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Discharging older people issue is the most important in today’s environment. Realising this, it is necessary to extract the fact in present situation of the older people. This study explored the experiences of older people being discharged from hospital to nursing and residential homes in the North East of England. While there has been considerable research which has looked at the discharge of patients from hospital to their own homes, little literature could be found which addressed discharge to care homes.
The discharge of older people to nursing and residential homes (care homes) represents a major life change for older people. Which has however received less attention in the nursing research and policy literature than discharge to the patient’s own home. These older people moving into nursing or residential care homes. However present a different set of responsibilities which may not be quite so obvious, or appear so pressing , yet which correspond with many of the definitions and model of nursing which emphasize the role of the nurse in supporting patients through process of loss and change.
Discharging planning research may focus on the primary secondary care interface, that is integration of hospital and community care services, care homes increasingly represent another sector the independent sector which is comprised of either private business or voluntary agencies. The National Health (NHS) and Community Care Act of 1990 (Department of Health 1990),where Social Services departments became responsible for developing and purchasing packages of care for older people, there has also been in increased requirement for health and Social services to work together.
This issues of collaboration and co operation are more complex than if the only interface involved is that between the hospital and community services. Interviews and written responses from members of staff in the hospital and in care homes, found that there was a lack of clarity over whose role it was to initiate such discussions.
This study explored the area of support for older people being discharged from hospital into a care home. The main aims of the study were to investigate the experiences of older people to identify possible forms of support that might be needed for available. The study was funded by a National Health Services Executive (Northern and Yorkshire Region) research programme which funded practice development studies in professions allied to medicine. The role of research team was not therefore to reflect and act upon a staff initiative, but to direct a study was suggested by a reading of the available literature research. The consequences of this position have been explored by some authors like Meyer 1993, and likely to impact upon processes of change in the way that the staff who are asked to develop their practice do not see themselves as having ownership of the research study.
The first chapter is about the experiences of the older people being discharged from hospital to discharge to nursing and residential homes in the North East of England. While there has been considerable research which has looked at the discharge of patients from hospital to their own homes, little literature could be found which addressed discharge to care homes. Similarly in other chapters describes about the reflect of an assumption that this form of discharge is less problematic, it is arguable that this is only the case for staff- there is a body of literature on re-location which suggests that the move to a care home is a major life event for older people. Taking a qualitative approach, this study interviewed 20 older people and 17 of their family members after discharge from hospital to a care home. We found that few people had been offered opportunities to discuss their move with nurses, and that older people tended to adopt a stoical attitude. In focus groups, interviews and written responses from 23 members of staff in the hospital and in care homes, we found that there was a clarity over whose role it was to initiate such discussions. The paper concludes with some discussion of the implication for nursing practice of changing care interfaces.
There is a body of research in the nursing literature which has looked at the discharge of older people from hospital. Discharge from the hospital has been an area of concern for nursing and health care practice for some time, with numerous research studies describing records of 32 older people who were to be discharged to the community following a hospital stay and found a lack of recorded information in all areas of the nursing process, from nursing assessment to care plan evaluation. This made the co-ordination of services to meet the needs of the older person difficult, and Waters concluded that neither doctors nor hospital nurses identified assessment planning for discharge home as a priority. Furthermore, a quarter of those older people interviewed did not recall having been asked about coping at home or being given any advice about his, even though all the sample had supposedly undergone some form of pre- discharge assessment. Waters also noted a lack of knowledge about medication by patients after discharge and identified the quality of information given to district nurses by the hospital as being problematic; for example, in some cases, problems identified in the nursing care plans as still being current at the time of discharge were not communicated to community nurses. Waters stressed the need for through assessment, accurate record-keeping and the availability of written information in order for successful discharge to take place, but also cautioned against generalising the results of her exploratory study. These findings, however, are supported by subsequent studies including King and Macmillan (1994), Jewell (1993), victor et al.(1993) and Tierney (1993).
A common theme throughout these studies is the issues of responsibility, in other words
among the various professions involved in the discharge process, in which one takes the lead in co- ordinating the process, or carrying out the different parts of it. Not only there is concern about formal allocations of responsibility, but also about informal negotiations different communication about the roles which different professionals take.
A number of recommendations have been made in the UK in response to these growing Professionals and public concerns. The department of Health (1998) recommendations, for example, stressed the need for discharge planning to commence as soon possible after admission; the importance of good communication networks between all parties involved in the process and the need for improvement of patient and relatives in decision making, ides that were also articulated in The Patient’s Charter (Department of Health 1992).
Moving into a care home
The literature in the discharge of older people from hospital, therefore , indicates that this area of practice is problematic, and that older people do not always receive the support that they need. There is also another body of literature which suggests that moving into a care home is an event or process which likely to increase the need for support, because of the stress involved, of disruption to lifestyles, of loss of home and of adopting to a new environment (Morgan et al. 1997).
For example, Nay (1995) has described both material and abstract losses attendant on moving into a care home. The loss of material possessions can include one’s home and personal belongings, while more abstract losses include loss of role , life style and freedom. Nay also highlighted the loss of home can mean much more than a change of living environment, as researchers have found, as older people have identified their home with feelings of autonomy and control and part of their identity (Golant 1984, Sixmith 1996, Willocks et al. 1987).
Moving into a new environment, such as a care home, is something which can carry be very stressful, both in anticipation and in realization (Reed and Rroskell Payton 1996, Reed et al.1997). Older people not only need to negotiate and to learn about a new physical environment, but also about the social world to the care home, the routines and behaviours of their fellow residents and to staff. For some, the prospect of such work can be daunting , and if apprehension is coupled with a sense of loss and dislocation from a previous lifestyles and personal identity, then being discharged from hospital into a care home represents a life event with, potentially a profound impact on older people , and one which requires some recognition and support from nurses. Moreover, previous studies by Johnson et al. (1994) and Retinas (1991) suggest that moving into a care homes is often accompanied or precipitated by major changes in health, social support and ability to cope.
A supportive role is advocated in much nursing literature where the nurse-patient relationship is discussed. Which some, like Armstrong (1983), might suggest that this relationship has been a recent ‘fabrication’ in nursing , the arguments for developing communication and interpersonal skills in nursing are difficult to refute. As smith (1992) has argued, ’emotional labour’ is an important part of nursing care if patients are to receive more than cursory processing through the health service system, and if they are to have some of their emotional and psychological needs addressed. Moving away from a restricted psychological and social aspects of health care is a move which is gaining around in many areas of nursing and health care, and which permits a more holistic view of the patient (Cooper et al. 1996). More specifically, Nolan et al. (1996) have argued that the nurse has an important role to play in the process of decision making when older people are considering moving into a care home, and that this role may involve advocacy to ensure that the interests of older people are addressed.
The literature, then, seems to indicate that the discharge of older people from hospital is something that is, by and large, poorly managed by nurses and other staff, with determined consequences for older people. The literature does not provide much information about the discharge of older people from hospital into care homes since much of it concentrates on discharge homes. We can, however, extrapolate from the literature that exists on the impact of relocation and loss of home on older people to argue that, while these administrative and organizational problems of ensuring that services are available which are attendant on a discharge home, that they present a different set of problems which are emotional and psychological. These problems may be primarily problems for the older people concerned, but there is also a strongly argument in the nursing literature to suggest that they should be the concern of nurses. The gap in the research literature therefore would seem to be in this area of support-what older people need and want, and how nurses can meet these needs.
The interviews with older people had a loosely structured interview agenda focusing on their experiences of discharge processes and any areas which they felt were problematic, or care that they found particularly helpful. This interview style was adopted in order to ensure that interviews were focused enough to allow respondents to introduce new topics areas. The discussion groups to develop guidelines adopted focus group techniques (Kitzinger 1995) to elicit opinions and ideas from the participants. Many focus group techniques assume that members have no previous contact with each other, and concentrate on eliciting spontaneous to questions and ideas. As members of the groups in this study were work colleagues, the interview format was designed to elicit general group perspectives in the context of professional roles and cultures (Reed and Payton 1997).
Patients recently discharged from the study hospital (part of a large acute care Trust in the North of England)to the independent sector within a 10-mile radius of New castle were identified from hospital records. They were visited by the researcher in the care home within 4 weeks of their discharge and invited to participate in the study. These patients and their significant others were interviewed to identify and describe their experiences of discharge. The interviews were conducted in the care home or in the respondent’s own home, and followed a semi-structured interview schedule which outlined the main areas of the study. Patients’ case notes were also examined for information about discharge arrangements and plans, and to provide background material.
In the analysis of the data, however, it was important to distinguish between the feeling of the older people about the loss of their home, process of moving, and their new life in the care home. Some people would be sad about the loss of their home but happy about the life in the care home. Others would be happy about leaving their home, but would not like the care home. It was clear that there were many different views which depended on personal perspectives and attitudes, and the circumstances precipitating hospital admission and discharge to a care home.
Among these individual stories, however, there was one theme which remained constant: the passivity of older people in the process of living. They did not expect support from staff, and their coping strategies centred mainly on stoicism. As one person told us:
Well, you just have to get on with it, I mean there’s no point in making a fuss.
Some older people expressed a concern to avoid being a burden to others, either staff or family members. These people ‘had better thing to do’ as one man put it, and for the staff is included looking after older people made comments that suggested that these ideas had also come from nursing staff- where they talked about nurses telling them that it was time to move on, or that they could not stay in the hospital for ever. For example one person argued that:
They (the staff) said that it was about time I was going, and they were right.
It was also striking that they did not think of themselves as people with any choices or control over care decisions- the older people in our study did not voice any objections to the verdicts of staff that they should move into a home, not did they seem to expect to exercise much choice over the home they moved to. The choice of home was delighted to family members or social workers, and could be made, given that they were too frail to visit home themselves. As one person told us:
My daughter sorted all that out- I could not go round those homes because I cannot get about. I had to rely on her.
It did not seem that any alternatives had been suggested, for example help in making a visit to the care home with transport and assistance.
The older people had also expected to have to fit in with care home regimes, and were surprised that the care home allowed them any choice or freedom. One lady, for example was surprised to be ‘allowed’ to order a newspaper- she had not expected to be able to do this. Their ideas about care homes had been vague and based on snippets of information gathered from friends, acquaintances and the media, rather than any clear information. As one person told us:
It was like taking a step in the dark. I did not know what to expect.
Care home staff confirmed this, saying that often older people seemed to have little idea about what life in a care home would be like.
The ideas that they were not needy enough to be in hospital seemed to be shared by staff and older people. Family members, however, seemed less convinced by this thinking, and expressed more concerns about the process being rushed. These concerns stemmed from anxieties over the health of the relative, but also because of the process of choosing carefully. As one family members told us:
I had to go out and find a place, quickly because she was coming out. I went to see a couple, but I did not have a time to work through the list.
The ‘list’ that this person talked about was a list of homes registered with the Registration bodies of the Local Authority and Health Authority, and as such contain no information beyond addressed and numbers of beds. For most people in the study this was not enough information- they had very little guidance on what to look for in a home, or how to evaluate the care given. At the same time, family members felt a huge sense of responsibility for making the ‘right’ decision. The decision to opt for care home services was often portrayed as a professional decision, but the selection of a specific home was fraught with dilemmas- they did not feel themselves to be ‘informed consumers’. The views of the older people themselves did not seem to be always actively sought- they were sometimes dismissed, or the older people themselves opted out of the process, and this resulted in a paradoxical situation of people wanting to find some where their relative would be happy, yet not involving them in the process of decision- making.
The staff view
The hospital nurses’ responses indicated that there were no standarised approach to dealing with this process- discussions, if they occured, were ad hoc, fragmented and arose only if the older person initiated them. These initiations, however, did not seem to occur very often, with the staff reporting that they did not welcome discussion or invite it- one nurse described older people as having ‘made up their mind to accept their fate, and they do not see the point in discussing it-they only become distressed’. One nurse did, however, indicate in a written response that older people might not openly invite discussion and that sometimes nurses have to encourage them to talk- ‘Sometimes patients do not openly ask for advice or support, but its up to the nurse to spot the signs of anxiety and to approach the subject casually’. Where nurses did give examples of having talked to older people about their impending move they described these conversations as taking place while they were doing other things with the older person, such as helping them to dress. This approach avoided making a ‘big thing’ out of discussions as being to ‘cheer up’ older people.
The nursing staff felt that they knew little about care homes, and could not offer much support. They were not clear, for example, about the difference between the nursing and residential care, about processes of inspection and registration, or about how such care was financed. They also felt that this was not part of their job to know these things, as other staff ( for example social workers) were in charge of the process. In addition, there was some degree of hostility or suspicion towards the independent sector, particularly privately run homes, which were described by one nurse as ‘just in it for the money’. Some nurses had worked in private homes as relief nurses and reported that the standards of care they had seen were low, and there was a reluctance to collaborate with staff from these homes. One nurse recounted a situation where a care home had asked for some information about a patient, but she had been reluctant to provide it:
…it seemed like laziness and should not have be assessing them for themselves. As their care will be completely different from a wards it seemed like a cop out.
Social workers had more contact with care homes, and more knowledge of the systems of regulation and funding care, but this expertise did not necessarily give them a feeling of control over the process. They felt that they were responding primarily to pressures from medical staff to organize discharges and did not have time to spend with patients discussing’ their choices and preferences. They talked about their professional skills in providing support as being eroded by their administrative role in processing assessments and arrangements for care. One social worker described her role as being driven by these demands:
I do not spend the time I used to – it’s just you get a message from the medical staff- this one’s to go out, and you just sort out the paper work and may be talk to the family. Sometimes I do not even get to see the client.
Medical staff, however, felt that their role was mainly in making discharge decisions and deciding the level of care required from a medical point of view. Their concern was governed by Social Service Department financial considerations. They talked of their concern with patients who were waiting to come into hospital, which had to over-ride their concern with those who had received treatment and who had no further need of acute care. When asked about providing support for older people moving into a care home they reported that they expected that social workers and nurses would provide the necessary support and advice to patients. This was partly because they felt that it priority- but also because of the way in which their time was managed and their contact with patients was organised. As one doctor put it:
We see people on a round or at appointments and then we go away. Once we have told them where they are going to go, we disappear, and if they want to think about it late or discuss it after they have had a think about it, we were not there, but the nurses and social workers are more around.
Conclusion and Recommendations
This research suggests that the apparent stoicism of older people moving into a care home can mask feelings of loss and anxiety. If nursing staff wish to support older people through this transitional process, then they may have to be proactive in initiating discussions rather than waiting for older people to do so. Such an approach, however, must be carefully negotiated with older people- some may not wish to discuss their feelings when offered the opportunity to do so. Such discussions will need to be informed, and there is a need for nurses in hospitals to learn more about the care home setting, and to reflect on some of the assumptions that they may make about the independent sector. Understanding how care homes work may help nurses to encourage older people to think of themselves as people with choices, and working through their personal preferences for activities and lifestyles may well encourage this. We would suggest, therefore, that attention is paid to ways in which nurses can learn more about the care homes, and how they can encourage older people to make active decisions about their move.
This will need to be based on a systematic approach, such as formal assessment and review procedures, rather than rely on ad hoc initiatives. Developing a formal assessment schedule which is written with patients and which focuses on life styles preferences may go some way towards supporting older people in exercising and expressing preferences, and if this were to accompany them to the care home it would provide valuable information for staff there. An extension of this study would involve the development of such a schedule.
In addition, the data suggest that there is some confusion between nursing staff, medical staff and social workers about who is responsible for which aspects of the discharge procedure, with each professional group assuming that another has chief responsibility or input. For the future development of discharge processes, multidisciplinary teams need to clarify exactly what responsibilities each group has , and ensure that contact with older people is documented to reflect this. As Penhale (1997) has argued, multidisciplinary working in discharge planning is fraught with problems which arise from different goals for practice, and different form of organisational power across professional groups, but such negotiations is essential if older people are to be given the support that they need at a time of great change and potential stress in their lives.
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