence, knowledge about the patient as well as a supportive environment. The different managers had different views regarding what they thought was important in order to facilitate the decision making process for nurses.

Changes in the older patients health (I) and their transferral created a process of transition for them. The transition might make them even more vulnerable, which became apparent during the long and uncomfortable wait at the ED (II). Even nurses and the organisation in the community went through a state of transition due to the considerable changes that occurred. It seems that in Sweden, there has developed what might be called an "in between syndrome" for older adults that have become ill.