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Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality


Care workers' abusive behavior to residents in care homes: a qualitative study of types of abuse, barriers, and facilitators to good care and development of an instrument for reporting of abuse anonymously.

Rationale of the Study

There has been dramatic change in social care in the past two decades with residential homes now having residents who in the past would have been in nursing homes. And now nursing homes are taking care of people who are in need of healthcare services in medical facilities. Demographics have shifted and people are faced with more complex geriatric conditions even as they live longer. Nursing homes are expected to do more difficult and complex jobs including taking care of acute needs in patients while simultaneously ensuring care is provided to the community (Hardy, 2015)

Healthcare workers in nursing homes are faced with challenges unique to the job. The typical working life is characterized by routine intimate care acts that are often carried out in one's privacy and in one's home. In nursing homes, the daily routine activities such as feeding, dressing, and bathing are translated into acts of labor that are to be performed by  paraprofessionals that are paid lowly often working under complex conditions  that put profit first above emotional care. Nursing homes' profit motives transform a challenging job to one that is exceedingly demanding and eventually limits and constrains the nurses' capacity to be emotionally attached to their work (Rodriguez, 2011, p. 265).

The NMC code of ethics stipulates that it is the nurse's role to raise concerns if he/she believes that a vulnerable person is at risk or is need of additional protection and support. The nurse is expected to treat people with compassion, respect, and kindness while upholding their dignity. In light of these tenets, this paper will critically analyze two articles: Wolff, A., Stuckler, D., & McKee, M. (2015)." Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality" and Cooper, C., Dow, B., Hay, S., Livingston, D. and Livingston, G., 2013. Care workers’ abusive behavior to residents in care homes: a qualitative study of types of abuse, barriers, and facilitators to good care and development of an instrument for reporting of abuse anonymously.

Two issues underpin the necessity of this study. The first is that the high prevalence of elderly abuse in care homes which often results in equally high mortality rates. The second is understaffing, undesirable working conditions, and individual nurses' well being as well as other work related factors in care homes. This paper seeks to link the relationship between these two underpinning factors and discuss the way forward with regard to improved elderly patient care satisfaction and enhanced quality of care provision by nursing staff. The first article will be critically analyzed using the CASP tool to show the extent and impact of elderly abuse in care homes while the second article will be analyzed for the possible reasons that precipitate elderly care abuse from the nurse's perspective.

Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality. 

In this research study, the focus was on hospital ailments that elderly patient s experience with a specific focus on dehydration. Hypernatraemia involves loss of body fluids which results in intense disruption of other bodily functions (El-Sharkawy,  Sahota, & Lobo, 2015, p. 97; Cheuvront , Kenefick, & Charkoudian, et al., 2013, p. 455). The body needs continuous water replenishment for it to function optimally (Popkin, D’Anci, & Rosenberg, 2010, p. 439). When the amount of fluids released from the cells surpasses that which a person consumes, dehydration becomes inevitable (Jequier & Constant, 2010,  p.115). Elderly patients are more prone to being dehydrated and it becomes a major risk factor to their overall wellbeing which may result in illnesses and even fatality(El-Sharkawy, Watson, &Neal, et al., 2015, p. 943; Shimizu, Kinoshita, & Hattor et al., 2012, p. 1207). The elderly need to be properly hydrated and it is upon the onus of nursing homes to take the necessary steps in ensuing that this is incorporated in the care plan of each patient (Moody &Bennet, 2015).

Are patients admitted to hospitals from care homes dehydrated? A retrospective analysis of hypernatraemia and in-hospital mortality

20 percent of elderly persons in care homes are reported as being dangerously dehydrated with those suffering from dementia being at a greater risk of dehydration. Older people with memory problems such as Alzheimer's are often denied fluids in nursing homes. Failure to ensure that elderly persons are properly hydrated causes a vicious cycle of decline in cognitive functions. Although it is difficult to identify dehydration, it can lead to accelerated hospital admission risk, disability, UTI, and mortality (Moody &Bennet, 2015)

Residents in nursing home facilities are reported as being dehydrated for a vast array of reasons. One possibility is difficulty in swallowing that some aged persons are challenged with. Other patients may find it difficult to communicate their need for fluids to the nursing staff.  In addition, language barrier may hinder successful communication between the elderly patient and the nurse, making it difficult for the patient to communicate their desire to be rehydrated. (Moody &Bennet, 2015).

Despite this, it is the responsibility of nursing homes to be conscious of the fact that not all patients will be able to request for fluids and hence nursing staff should ensure that no patient lacks fluids. It may also be possible that nurses are inadequately trained in understanding the needs of elderly patients and that this requirement is overlooked by many staffs (Nursing Home Abuse Guide, 2016).

In this study, the authors compared hypernatraemia risks among patient admitted in hospitals and who were identified as residents in care homes and proceeded to evaluate the relationship of hospital mortality to hypernatraemia. The study was conducted in light of the recent concerns over elderly patients' dehydration incidences among those residing in various UK nursing homes. The study was significant as it was the first to analyze the relationship between residency in care home with hypernatraemia and mortality rates which made it possible to test the research hypothesis that increased incidences of hypernatraemia in care homes resulted in ultimate increase in risk of hospital mortality.

Inclusion and Exclusion criteria

The researchers related data from two key sources that are operated by the NHS Trust :the Barnet and Chase Farm Hospitals. The Patient Administration System was used to access socio demographic data such as gender, DoB, address, admission and discharge modes. The laboratory system was used in accessing tests dates, times, and results. This information was available from the hospital's Oracle database.  The researchers carried out a retrospective analysis of every individual that had previously been admitted at the hospitals within the 2 year period and who were 65years of age and above, and had been admitted between 01.01.2011 and 31.12.2013. The first admission was the only one considered which totaled to 27,603. Of the total sampled, plasma sodium was measured in 21,833 within the first 24 hours after getting admitted. A total of 143 records lacked a postcode that was valid and were therefore excluded.90 records did not have an admission code that was valid and were also excluded. Independence between patients' admissions was ensured through using the first admission only in the analysis.

Methodology

For every admission, the researchers extracted the patient's gender, age, home postcode, admission type (emergency or planned) ,whether measured for concentration of plasma sodium immediately upon admission, and whether on final discharge the  patient was alive or not. Those that were discharged alive were included in the analysis

 The classification standards were used in coding patients with hypernatraemia and who had concentrations of plasma sodium above145 mmol/L. The hypernatraemia on admission frequency varied with the patient's age and also on the time of admission (whether it was an emergency admission). The final analysis was done on 21,610 admissions which comprised of 1413 hospital mortalities and 432 hypernatraemia cases.

A retrospective cohort study is also referred to as a historic cohort study, and is described as a  longitudinal cohort study which seeks to analyze individuals in a given cohort, who share an exposure factor that is common to all, in determining the disease development influence (Song and Chung, 2010, p. 2234). This cohort group is compared to another group comprising of similar individual characteristics but who have not been exposed to the disease factor. The main advantage of retrospective cohort studies is that they have the potential to address a rare disease occurrence which would ordinarily require a large data sample if the study was done in a prospective way(Bruce, Pope, & Stanistreet, 2008). In a retrospective study, the people with the disease are already identified hence making this kind of study useful in addressing low incidence disease (FAO, 2014).

However, the retrospective cohort study can face a number of biases the top on the list being information or misclassification bias, or selection bias. In addition, researchers are unable to control outcome or exposure assessment but rather, they rely on other researchers to keep accurate records (FAO, 2014).

The retrospective cohort study was appropriate for this study as it involved a very large sample group and caring out a prospective study would have been time and resource intensive. In addition, the study design was a good option for analysis of multiple outcomes in this case: incidences of hypernatraemia in residential or nursing homes, and mortality rates in the same (FAO, 2014)

90 care homes were identified via www.carehome.co.uk which served the two NHS hospitals in the study. Homes that did not offer nursing care were excluded. The Patient Administration System proved to be an inadequate source of patient's admission source. The researchers then matched the care home with admission data by matching postcodes with persons aged 65years and above, with more than 20admissions, over the two-year period under study. This resulted in identification of 53 homes. It was assumed that a patient that had given a postcode of a care home was a resident of the same.

The coding used was thorough and appropriate as it factored in all the possibilities with regard to determining the residence of the elderly patients and also in light of the fact that the patient administration system was unreliable in providing patient addresses. Coding is a necessary step in quantitative research as it enables processing and analysis of data using computer software.

The researchers opted to use Multivariate logistic regression models for adjustment of possible confounding factors such as sex, admission mode, age-bands, and made comparisons with patients who had not been admitted form care homes by utilizing multivariate regression. The next step was to create a link between mortality risk associated to in-hospital including status of care residency as a dummy variable. STRATA v.13.1 was used with standard errors clustering done using residence of the patients for sampling non-independence adjustment.

Simple logistic regression is an analysis that is done where the application of regression utilizes a single dichotomous outcome as well as a single independent variable; Multiple logistic regression is an analysis that is utilizes one dichotomous outcome and several independent variables.  This study used multiple logistic regressions which was appropriate in analyzing the relationship between patient incidence of hypernatraemia against residence status and mortality rates.

The researchers found that patients in care homes had a higher likelihood of suffering from dementia as well as hypernatraemia compared to those from residential homes. The odds of a patient becoming hypernatraemic was ten times greater among patients in care homes prior to confounding factor being adjusted (the odds rate was set at 10.5, while  the confidence interval was 95%: 8.43–13.0). Hence, care homes factors were attributed 90.5% while hypernatraemia factors were attributed 36.0%. 

Mortality rates were also higher for patients who were care home residents compared to those from their individual homes (14.2% and 6.0% respectively). In line with the mechanism evidence, the researchers found that hypernatraemia inclusion into the model resulted in care homes' association attenuation  with approximately 50% increased mortality (confidence interval of 95%: 1.26-2.06, AOR: 1.61). Hypernatraemia was individually linked to mortality risk within hospitals and was found to be five times greater (confidence interval of 95%: 3.71-7.0, AOR: 5.10).

A process is deemed to be robust with regard to model hypothesis deviation when the process remains undeterred even when initial assumptions are eliminated. Robustness may be used to describe the reproducibility of  an analytical method in different conditions with no occurrence of unexpected differences in the final results as well as a test of robustness at the set up of the experiment .

The results of the study were subjected to robustness tests where controls for age intervals were re-estimated using age intervals of five years. This showed that alteration of the results was not significant. The next step involved removing potential outliers that were based on standardised residuals that were more than |2|. The results remained unchanged. The next step was disaggregation of hypernatraemia risk on admission for identified care homes in order to identify whether the cases were sourced from a small number of clusters. This showed that patient admission from care homes was not associated inevitably with hypernatraemia, but that there was a significant increase in the probability in approximately a third of care homes when adjustments were made for gender, age, dementia, and admission types. The final step was to adjust for frailty that was unobserved and patient death was included to determine whether it occurred due to other unobserved frailty and still, the results remained unchanged

The results were put into a clinical perspective by quantifying hypernatraemia probability of four scenarios for patients aged 80 years as follows: care home/own-home/ dementia/ no dementia. The lowest admission hypernatraemia probability was found among patients who had been admitted from their own homes (0.9%), followed by patients with dementia (3.3%), those who had no dementia (5.6%), and those from care homes and with dementia (14.7%). What this means is that the odds of a person living in their own residence and with dementia are lower for probability of hypernatraemia occurrence than one living in a care home with no dementia.

The first limitation in this study was the difficulty in separation of causation from association even when adjustments were made for probable confounders. The second limitation was the probability of mis-specification risk of a patient as residing in care home while yet the patient resided in a domestic residence. The third limitation was that the study included only one NHS trust hence the results of the study are not generalizable. These results can only be used with caution in reference to other care intuitions.

 The hospitals under study are located in a suburban area where there are several care homes. Inner city hospitals such as those in London are characterized by property that are of high value and hence will receive fewer numbers of patients  in care homes thus, incidence of hypernatraemia magnitude may be significantly lower than that in the population studied.

The study moved from other previous studies in evaluating patient outcomes upon admission in hospitals. Where residents in care homes are reported as being dehydrated, the possible reasons are few. The first may be that the patients refuse to drink or if they do, they only take little amounts of fluids. The second probability is where the care home staff does not give the patients sufficient fluid amounts either because of omission or commission where the act is deliberate in an attempt to minimize frequent assistance requests as well as reducing incontinence. There is no clear understanding of how these two probable reasons balance. The observations made in this study showed that prevalence of hypernatraemia in care home settings was significantly higher as well as its link to in-hospital mortality. The results from the study demonstrate that a patient with dementia but residing in their own homes has a lower probability of hypernatraemia (1%) compared to one who has no dementia but living in a care home. It therefore seems reasonable that a patient presented from a care home to a hospital with sodium level that are above 145 mmol/L ought to trigger concerns as indicated in discharge summaries presented to a GPs attending to patients in the care homes. A patient admitted a second time presenting with hypernatraemia over a given period should also act as a trigger of concern over a systemic problem within the care home and a formal complaint should be raised with potential involvement of Care Quality Commission. When all information is compounded from this study, the need for a follow up intervention study is necessitated; one that includes active encouragement and education of fluid intake within care home settings ought to be undertaken.

Critical Appraisal: 12/12

Accounted confounding factors

Yes

Clear description of data selection

Yes

Confidence intervals stated

Yes

Issue on focus was addressed

Yes

Measures were valid and reliable

Yes

Pre-study considerations prior to data selection

Yes

Sample data could introduce bias

Yes

Satisfactory rate of response

Yes

Selected data represents population inferred by the research

Yes

Statistical significance assessment

Yes

Use of appropriate research method

Yes

Results applicable to current study I am working on

Yes

Care workers’ abusive behavior to residents in care homes: a qualitative study of types of abuse, barriers, and facilitators to good care and development of an instrument for reporting of abuse anonymously. 

In this study the researchers used focus groups to measure anonymous self reporting of caregivers with regard to physical abuse of elderly patients which included excessive restraints use, refusal to relieve pain, personal care neglect, financial and verbal abuse. The workers views were elicited about the common occurrence of abusive incidences and in a way that was acceptable to them.

Purposive sampling was used to sample participants from residential and nursing homes in London. The care settings were voluntary, private residential or nursing, local authority, and specialized units for patients with dementia or not. Persons who had direct contact with dementia patients were approached to participate in the focus groups. The first focus group ended with the exclusion of managers as they hindered open and frank communication by the caregivers and nursing staff. The study aimed at finding out what makes it difficult for caregivers to provide quality care to patients with dementia and what helps them in providing good quality care.

The research observed participant confidentiality and was also reliable as the participant's anonymity (Kaiser, 2009, p. 1632)was maintained in addition to the participants agreeing to take part voluntarily. Further, the researchers got prior permission from the West London Research Ethics Committee, thus the research met ethical considerations. In addition, the researchers assured participants of their personal safety in the event that disclosure of information out the participants at risk of harm (Giordano, O'Reilly, & Taylor et al., 2007, p. 264).

2to 3 researchers facilitated the focus groups The discussions lasted between 60-90 minutes with each group comprising of 6-13 participants. The participants were required to fill a demographic survey prior to participating in the focus group.

Care givers were asked to give specific examples of barriers they experienced in delivering quality services to patients with dementia. They were also to give incidences where they had been concerned over occurrence of abuse or failure for quality care being administered to the patients. The first discussion group did not yield sufficient information as the participants were finding it difficult to visualize scenarios when quality care was denied to a patient. The researchers resulted in creating a vignette that was used as the point of discussion.

The first group was introduced to the Modified Conflict Tactics Scale which aims at getting information from caregivers in both residential and nursing homes on elder abuse meted on patients with dementia. The participants were asked to evaluate the relevance of the MCTS items in measuring anonymity. Feedback was used to revise the instrument after which it was presented to the next focus group. The participants were also asked to state their likelihood of completing the MCTS.

The qualitative research methodology that was used was appropriate for this study as it was investigating a new field with regard to caseworker anonymous reporting using the MCTS Corbin &Strauss, 2007 p.14; Creswell, 2007 p. 23).  The use of focus groups requires respondents to answer and discuss open ended questions while remain gin focused on the issue at hand without digressing. Semi-structured interviews are used in focus groups and are not repeated (Corbin &Strauss,  2008 p.18) The focus group discussions last a minimum of half hour with data captured via audio recording as was witnessed in this study (Bryman, 2008; Noor, 2008, p. 1602).

The data analysis was founded on the grounded theory by using a thematic framework theoretic approach (Sbaraini, Carter, & Evans et al., 2011). This is where information that is collected is used to construct the next step in data collection (Corbin, 2008). In this study, the researchers used the feedback they got from the first focus group to modify the anonymity instrument. The grounded theory was appropriate for this study as it helped in modifying the instrument to meet the needs of the participants (Kuper, Reeves, &Levinson et al., 2008). By refining the instrument based on participant's feedback, the researchers were able to get a better grasp of what would encourage caregivers to report any form of abuse anonymously.

The analysis focused on two areas that were based on the type of questions asked; MCTS content acceptability, and the types of abuse that caregivers witnessed. Once data saturation was reached, the instrument was modified and the final version sent to participants via mail for any additional suggestions on changing it.

Abusive behaviour reports were categorized into three general groups: 1) situations where competing demands or competition of resources was perceived by caregivers as the reason for incidences of poor quality service delivery. Examples included waiting for longer periods to get personal care, denial of care with regard to mobility or emotional support.2) instances of potentially abusive acts which were deemed to be better options for patient adherence to care for example, issuing of threats, restraining of patients to prevent them from soiling themselves, and requiring high falls risk patient to walk so as to enable him not to forget the skill. 3) Situations that were in tandem with in-house practices such as patients not being given sufficient meal time due to the fact that the kitchen closed early.

The likelihood of occurrence of abuse was attributed to institutional factors such as bureaucracy that hindered quality care provision, miscommunication where frontline nurses were not informed about new patients reporting to the facilities. Another reason was understaffing and unreliable equipment. In addition, all focus groups resonated the feeling that the care workers were undervalued, underpaid, ignored, blamed for things that went wrong, and all these resulted in a buildup of frustration that the caregivers meted on patients through abusive behaviour. Further, patients that were aggressive and confrontational were often met with equal aggression by the care workers.

With regard to the MCTS, the use of negative words such as threatened, elicited negative responses form care workers and hence these were interspersed with items that were positive. Participants also stated they thought that the survey was relevant and that the likelihood of filling it was increased if the survey was sent to their homes where they were assured of privacy.

The research was centered on focus groups where participants were involved in discussions. However, though willing to admit that the incidences of elderly abuse do occur in their respective workplaces, none except one participant was willing to admit to abusing an elderly patient. This in itself beats the purpose of the MCTS instrument that is supposed to encourage reporting of abuse including self reporting, at the time of the research study. The fact that participants were unwilling to admit their part in elderly abuse put into question the reliability of information that persons filling the MCTS survey would be.

Another limitation was the sample size which comprised of care workers from only four homes located in London. The results can therefore, not be generalized and any interpretations of the same is open to caution during application.

Elder abuse can be described as the infliction of psychological/emotional, physical, financial, or sexual harm on an older adult. Abuse can also be in the form of unintentional or intentional neglect by a caregiver to an older adult (APA, 2016). Neglect by a caregiver can range between strategies of care giving that hold back attention from an individual and that is appropriate to the intentional failure to meet the emotional, social, or physical needs of an older adult (Dong, Simon, & Gorbien, 2007). Acts of neglect can include failure of provision of medications, clothing, water, food, and assistance with ADLs or personal hygiene assistance (Acierno, Hernandez, & Amstadter  et al., 2010, p. 292).

Care giving can be a  stressful service that can affect both the recipients of care and the caregivers as well, and may trigger behaviours in caregivers that are potentially harmful and which place the elderly and dependent patients at risk of abuse (Laumann, Leitsch, &Waite, 2008, p.248; Cohen, Levin, & Gagin et al., 2007, p.1224).A caregiver going through personal challenges and problems such as personal crises, drug and alcohol abuse, emotional or mental illness, caregiver stress, and a tendency to be violent in solving problems, can result in abusing older frail patients (Cooper, Selwood, & Livingstone, 2008, p. 151). In some incidences, the older patient receiving care may become violent or physically abusive as witnessed often in patients with Alzheimer's disease or other dementia forms (Perez, Izal,& Montorio, 2009, p. 17).

Another significant risk factor for abuse and neglect of older patient is caregiver stress (Garre, Planas, & Lopez et al., 2009, p.815). When untrained or uninformed care givers are tasked with caring for elderly patients while striking a balance between personal needs and the needs of the patient, intense frustration often results accompanied by anger and which can lead to abusive behaviour (MacNeil, Kosberg, Durkin  et al., 2010, p. 76; Lindbloom, Brandt, & Hough et al., 2007, p. 610).

The risk of abuse of elderly patients is increased more so when the patient is  mentally or physically impaired or is sick. Caregivers tasked with caring for such patients under such stressful situations will often experience feeling of hopelessness and being trapped (Selwood, Cooper, & Owens et al., 2009, p. 309) and can result in using physical force.

Conclusion

The role of nurses in preventing elder abuse is espoused in the NMC code of ethics which outlines the expectations from nurses with regard to elderly patient care under the duties of beneficence (the intention for a nurse to do good); non-malfecience (the intention for a nurse not to do any harm); justice (to treat every patient with equality and fairness); and autonomy (to respect and assist patients with their right to self determination). Nurses are obligated under the NMC code of ethics, to report any kind of abuse they suspect or have witnessed in their place of work with regard to patient care. A nurse ought to report immediately to the immediate supervisor and the notification and incidence documented appropriately to serve as a witness once the perpetrator of the abuse is summoned by higher authority.

Nurses are obligated and have the opportunity to detect any form of elder abuse and report accordingly. By so doing, nurses can play a significant role in prevention of elder abuse. There are several resources that are availed for nurses that can assist in the abuse report process. In addition, support programs are a good way of helping caregivers get connected with others that find themselves in similar stressful positions and offer coping mechanisms related to caregiver stress.

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