Close observation by 'specials' to promote the safety of the older person with behavioural disturbances in the acute care setting
Family and Community Health Research Group (FaCH), Clinical Nursing Research Unit, Nepean Hospital; University of Western Sydney and Sydney West Area Health Service, Sydney NSW
Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Broadway, NSW
Family and Community Health Research Group (FaCH), University of Western Sydney, Sydney NSW
Clinical Nursing Research, Gold Coast Health Service District; Griffith University, Southport QLD
PP: 131 - 142
This paper reports a two-phased pilot study that explored the concept of 'specialling' older patients with challenging behaviours in acute ward situations. Previous research suggests that the nursing workforce is not equipped with the skills and resources required to provide quality care for these patients.
The hospital in which this study was conducted, instigated a model where these patients were closely observed by 'specials'. Phase 1 of the study involved a retrospective analysis of de-identified 'Specials' Observation Charts' and 'Request for Patient Special' forms of patients aged 65 years and above, over 12 months in 2006. Phase 2 involved in-depth interviews with the nurses caring for these patients.
Findings revealed inadequacy of the forms, gaps in service provision for this vulnerable group of patients and the need for education of specials and ward staff, with suggestions to improve care for this patient group. Findings suggest the necessity to design and structure the observation forms more efficiently. It is important to formulate clear assessment criteria for these patients and incorporate in-service education programmes for 'specials' and ward staff and adequately prepare and support them to meet the challenges of caring for older persons with behavioural disturbances in ward situations.
nursing; acute care; specials
Andersson, E. M., Hallberg, I. R., Norberg, A., & Edberg, A. K. (2002). The meaning of acute confusional state from the perspective of elderly patients. International Journal of Geriatric Psychiatry, 17(7), 652-663.
Australian Government Department of Health and Ageing. (2007). Older Australians in hospital. In The state of our public hospitals, June 2007 report (pp. 57-64). Canberra: Author.
Balas, M. C., Gale, M., & Kagan, S. H. (2004). Delirium doulas: An innovative approach to enhance care for critically ill older adults. Critical Care Nurse, 24(4), 36-46.
Borbasi, S., Jones, J., Lockwood, C., & Emden, C. (2006). Health professionals' perspectives of providing care to people with dementia in acute setting: Towards better practice. Geriatric Nursing, 27(5), 300-308.
Bourbonniere, M., Strumpf, N. E., Evans, L. K., & Maislin, G. (2003). Organisational characteristics and restraint use for hospitalised nursing home residents. Journal of American Geriatric Society, 51(8), 1079-1084.
Bowers, L., & Park, A. (2001). Special observation in the care of psychiatric in-patients: A literature review. Issues in Mental Health Nursing, 22(8), 769-786.
Bowles, N., Dodds, P., Hackney, D., Sunderland, C., & Thomas, P. (2002). Formal observations and engagement: A discussion paper. Journal of Psychiatric and Mental Health Nursing, 9(3), 255-260.
Bradley, E., Webster, T., Schlesinger, M., Baker, D., & Inouye, S. K. (2006). The role of senior management in improving hospital experiences for frail older adults. Journal of Healthcare Management, 51, 323-336.
Buchanan-Barker, P., & Barker, P. (2005). Observation: The original sin of mental health nursing? Journal of Psychiatric and Mental Health Nursing, 12(5), 541-549.
Cherry, J., & Reid, J. (2001). Fast-tracking older people through A&E. Nursing Standard, 15(16), 42-44.
Courtney, M., Tong, S., & Walsh, A. (2000). Older patients in the acute care setting: Rural and metropolitan nurses' knowledge, attitudes and practices. Australia Journal of Rural Health, 8, 94-102.
Cummings, S. (1999). Adequacy of discharge plans and rehospitalisation among hospitalised dementia patients. Health and Social Work, 24(4), 249.
Cutillo-Schmitter, T. (1996). Aging: Broadening our view for improved nursing care. Journal of Gerontological Nursing, 22(7), 31-43.
Dellasega, C., & Curriero, F. C. (1991). The effects of institutional and community experiences on nursing students' intentions toward work with the elderly. Journal of Nursing Education, 30(9), 405-410.
Dennis, S. (1997). Close observation: How to improve assessments. Nursing Times, 93(24), 54-56.
Duffy, D. (1995). Out of the shadows: A study of the special observation of suicidal psychiatric in-patients. Journal of Advanced Nursing, 21(5), 944-950.
Fagerberg, I., Ekman, S., & Heyman, I. (1999). Nursing students' reasoning about two fi ctitious elderly patient cases. Scandinavian Journal of Caring Sciences, 13(4), 247-253.
Fagerberg, I., & Jonhagen, M. E. (2002). Temporary confusion: A fearful experience. Journal of Psychiatric and Mental Health Nursing, 9, 339-346.
Foreman, M. D., Mion, L. C., Tryostad, L., & Fletcher, K. (1999). Standard of practice protocol: Acute confusion/delirium. Geriatric Nursing, 20(3), 147-152.
Frengley, J. D., & Mion, L. C. (1986). Incidence of physical restraints on acute general medical wards. Journal of American Geriatric Society, 34, 565-568.
Holden, J., Jayathissa, S., & Young, G. (2008). Delirium among elderly general medical patients in a New Zealand hospital. Internal Medicine Journal, 38(8), 629-634.
Hsu, M., Moyle, W., Creedy, D., & Venturato, L. (2005). An investigation of aged care mental health knowledge of Queensland aged care nurses. International Journal of Mental Health Nursing, 14, 16-23.
Kovach, C. R., & Wells, T. (2002). Pacing of activity as a predictor of agitation for person with dementia in acute care. Journal of Gerontological Nursing, 22(1), 28-35.
Laurila, J. V., Pitkala, K. H., Strandberg, T. E., & Tilvis, R. S. (2004). Detection and documentation of dementia and delirium in acute geriatric wards. General Hospital Psychiatry, 26, 31-35.
Lusk, S. L., Williams, R. A., & Hsuing, S. (1995). Evaluation of the facts on aging quizzes I and II. Journal of Nursing Education, 34(7), 317-324.
Maas, M., Swanson, E., Specht, J., & Buckwalter, K. (1994). Alzheimer special care units. Nursing Clinics of North America, 29(1), 173-194.
Marshall, M. (1997). Therapeutic design for people with dementia. In S. Hunter (Ed.), Dementia challenges and new directions (pp. 181-194). London: Jessica Kingsley.
McCloskey, R. (2004). Functional and self-efficacy changes of patients admitted to a geriatric rehabilitation unit. Journal of Advanced Nursing, 46(2), 186-193.
Mentes, J., Culp, K., Maas, M., & Rantz, M. (1999). Acute confusion indicators: Risk factors and prevalence. Using MDS data. Research in Nursing and Health, 22, 95-105.
Michaud, L., Bula, C., Berney, A., Camus, V., Voellinger, R., Stiefel, F., et al. (2007). Delirium: Guidelines for general hospitals. Journal of Psychosomatic Research, 62, 371-383.
Miles, S. H., & Irvine, P. (1992). Deaths caused by physical restraints. Gerontologist, 32, 762-766.
Morgan, D., & Stewart, N. (1997). The importance of the social environment in dementia care. Western Journal of Nursing Research, 19(6), 740-761.
Morgan, D., & Stewart, N. (1999). The physical environment of special care units: Needs of residents with dementia from the perspective of staff and family caregivers. Qualitative Health Research, 9(1), 105-118.
Mott, S., Poole, J., & Kenrick, M. (2005). Physical and chemical restraints in acute care: Their potential impact on the rehabilitation of older people. International Journal of Nursing Practice, 11, 95-101.
Moyle, W., Borbasi, S., Wallis, M., Olorenshaw, R., & Gracia, N. (2010). Acute care management of older people with dementia: A qualitative perspective. Journal of Clinical Nursing. (online early, doi: 10.1111/j.1365-2702.2010.03521.x) Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2010.03521.x/pdf
Neilson, P., & Brennan, W. (2001). The use of special observations: An audit within a psychiatric unit. Journal of Psychiatric and Mental Health Nursing, 8(2), 147-155.
Poole, J., & Mott, S. (2003). Agitated older patients: Nurses' perceptions and reality. International Journal of Nursing Practice, 9, 306-312.
Reed, J., & Clarke, C. (1999). Nursing older people. Constructing need and care. Nursing Enquiry, 6, 208-215.
Reid, W., & Long, A. (1993). The role of the nurse providing therapeutic care for the suicidal patient. Journal of Advanced Nursing, 18(9), 1369-1376.
Rohrer, J., & Schiffer, R. (2000). Risk factors for hospital admission of long term dementia patients. Texas Journal of Rural Health, 18(3), 66-71.
Schofi eld, I. (2008). Delirium: Challenges for clinical governance. Journal of Nursing Management, 16, 127-133.
Sharma, V. (2006). Working hard to reduce falls. Editorial. Nursing Older People, 18, 3.
Stenwall, E., Sandberg, J., Jonhagen, M. E., & Fagerberg, I. (2007). Encountering the older confused patient: Professional carers' experiences. Nordic College of Caring Sciences, 21(4), 515-522.
Sullivan-Marx, E. M. (2000). Achieving restraint-free care of acutely confused older adults. Journal of Gerontological Nursing, 27, 56-61.
Taft, L. B., Fazio, S., Seman, D., & Stansell, J. (1997). A psychosocial model of dementia care: Theoretical and empirical support. Archives of Psychiatric Nursing, 11, 13-20.
Tolson, D., Smith, M., & Knight, P. (1999). An investigation of the components of best nursing practice in the care of acutely ill hospitalised older patients with coincidental dementia: A multi-method design. Journal of Advanced Nursing, 30, 1127-1136.
Williams-Burgess, C., Ugarriza, D., & Gabbai, M. (1996). Agitation in older persons with dementia: A research synthesis. The Online Journal of Knowledge Synthesis for Nursing, 3(13), 1-24.
Zernike, W., & Sharp, P. (1998). Patient aggression in a general hospital setting: Do nurses perceive it to be a problem? International Journal of Nursing Practice, 4(2), 126-133.