Caring for Older People

A Shared Approach

Christine Brown Wilson

• Éditeur: SAGE Publications Ltd
• Année: 2012
• ISBN:
  9781446290378
• Édition: 1
• Sujet: Medicina
• Sous-sujet: Infermieristica gerontologica

Caring for Older People is a timely and welcome addition to the nursing and health-care literature. The book introduces and describes collaborative ways of working with older people, ensuring that students and practitioners are better equipped to provide consistently high-quality care that can make a positive difference to the lives of older people and their families.

Providing an accessible, evidence-based framework and a wealth of practical strategies which can be implemented on a daily basis, Christine Brown Wilson takes the reader step by step through different approaches to nursing care and shows clearly how that care can move from being a task-focused to a person-focused experience.

Case-based scenarios threaded throughout the book also illustrate how the quality of care can be enhanced, and how students and practitioners can work effectively with older people while balancing the competing demands of the health and social care system. The author also shows how nurses can influence current practice, equipping the reader with key skills that can be used to challenge poor ways of working and to identify methods through which inadequate provision can be turned around.

This book will be indispensable reading for all nursing and healthcare students and practitioners who want to improve the quality of life for older people.

PART 1

UNDERPINNING PRINCIPLES

INTRODUCTION

Working with older people is often seen as something that anyone can do without needing specialist education. This is evidenced in the discipline of nursing by the decline in post-registration qualifications in working with older people and the lack of specialist content in the nursing undergraduate curriculum, particularly in the UK. This book is designed to provide students with an evidence-based framework that will support them to articulate their contribution when working with older people in an inter-disciplinary context. I have spoken to university educators in the USA, Australia and Canada, where everyone shared common stories about the difficulties in promoting the older person in the nursing curriculum. This may be because working with older people remains undervalued both by curriculum managers as well as by students themselves. This book provides practical strategies to support students and educators to articulate what makes working with older people so important and rewarding.

THE DEMOGRAPHICS: WHAT ARE THE IMPLICATIONS FOR HEALTH AND SOCIAL CARE?

We are living in an ageing society where older people are beginning to outnumber younger people in many countries in the developing world (World Health Organization [WHO], 2009). Asian countries have a high proportion of older people, with Japan having the ‘oldest’ population in the developed world. Although previously many Asian countries could depend on families for providing care and support, this is becoming less common (Lee and Mason, 2011). In Western developed countries, we are beginning to see the generation commonly known as ‘baby boomers’, who were born in the post-war years to the early 1960s, now entering their later life. These people have come through a highly consumerist culture and have differing expectations of services. This means the current ‘low-level’ expectations that older people hold of health and social care (Tadd et al., 2011) are likely to change with successive waves of the baby boomer generation.

We are also seeing a growing global trend where the birth rate is falling below replacement level in many countries (Lee and Mason, 2011). In the UK, for example, fewer babies are being born compared with the numbers of people who are dying (Baylis and Sly, 2010), which means that in coming years there will be fewer people working to pay the taxes that currently fund state support for older people in retirement. This will have future implications for the National Health Service (NHS) if care is to remain free at the point of delivery. This is a growing phenomenon across the world as many governments consider the financial implications of supporting a growing population of older people.

Older people are also living longer in retirement than in the years they had been working. Although longevity is currently increasing (i.e. the length of time older people are living for), many of these years are spent with disability, primarily due to life-limiting chronic conditions, which may account for the higher numbers of people aged 60 and over using health care services (Dew, 2011). With the growing population of older people, healthcare utilisation remains an area for concern as older people tend to be treated in emergency departments as unscheduled admissions more frequently for conditions that could be treated in less acute environments (Gruneir et al., 2011). Part of the reason for this may be that there are insufficient community-based services available to support older people in managing their health more effectively. If the additional years many older people are living are to be disability-free, there needs to be a greater emphasis on promoting health and activity for this group as long as possible.

THE PATIENT JOURNEY: DOES CONTEXT MATTER?

We are now seeing an ongoing squeeze on resources with policy focusing on keeping older people living in their community for as long as possible. This is partly due to the increased cost of residential environments, and partly because this is what older people choose. The focus on health and social care policy has and will continue to be on promoting independence, autonomy and choice, enabling older people to live in their community for longer (WHO, 2002). This is reflected in different government initiatives such as the monitoring of the discharge of older people from hospital to ensure they return sooner to a community environment for intermediate care or re-enablement services. One such indicator being used is how many people are still living at home three months after their discharge from hospital and this figure is currently at 78% for England (NHS Information, 2012).

Although older people wish to stay in their homes for longer, in the English Longitudinal Study into Ageing (ELSA) wellbeing scores were found to decrease after age 65. This suggested that as people age, their wellbeing reduces in the control they feel they have over their environment; the opportunities they have to make decisions without unwanted interference; and their sense of fulfilment or pleasure derived from the more active aspects of life. This decrease in wellbeing may be attributed to factors such as poorer health in later life, loss of immediate family or friends and reduced mobility in older age (Baylis and Sly, 2010). However, if we are supporting a growing population of older people who are living longer, possibly with life-limiting conditions, we need to (re)consider how we conceptualise health and social care to improve the quality of life for older people through the services we provide.

While nursing espouses a ‘holistic approach’, many students I teach continue to raise concerns about the lack of time available to consider the needs of older people. This is compounded by the focus on tasks so that when students are speaking with older people, they feel they should be ‘doing’ something else. Many of the stories student nurses recount include small acts that take little time but make a real difference to the wellbeing of the older person. This suggests that time spent in conversation with the older person may be transferred effectively into their care, even in the busiest environments. To value time spent in conversation, we need to see the older person not just as a recipient of care but a person capable of self-fulfilment and pleasure derived from the more active aspects of life.

This book is divided into two parts. Part 1 outlines the underpinning principles of approaches to care derived initially from research I have undertaken in long-term care. The discussion is underpinned by student examples of how they have applied these principles in other contexts. Part 2 provides practical examples from research and practice to demonstrate how these approaches might be enacted across different care environments to support older people more effectively.

Part 1 presents three approaches to care that focus on relationships in different ways. Each approach involves the older person, their family and staff, and is broken down into easily identifiable components that can be integrated into everyday health and social care practice. The final chapter in Part 1 considers how we might use this information to reconceptualise quality, given the policy debates on the ‘user experience’.

Chapter 1 critically examines the notion of patient-centred, person-centred and relationship-centred care from a policy and practice perspective. The chapter discusses what each of these terms means in practice and how they might be operationalised to enhance the experience of the older person.

Chapter 2 presents the individualised task-centred approach to care. This approach supports preferences for older people, knowing what they like to eat and when they like to get up/go to bed, etc. This approach infers good quality clinical care that focuses solely on physical aspects of caregiving. Individualising care in this way can support staff in avoiding poor clinical care.

Chapter 3 discusses how a person-centred approach promotes understanding of why something is significant in an older person’s life. This moves beyond likes and dislikes to understanding why different routines or aspects of a person’s care are important to them by locating this information in the context of a person’s biography. The chapter focuses on the contribution older people and families make to supporting the development of this knowledge through the stories people share.

Chapter 4 presents a way of considering the organisational context of care, enabling person-centred care to be delivered in a busy communal context. The relationship-centred approach is presented so that the needs of everyone involved in the relationship – older people, families and staff – might be considered.

Chapter 5 considers the impact that the different approaches discussed in the preceding chapters might have on older people, families and staff, and how this might influence what is meant by a ‘quality service’. An alternative approach to quality is proposed that reflects the experience of older people and their families by considering how the quality of care might be assessed using the following concepts: care that satisfies ‘me’; care that matters to ‘me’; care that involves ‘all of us’.

CHAPTER 1

Defining the continuum of care for older people

Learning outcomes

After reading this chapter, the student will be able to:

• Identify the key attributes of person-centred care
• Describe how person-centred care might differ from other approaches of care
• Describe what is meant by relationship-centred care
• Critically examine the differences between the different approaches along a continuum of care that seek to integrate the perspective of staff, older people and their families

Introduction

Within the literature there is a range of terms that are at times used interchangeably within practice, but do not always mean the same thing. This contributes to confusion within the practice environment as to which approach is best adopted and how such approaches might be incorporated into everyday practice. This may result in nurses reverting back to an approach to practice where they know the job will get done. Lack of time and other organisational constraints beyond their control are often given as reasons why nurses are unable to do more than focus on the task (Bradbury-Jones et al., 2011). Student nurses also struggle to focus on the person as they contend with the range of environments, the different approaches to mentorship with older people and the pressure of their university assessments (Brown et al., 2008).

Different ways of conceptualising care in relation to the individuality of people emerged within the 1990s as a more consumerist approach to health care was being adopted both in the UK, United States (US) and Australia. In considering the literature of the 1990s in respect to developing relationships, a number of models emerged from a very functional approach to patient-centred (Lutz and Bowers, 2000) and person-centred care to approaches that valued the personhood of the older person (Kitwood, 1997). Relationship-centred care also emerged to consider the wider relationships within the community and how this influenced the person’s approach to their health (Tresolini and the Pew-Fetzer Task Force, 1994). In reviewing these different approaches, we see a pattern of movement from health care being ‘done to a person’ to becoming an increasingly ‘shared’ endeavour. This chapter presents a systematic synthesis of this literature.

This chapter presents a synthesis of the literature, based on concept analysis (Risjord, 2009). Published literature, including grey literature such as doctorial theses, was searched to identify the key models of person-centred, patient-centred and relationship-centred care. One of the key themes that spanned these models was the concept of participation. I considered how central the concept of participation was to each model and the stakeholders that this participation extended to. These stakeholders could include older people, families, or staff.

Undertaking a concept analysis such as this has its limitations. For example, much of the literature is theoretical with limited empirical research available within this field. This means that it may be difficult to generalise findings. In addition, this analysis is subjective, based on my personal interpretation of what participation might mean within each of these models. However, this analysis provides a staring point by which we might consider what participation might mean from the perspective of older people, families and staff in different contexts of care.

In previous work I have undertaken (Brown Wilson and Davies, 2009), the approach staff adopted often influenced the ability of the older person or family member to be involved in care. Therefore, I have used the following approaches of staff to discuss the synthesis of the literature in relation to participation:

• Seeing the task
• Seeing the person
• Seeing the relationships

In addition to discussing the synthesis of the literature, I will be using case studies that demonstrate the end result of adopting each of these different themes.

Seeing the task

Wherever we are supporting older people, when our main focus is on the task, we adopt an attitude towards the older person which is then communicated in ways that we often don’t recognise.

Practice scenario: Medical unit

Martha was admitted with a chest infection. During the assessment Martha mentions activities that she has been struggling with at home. The priority for the nurse was that Martha’s chest infection was treated and so she told Martha that everything else would be dealt with later. Martha was prescribed antibiotics and intravenous fluids for dehydration with her fluid balance monitored. These activities were focused on the restoration of health and very necessary. However, Martha was made to feel that the other issues she had concerns about were not important to the nurse. This would make it difficult for Martha to tell the nurse what was on her mind in future.

We might be concerned about the time needed to work with an older person given the pressures of our workload. This means there may be a tendency to label all older people as ‘hard work’, or even ‘nuisances’. When older people enter the acute setting, they initially ignore assaults on their dignity that come from these attitudes (Jacelon, 2003). Labels can also be created to help us categorise people and may even be used as a form of shorthand. For example, as professionals, we tend to label older people according to the services they are receiving; this may be as patients in health care, clients in community care, service users or residents in long-term care. If we take the example of the label ‘patients’, this denotes the fact that someone has entered an acute hospital setting and professionals expect people to have the attributes of a ‘patient’ – requiring support from registered professionals who have the knowledge and skills to help that person, often in an acute crisis. However, many older people do not fit the ‘neat package’ that the label ‘patient’ infers and many nurses struggle to provide the care required for older people with complex needs. Jacelon (...