How do nurses care for hospitalized older adults at risk for delirium?
Creators: name: Dahlke, Sherry Ann
Publisher: name: University of British Columbia
Year: 2009

description: How do Nurses care for Hospitalized Older Adults at Risk for Delirium? Almost half of the people in our hospitals are over the age of sixty-five, and this demographic is only going to rise with the aging of our population. Up to fifty-six percent of hospitalized older adults are at risk of experiencing delirium either on admission or at some point during their stay. As one would expect with a subject of such magnitude, there is an abundance of literature describing how best to assess, manage, and prevent delirium in the older adult. The literature also identifies nurses as key to intervening with delirious older adults and describes how to educate nurses to care for this population. However, although a large population experiences delirium every day in our hospitals, nurses recognize only thirty percent of cases. Since recognition of delirium is necessary in order to plan care, this is an alarming statistic. If delirium is not treated it can lead to serious outcomes, even death to older adults. Not only do older adults experience detrimental consequences from delirium, but nurses experience frustration due to the increased workload, and institutional costs for hospitalization rise due to increased lengths of stay caused by delirium. What is clearly lacking in the literature is an understanding of how nurses currently care for this population. Attempts to implement best practices as described in the literature will fall short until there is an understanding of current practice, what is working and what the challenges are. To understand current practice a qualitative study was conducted in a small regional hospital. Since a large portion of seniors in British Columbia are cared for in small regional hospitals, understanding the context of this type of setting is important. Twelve nurses were interviewed with the research objective of determining the strategies nurses use to assess, prevent, and manage delirium in older adults. Data analysis revealed that nurses care for older adults in a setting that is focused on efficiency of moving patients through the system. The efficiency is determined by acute medical illness rather than the age. This approach to care leads to nurse frustration as the speed at which the nurse must complete her or his patient care activities does not match the speed which older adults are able to function. To manage this conflict, nurses made^choices about how to manage the care of the older adult and still get their work done. Nurses used safety as a guiding principle in choosing how to manage care of this population. To achieve safety, nurses positioned patients so that they could frequently monitor them, and they used chemical and physical restraints. To determine the cognitive status of the older adult and thus anticipate safety needs, they used purposeful questioning and careful attention to subtle physical cues. Nurses reported that their ability to pick up on, and manage delirium developed over time, with experience, and through watching other nurses. They talked about how "wished" they could care for older adults if they had more time. Caring for older adults occurs without the spoken recognition that we are caring for an older population with complex needs. Thus, nurses manage their workload by chemically and physically restraining older adults, so they can complete their necessary patient care activities. Nurses identified that there is a lack of people resources, education, and appropriate physical space to care for this population differently. They also spoke of the assumptions implicit in practice that old people are confused, and dealing with that is just part of nurses' work. Implications for practice are that when we examine which population we are caring for, and address how best to meet their unique needs, we will ultimately move older adults through their illness more efficiently. This includes developing staffing levels, education, and physical spaces that support caring safely for older adults. It is time for the system to acknowledge that efficiency with older adults will look different from efficiency with a younger population.