Journal of Advanced Nursing - 2022 - Grealish - Barriers and enablers to embedding fundamental nursing care for older

Page 1: Introduction and Background

Study Overview

• Title: Barriers and Enablers to Embedding Fundamental Nursing Care for Older Patients

• Authors: Laurie Grealish, Kristen Ranse, Jo-Anne Todd, Lyn Armit, Stephen Billett, Leigh Collier, Kasia Bail, Wendy Moyle

• Design: Explanatory sequential mixed methods design

• Aims: To understand the enablers and barriers for delivering fundamental care to hospitalized older patients.

• Location: Tertiary hospital in Southeast Queensland, Australia.

• Observations: Conducted over two 2-week periods in 2019.

Research Funding

• Supported by Gold Coast Health and Gold Coast Hospital Foundation Collaborative Research (Grant No: RGS201800011).

Key Findings

• Observations: Key nursing activities recorded in approximately 26% (medical unit) and 22% (surgical unit) of all observations.

  • Indirect care was the highest, at 41% (medical) and 43% (surgical).

• Important care is prioritized over fundamental care, leading to potential omissions in fundamental nursing duties.

• Cultural acceptance of missed nursing care may diminish public trust in healthcare systems.

Implications for Nursing Leadership

• Enhance the importance of fundamental care within nursing practice.

• Promote educational strategies emphasizing the implications of missed fundamental care on older patients.

• Investigate work interruptions that hinder care delivery.

Page 2: Fundamental Care Definition and Challenges

Definition of Fundamental Care

• Fundamental care refers to essential physical, psychosocial, and relational tasks needed to meet patient needs.

• Often viewed as basic or common-sense care but integrating it into acute settings is challenging.

Importance for Older Patients

• Vital for preventing functional decline and improving outcomes.

• Missed fundamental care correlates with poor health outcomes for older hospitalized patients.

Statistics on Hospital-associated Complications

• Functional Disability: 30% of patients aged 65+ experienced functional disability, regardless of hospital stay length.

• Complications: Four major complications (e.g., UTIs, pneumonia, pressure injuries) account for significant healthcare costs and prolonged stays.

Key Organizational Factors

• Factors influencing fundamental care include nurse staffing levels, context of care delivery, and available time.

• Limited research exists on non-workforce-related barriers to implementing fundamental care.

Focus of the Study

• Aim to clarify the challenges and supportive leadership needed for enhancing fundamental care delivery to older patients.

Page 3: Perceptions and Discrepancies in Fundamental Care

Variability in Care Provision

• Assessment Practices: Adherence to nursing practices varied; specifically, nutrition/hydration adherence was high, while pain assessment was low.

• Need for further research into why fundamental care is often overlooked.

Lack of Consensus on Fundamental Care

• No universal agreement exists on defining and delivering fundamental care, complicating its integration into nursing practice.

• Distinctions between compassionate care and fundamental care often obscure its importance.

Recording Systems in Healthcare

• Current organizational record-keeping systems favor medications and procedures, sidelining the importance of fundamental care tasks.

• Inadequate documentation of fundamental nursing care exacerbates its invisibility in healthcare organizations.

Delegation Challenges and Care Worker Roles

• Minimally trained care assistants often receive care delegation, complicating comprehensive care and communication for fundamental tasks.

Existing Programs for Fundamental Care Integration

• Programs implementing fundamental care show mixed outcomes; e.g., delirium prevention programs require supplemental resources for effective implementation.

Page 4: Study Methodology

Aims and Design of the Study

• Explore barriers and enablers to delivering fundamental care to hospitalized older patients using a mixed-methods design.

• Phase 1: Quantitative description of nursing activities.

• Phase 2: Qualitative group discussions to explain observations from Phase 1.

Data Collection Procedure

• Conducted in two different medical and surgical units where over half of the patients were aged 65+.

• Convenience sampling of nurses was utilized to gather representative insights during the study periods.

Instruments and Observation Details

• Work Sampling Technique: Employed to collect data regarding the frequency of specific nursing activities.

• Observations conducted over two 2-week bursts through fixed interval sampling to ensure comprehensive data.

Page 5: Observation Framework

Detailed Collection Protocols

• Observers recorded nursing activities every 10 minutes, focusing on relevant categories based on defined nursing tasks.

Collected Activity Categories

• The method categorized activities into five dimensions (Direct Care-Fundamental, Direct Care-Other, Indirect Care, Unit Related, Personal), as detailed in the study.

Page 6: Ethics and Quality Control

Ethics Considerations

• Ethical approval obtained through relevant institutional committees.

• Nurses and patients provided informed consent and assurance of privacy.

Data Analysis Methods

• Employing statistical methods to analyze the frequency of observed nursing activities

• Qualitative content analysis conducted on interview responses for thematic trends.

• Validity checks ensured through inter-rater reliability tests and participant feedback on findings.

Page 7: Study Results – Observations

Observational Findings Summary

• Total of over 2700 observations across medical/surgical units highlighted clear task prioritization disparities.

• Fundamental care activities represented about 22%-26% of nursing activities observed.

Breakdown of Care Activities

• Detailed anonymized data was presented, revealing overall distributions across care categories and the impact of staff interactions.

Page 8: Group Interview Themes

Identified Discussion Themes

1. The focus on reportable tasks over fundamental care led to discrepancies in care provision.

2. Indirect care delays undermine timely delivery of fundamental care, straining resources and impacting quality.

3. High care needs of some patients complicate equitable care distribution among all patients.

Prioritization Patterns Reported by Nurses

• Nurses discussed a tendency to prioritize quicker, reportable tasks, potentially neglecting comprehensive patient care.

Page 9: Discussion of Findings

Implications for Nurse Leadership

• Discussed the need for relational leadership to promote the importance of fundamental care in nursing education and practice.

• Increased focus on making nursing leaders aware of the implications of care neglect for hospital-acquired complications.

Care Delivery Challenges Recognized

• Identified barriers stemming from institutional practices that often deprioritize direct, fundamental patient care.

Page 10: Study Limitations and Conclusions

Study Limitations

• Limited generalizability due to unidirectional site data collection and convenience sampling biases.

• Inability to assess time allocations for each observed activity.

Closing Thoughts

• Urgent need for institutional changes to prioritize fundamental care within nursing practice.

• Advocacy for further investigations and development of comprehensive frameworks surrounding fundamental patient care.