Emergency nurses perceptions of the role of family/carers in caring for cognitively impaired older persons in pain: A descriptive qualitative study

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Abstract

Background

On arrival to the emergency department many older persons are accompanied by family/carers. Yet the role of family/carers in the emergency department is unclear. We know very little about how emergency department nurses balance care practices to accommodate family/carers while specifically meeting the needs of cognitively impaired older persons experiencing pain.

Objectives

The aim of this paper was to understand emergency nurses’ perceptions of the role of family/carers in caring for the older cognitively impaired person experiencing pain.

Design

Emergency nurses were invited to participate in focus group interviews. A semi-structured interview tool was developed from the literature and comprised open-ended questions and three Likert scale items which assisted to focus nurses’ thoughts on their perceived role of family/carers in the emergency department.

Settings

The study was undertaken across four emergency departments in Sydney, Australia and included two district hospitals and two tertiary referral hospitals.

Participants

Emergency nurses were invited to participate in one face to face, focus group interview. Purposive sampling was used and inclusion criteria included at least one year emergency department experience.

Methods

Interview data were analysed and organised thematically. Two expert qualitative researchers independently reviewed transcripts and emerging coding and interpretation.

Results

Eighty nurses participated in 16 focus group interviews across four hospitals. Participating nurses included 67 (84%) females and 13 (16%) males with 8.6 years (mean; SD ±8.64) experience in the emergency department. Three key themes relating to family/carers emerged from the analysis. The themes included (i) the role of families and carers in building a clinical picture; (ii) family and carers as a hidden workforce; and (iii) family and carer roles in pain management decision making.

Conclusions

The study has provided insight into the role of family/carers as perceived by emergency nurses. There were many benefits in partnering with family/carers when information gathering on the older cognitively impaired person in pain. Family/carers are sensitive to health behaviour changes of older cognitively impaired people, which can assist nurses to optimise pain management.

Introduction

Globally, the prevalence of cognitive impairment in older people is increasing significantly (The Lancet, 2006). For example, in Australia, Belgium, Canada, Germany, Iceland, India, and Sweden, there is a high prevalence of older people presenting to the emergency department, with up to 27% of people aged over 75 years exhibiting evidence of cognitive impairment (Gray et al., 2013). Specifically, in Australia it has been estimated that 9% of those over 65 years and 30% over 85 years have cognitive impairment (Australian Institute of Health and Welfare, 2012a, Australian Institute of Health and Welfare, 2012b, National Pain Summit Initiative, 2010). Cognitive impairment refers to a number of disorders which affect a person's ability to think, concentrate and communicate (Folstein et al., 1975).

Across Australia the majority of people with cognitive impairment are cared for and/or supported by family/carers in the community (Clark et al., 2014), which is consistent with international literature (Alzheimer's Disease International Consortium, 2009, Gray et al., 2013, Salvage et al., 1989). A family is social system defined by a blood relation or by instituted social bonds, such as marriage (Geertz, 2001). While, a carer in Australia, as defined by the Carer Recognition Act (2010), is “an individual who provides personal care, support and assistance to another individual who needs it because that other individual: has a disability; or has a medical condition (including a terminal or chronic illness); or has a mental illness; or is frail and aged.” Family and carers involve different care dynamics, but we also recognise at times families and carers can be mutually exclusive (Gallagher et al., 2014).

Across the USA, France, Taiwan, Singapore and Australia older people are presenting to emergency departments more frequently and being admitted to hospital compared to younger groups (Boltz et al., 2013, Bookman and Harrington, 2007, Commonwealth of Australia, 2008, Samaras et al., 2010). In 2012, 21% (n = 6,712,224) of Australian emergency department presentations comprised people over 65 years (Australian Institute of Health and Welfare, 2012a, Australian Institute of Health and Welfare, 2012b) and of these about 25% have been noted to have cognitive impairment. Australian emergency departments frequently provide a portal into the acute hospital system for many older persons (Australian Institute of Health and Welfare, 2012a, Australian Institute of Health and Welfare, 2012b).

Older people with cognitive impairment are high users of emergency department services and often present with a complaint of pain. Researchers have identified that between 50% and 80% of patients presenting to emergency departments present with a complaint of pain (Holdcroft and Power, 2003, Tcherny-Lessenot et al., 2003). There is evidence that cognitive impairment is a risk factor for delay in analgesia (Fry et al., 2014). Many older people with cognitive impairment who are experiencing pain are accompanied by family/carers to emergency department (Fealy et al., 2012). One study has shown that older cognitively impaired persons consider the presence of family/carers in the emergency department important (Nikki et al., 2012) as they can provide information to emergency nurses when communication difficulties exist (Nikki et al., 2012, Shanley et al., 2008). However, currently little is known about the way that emergency nurses organise care practices to accommodate the presence of family/carers while supporting the cognitively impaired older person experiencing pain (Boltz et al., 2013).

The literature identifies that older people commonly present with more urgent conditions, more frequently require hospital admission from the emergency department and experience a longer length of stay than younger adults (Aminzadeh and Dalziel, 2002, Lutze et al., 2015). Further, evidence suggests that older people are more likely to experience negative health outcomes, declining cognition and functional ability as a result of hospital admission (Sirois et al., 2013). Given the risk of poor health outcomes for older people, emergency departments are challenged to address the often unpredictable, chaotic and noxious stimuli environment to ensure the safety of older people, especially the person with a cognitive impairment (Kihlgren et al., 2005, Shanley et al., 2008). When emergency department staff are unable to give immediate and frequent attention to the many needs of the older person, their health outcomes can be compromised, especially if they also present with or develop a cognitive impairment (Arendts and Fry, 2006, Fry et al., 2014).

In many instances, older people with cognitive impairment are often accompanied by family/carers to the emergency department (Nikki et al., 2012). There is evidence that the negative effects of the emergency setting can be minimised by the presence of family/carers, particularly if they remain with the person (Bhalla et al., 2014, Boltz et al., 2013). Internationally, across seven countries, 46% of older people were dependent on family/carers in one or more aspects of personal activities of daily living (Gray et al., 2013). Family/carers have a key role to play in caring for an older person with cognitive impairment. For example, in the Australian context an unpaid carer or a close friend or relative can consent to or refuse medical treatment on the behalf of a cognitively impaired patient who is not competent to provide consent, and there is a legal procedure to govern this process within hospitals (Stewart et al., 2007). However, despite their importance, the role of family/carers in the emergency department is often unclear (Gallagher et al., 2014).

The aim of this paper was to understand emergency nurses’ perceptions of the role of family/carers in caring for the older cognitively impaired person experiencing pain.

Section snippets

Method

This study was part of a large multicentre programme of research seeking to understand nursing care practices for older people with a cognitive impairment who were experiencing pain and had a long bone fracture.

Results

Across four hospital sites 16 focus group interviews (n = 80) were conducted. Four focus group interviews were conducted at each site. The average group size was 5 with the range between 2 and 8 participants. One group contained only 2 participants as on the day the clinical floor was very busy and those wishing to attend were unable to do so given service demand. Participating nurses included 67 (84%) females and 13 (16%) males, and participants had an average of 12.5 years as a Registered Nurse

Discussion

Overwhelmingly, the nurses reported that, in the presence of cognitive impairment and pain in the older person, family/carers can greatly enhance the nurse's ability to gain a more detailed and clearer clinical history, obtain more accurate data on the older person's baseline mood and behaviour and improve the older person's feelings of well-being in the emergency department. Family/carers were perceived as a valuable resource in supporting many of the older person's needs, especially in

Limitations

There are a number of limitations with the study that need to be acknowledged. While a range of emergency departments were selected as study sites, it is possible that the perspectives of the participants may not be applicable to other emergency sites. The study provides data on the role of family/carers as perceived by emergency nurses, which may be very different to family/carers perceptions. Hence, future research needs to involve family/carers to determine their perceptions of emergency

Conclusion

The study has provided new insight into how emergency nurses, when caring for cognitively impaired older people in pain, perceive the role of family/carers. There were many benefits in utilising family/carers when information gathering, specifically for older cognitively impaired people, as they can provide a baseline understanding of their clinical history, functional abilities, cognition, mood and behaviour which can better support pain management practices. Family/carers are often sensitive

Acknowledgment

This research was supported by the Emergency Care Institute and the Agency for Clinical Innovation of New South Wales (ACI/D12/1275).

Conflict of interest: None declared.

Funding: Funding was received from the Emergency Care Institute of New South Wales and the Agency for Clinical Innovation. Neither body has had any role in the conduct of the research nor the preparation of the manuscript.

Ethical approval: Approval was obtained from the hospitals’ health districts’ Human Research Ethics

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