Holding momentum : a grounded theory study of strategies for sustaining living at home in older persons

Purpose: Government strategies are putting increasing emphasis on sustaining the capacity of older persons to continue living independently in their own homes to ease strain on aged care services. The aim of this study was to understand the experiences and strategies that older people utilize to remain living at home from their own perspective. Methods: A grounded theory methodology was used to explore the actions and strategies used by persons over the age of 65 to enable them to remain living in their own homes. Data were collected from 21 women and men in three focus group discussions and 10 in-depth semi-structured interviews. Results: The data revealed that the central process participants used to hold momentum and sustain living at home involves a circular process in which older people acknowledge change and make ongoing evaluations and decisions about ageing at home. Conclusion: These findings have implications for informing policy and service provision by identifying appropriate resources and services to promote successful ageing at home

Early fluid bolus in adults with sepsis in the emergency department : a systematic review, meta-analysis and narrative synthesis

Background: Early intravenous fluids for patients with sepsis presenting with hypoperfusion or shock in the emergency department remains one of the key recommendations of the Surviving Sepsis Campaign guidelines to reduce mortality. However, compliance with the recommendation remains poor. While several interventions have been implemented to improve early fluid administration as part of sepsis protocols, the extent to which they have improved compliance with fluid resuscitation is unknown. The factors associated with the lack of compliance are also poorly understood. Methods: We conducted a systematic review, meta-analysis and narrative review to investigate the effectiveness of interventions in emergency departments in improving compliance with early fluid administration and examine the non-interventional facilitators and barriers that may influence appropriate fluid administration in adults with sepsis. We searched MEDLINE Ovid/PubMed, Ovid EMBASE, CINAHL, and SCOPUS databases for studies of any design to April 2021. We synthesised results from the studies reporting effectiveness of interventions in a meta-analysis and conducted a narrative synthesis of studies reporting non-interventional factors. Results: We included 31 studies out of the 825 unique articles identified in the systematic review of which 21 were included in the meta-analysis and 11 in the narrative synthesis. In meta-analysis, interventions were associated with a 47% improvement in the rate of compliance [(Random Effects (RE) Relative Risk (RR) = 1.47, 95% Confidence Interval (CI), 1.25–1.74, p-value < 0.01)]; an average 24 min reduction in the time to fluids [RE mean difference = − 24.11(95% CI − 14.09 to − 34.14 min, p value < 0.01)], and patients receiving an additional 575 mL fluids [RE mean difference = 575.40 (95% CI 202.28–1353.08, p value < 0.01)]. The compliance rate of early fluid administration reported in the studies included in the narrative synthesis is 48% [RR = 0.48 (95% CI 0.24–0.72)]. Conclusion: Performance improvement interventions improve compliance and time and volume of fluids administered to patients with sepsis in the emergency department. While patient-related factors such as advanced age, co-morbidities, cryptic shock were associated with poor compliance, important organisational factors such as inexperience of clinicians, overcrowding and inter-hospital transfers were also identified. A comprehensive understanding of the facilitators and barriers to early fluid administration is essential to design quality improvement projects

Identifying factors associated with intravenous fluid administration in patients with sepsis presenting to the emergency department : a retrospective cohort study

Background: Appropriate and timely administration of intravenous fluids to patients with sepsis-induced hypotension is one of the mainstays of sepsis management in the emergency department (ED), however, fluid resuscitation remains an ongoing challenge in ED. Our study has been undertaken with two specific aims: firstly, for patients with sepsis, to identify factors associated with receiving intravenous fluids while in the ED; and, secondly to identify determinants associated with the actual time to fluid administration. Methods: We conducted a retrospective multicentre cohort study of adult ED presentations between October 2018 and May 2019 in four metropolitan hospitals in Western Sydney, Australia. Patients meeting pre-specified criteria for sepsis and septic shock and treated with antibiotics within the first 24 h of presentation were included. Multivariable models were used to identify factors associated with fluid administration in sepsis. Results: Four thousand one hundred forty-six patients met the inclusion criteria, among these 2,300 (55.5%) patients with sepsis received intravenous fluids in ED. The median time to fluid administration from the time of diagnosis of sepsis was 1.6 h (Interquartile Range (IQR) 0.5 to 3.8), and the median volume of fluids administered was 1,100 mL (IQR 750 to 2058). Factors associated with patients receiving fluids were younger age (Odds Ratio (OR) 1.05, 95% Confidence Interval (CI (1.03 to 1.07), p < 0.001); lower systolic blood pressure (OR 1.11, 95% CI (1.08 to 1.13), p < 0.001); presenting to smaller hospital (OR 1.48, 95% CI (1.25 to 1.75, p < 0.001) and a Clinical Rapid Response alert activated (OR 1.64, 95% CI (1.28 to 2.11), p < 0.001). Patients with Triage Category 1 received fluids 101.22 min earlier (95% CI (59.3 to131.2), p < 0.001) and those with Category 2 received fluids 43.58 min earlier (95% CI (9.6 to 63.1), p < 0.001) compared to patients with Triage Category 3-5. Other factors associated with receiving fluids earlier included septic shock (-49.37 min (95% CI (-86.4 to -12.4), p < 0.001)); each mmol/L increase in serum lactate levels (-9.0 min, 95% CI (-15.7 to -2.3), p < 0.001) and presenting to smaller hospitals (-74.61 min, 95% CI (-94.0 to -55.3), p < 0.001). Conclusions: Younger age, greater severity of sepsis, and presenting to a smaller hospital increased the probability of receiving fluids and receiving it earlier. Recognition of these factors may assist in effective implementation of sepsis management guidelines which should translate into better patient outcomes. Future studies are needed to identify other associated factors that we have not explored

Factors influencing management of agitation in aged care facilities : a qualitative study of staff perceptions

Background: Agitation in older people is commonly associated with cognitive decline, complex medical diagnoses and polypharmacy. Impaired communication and comprehension within a dementia trajectory adds complexity to assessment and management. Despite high prevalence, agitated behaviours remain challenging to manage in residential aged care settings. Aim: To explore staff perceptions of agitation in residents of aged care facilities, including the influence of dementia, when selecting management strategies to reduce agitated behaviour. Design: Qualitative descriptive. Methods: Semi-structured interviews with 11 aged care staff were conducted at two aged care sites. Transcripts were examined using content analysis to identify common issues and categories. The study complied with COREQ guidelines (see. Appendix S1). Results: Participants reported managing resident agitation at least once per shift; most frequently manifesting as wandering, restlessness or aggression. Management strategies included distraction, providing space, knowing the resident, identifying causative factors, spending individual time and if necessary medication administration. Agitation management was more challenging for residents with dementia due to impaired communication or comprehension of instruction. Conclusions: While participants strived to deliver individualized person-centred care, this was difficult given time and resource constraints. Contemporary management of agitation therefore remains variable in everyday practice, with resident preference used when causative factors were known. Conversely, for residents with impaired communication and/or comprehension, distraction and chemical restraint were commonly used. Nuanced education for assessment and management is recommended to better address this unmet need for some residents. Relevance to clinical practice: For optimal care, appropriate allocation of time and resources is necessary to identify causative and contextual factors for individual residents. Recommendations are for additional staff training in communication and attitude, and collaborating with frontline staff to develop a practical guide for management of agitation in aged care. These simple initiatives may help to improve consistency of care delivery and resident outcomes

The demographic profile of nursing students in Queensland : a comparison between higher education and hospital recruits

This study compares the demographic characteristics of 142 nursing students in hospital programs and 365 nursing students in higher education programs in Queensland. Data were collected on a questionnaire distributed to students during lecture times by a contact person in each institution. No significant difference was found in the gender and age of entry variable. Males from Catholic schools and enrolled nurses were more likely to enter higher education programs than hospital programs. There was no significant difference in the geographic location of the school attended by students between the two institutional sub-groups which suggests that the national transfer of nurse education to higher education institutions will not be a disadvantage to country students

Developing person-centered care through the biographies of the older adult

Background: A lack of specialized knowledge about providing health care to older people decreases their health outcomes and quality of life. This article presents an innovative learning strategy for preregistration nursing students to raise awareness of person-centered care of the older adult. Method: This report is based on the authors' own experience and includes comments from students to the authors who taught the unit of study from 2010 to 2015, supported by current literature and theory discussing contemporary educational strategies. Results: Students came to value the older adult as a person to whom they could relate and the learning promoted person-centered care delivery. Although many students found this approach to learning to be challenging, student feedback demonstrated that the overall reception of the strategy was very positive. Conclusion: This strategy facilitated learning to improve person-centered care and addressed negative attitudes toward older adults, which improved health outcomes and their quality of life

Understanding organisational culture in the community health setting

Nurses work across a variety of settings, including the community. With an increasing ageing population, the associated growth in chronic health conditions and the current focus of government health policies targeting primary healthcare, nurses will be at the forefront of providing support and care to a growing number of people in the community. The organisational culture of community health settings is ever changing in response to the health needs of people in the community. Nurses require an understanding of ways in which the provision of community health services (CHSs) are structured in order to practise effectively and in collaboration with other health professionals and service providers. It is from this understanding that the healthcare needs of people in the community can be most effectively assessed, planned for and responded to by community nurses

Understanding organisational culture in the community health setting

Nurses work across a variety of settings, including the community. With an increasing ageing population, the associated growth in chronic health conditions and the current focus of government health policies targeting primary healthcare, nurses will be at the forefront of providing support and care to a growing number of clients in the community. The organisational culture of community health settings is ever changing in response to the health needs of people in the community. Nurses require an understanding of ways in which the provision of community health services (CHS) are structured in order to practise effectively and in collaboration with other health professionals and service providers. It is from this understanding that the healthcare needs of people in the community can most effectively be assessed, planned for and responded to by community health nurses. The organisational structure of CHS in Australia and New Zealand is complex. With this in mind, the intent of this chapter is to provide an overview of organisational culture and to explore the organisational culture of community nursing, its history, governance and funding. Within this chapter, particular emphasis is placed on exploring the role of primary healthcare and health promotion and their importance to the culture and organisation of community health nursing. The chapter concludes with a discussion of the roles of community health nurses

Healthy ageing and the older person

The aim of this chapter is to develop an understanding of how older people age well and the factors that influence healthy ageing. Whilst the focus of this chapter is on older people living in Australia, we have also included some discussion on older people living in New Zealand. This is not a comprehensive exploration of ageing - rather, this chapter provides an examination of contemporary issues influencing the health of older people. Understanding healthy ageing is important because of the increasing ageing population in Australia and New Zealand. This chapter provides an overview of healthy ageing within a primary healthcare (PHC) context. The chapter is divided into four sections. First, we discuss knowledge and attitudes about ageing. We then move on to explore how PHC supports healthy ageing. Following this, we look at societal factors that influence healthy ageing and finally we examine the importance of policy and service provision in maintaining and supporting the health of older people. Throughout this chapter, the term 'older person' is used to refer to all individuals over 65 years

Promoting sleep

Sleep is important for health and wellbeing. It is a calm period in which body systems are able to rest, restore energy and repair tissue damage. It is also an important time for the brain to make new pathways for information processing and to store into memory information gained throughout the day (Porth, 2011). We all need a good night's sleep; however, our need for sleep and our patterns of sleep change as we age and this can lead to sleep disturbance. Those of us who have experienced sleepless nights know about the subsequent impact on our ability to function the next day. For a person with dementia, disturbed sleep patterns can cause problems not only for themselves but also for their carers. This chapter will present an overview of sleep, summarising the stages of sleep and the disruptions to sleep relating to ageing and dementia. It will describe common causes of sleep disturbance, as well as strategies to assist you in managing these disturbances and promoting sleep for the person with dementia. It will highlight the importance of a good night's sleep to enhance the safety, health and wellbeing of the person with dementia and your ability to provide care for them