NOTE: I only need help with these set of questions, the rest I can do on my own. Please provide rationale so I can understand it myself for future use. Any tips are greatly appreciated.

What methods did the researcher use for collecting data and are these described in enough detail?

What methods did the researcher use to analyze the data?

( i dont know the difference from the first question and the second one)

Has the relationship between researchers and participants been adequately considered?

(I dont know what they mean by adequately considered)

Are the results credible, and if so, are they clinically important?

What conclusions were drawn, and are they justified by the results?

Are the findings of the study transferable to other clinical settings?

Discharging older people from hospital to care homes: implications for nursing

REED J. & MORGAN D. (1999) Journal of Advanced Nursing 29(4), 819-825 Discharging older people from hospital to care homes: implications for nursing This paper summarizes a research study which explored the experiences of older people being discharged from hospital to nursing and residential homes in the North East of England. While there has been considerable research which has looked at the discharge of patients from hospital to their own homes, little literature could be found which addressed discharge to care homes. While this may reflect an assumption that this form of discharge is less problematic, it is arguable that this is only the case for staff there is a body of literature on re-location which suggests that the move to a care home is a major life event for older people. Taking a qualitative approach, this study interviewed 20 older people and 17 of their family members after discharge from hospital to a care home. We found that few people had been offered opportunities to discuss their move with nurses, and that older people tended to adopt a stoical attitude. In focus groups, interviews and written responses from 23 members of staff in the hospital and in care homes, we found that there was a lack of clarity over whose role it was to initiate such discussions. The paper concludes with some discussion of the implications for nursing practice of changing care interfaces.

INTRODUCTION

The discharge of older people to nursing and residential homes (care homes) represents a major life change for older people. It has, however, received less attention in the nursing research and policy literature than discharge to the patient's own home. This may be because managing the discharge of patients to their own home presents nurses with responsibilities for organizing and coordinating a range of professionals, careers and agencies, and therefore constitutes an obvious set of activities for nurses to engage in. Older people moving into nursing or residential care homes, however, present a different set of responsibilities which may not be quite so obvious, or appear so pressing, yet which correspond with many of the definitions and models of nursing which emphasize the role of the nurse in supporting patients through processes of loss and change. Moreover, the issues which arise when older people move from hospitals to care home are reflective of the changing climate of care provision in the United Kingdom (UK). While discharge planning research may focus on the primary/secondary care interface, that is integration of hospital and community care services. (p. 819)

es, care homes increasingly represent another sector the independent sector which is comprised of either private businesses or voluntary agencies. Since the National Health Service (NHS) & Community Care Act of 1990 (Department of Health 1990), where Social Services departments became responsible for developing and purchasing packages of care for older people, there has also been an increased requirement for health and social services to work together. Moving into a care home therefore represents a move across the statutory/independent sector interface and collaboration across the health and social care sectors. The issues of collaboration and cooperation are therefore much more complex than if the only interface involved is that between the hospital and community services. The study reported in this paper investigated the experiences of older people making a move into a care home, and the observations of those that care for them, in order to identify indicators for practice development.

LITERATURE REVIEW

Discharge home There is a body of research in the nursing literature which has looked at the discharge of older people from hospital. Discharge from hospital has been an area of concern for nursing and health care practice for some time, with numerous research studies describing the problems older people face when they leave hospital. Waters (1987), for example, studied the hospital records of 32 older people who were to be discharged to the community following a hospital stay and found a lack of recorded information in all areas of the nursing process, from nursing assessment to care plan evaluation. This made the co-ordination of services to meet the needs of the older person difficult, and Waters concluded that neither doctors nor hospital nurses identified assessment and planning for discharge home as a priority. Furthermore, a quarter of those older people interviewed did not recall having been asked about coping at home or being given any advice about this, even though all the sample had supposedly undergone some form of pre-discharge assessment. Waters also noted a lack of knowledge about medication by patients after discharge and identified the quality of information given to district nurses by the hospital staff as being problematic; for example, in some cases, problems identified in the nursing care plans as still being current at the time of discharge were not communicated to community nurses. Waters stressed the need for thorough assessment, accurate record-keeping and the availability of written information in order for successful discharges to take place, but also cautioned against generalizing the results of her exploratory study. These findings, however, are supported by subsequent studies including King & Macmillan (1994), Jewell (1993), Victor et al. (1993) and Tierney (1993). A common theme throughout these studies is the issue of responsibility, in other words among the various professions involved in the discharge process, in which one takes the lead in coordinating the process or carrying out the different parts of it. Not only there is concern about formal allocations of responsibility, but also about informal negotiations and communication about the roles which different professionals take. A number of recommendations have been made in the UK in response to these growing professional and public concerns. The Department of Health (1989) recommendations, for example, stressed the need for discharge planning to commence as soon as possible after admission; the importance of good communication networks between all parties involved in the process and the need for involvement of patient and relatives in decision making, ideas that were also articulated in The Patient's Charter (Department of Health 1992). At the same time, however, there are other developments in health services, such as the emphasis on the reduction of waiting list times, and the resultant pressure to increase patient turnover (Manthorpe et al. 1996).

Moving into a care home

The literature on the discharge of older people from hospital, therefore, indicates that this area of practice is problematic, and that older people do not always receive the support that they need. There is also another body of literature which suggests that moving into a care home is an event or process which is likely to increase the need for support, because of the stresses involved, of disruption to lifestyles, of loss of home and of adapting to a new environment (Morgan et al. 1997). For example, Nay (1995) has described both material and abstract losses attendant on moving into a care home. The loss of material possessions can include one's home and personal belongings, while more abstract losses include loss of role, lifestyle and freedom. Nay also highlighted the loss of social contacts such as friends, family and pets as being of importance. The loss of home can mean much more than a change of living environment, as researchers have found, as older people have identified their home with feelings of autonomy and control and part of their identity (Golant 1984, Sixsmith 1986, Willocks et al. 1987). Moving into a new environment, such as a care home, is something which can be very stressful, both in anticipation and in realization (Reed & Roskell Payton 1996, Reed et al. 1997). Older people not only need to negotiate and to learn about a new physical environment, but also about the social world of the care home, the routines and behaviors of their fellow residents and of staff. For some, (end of page 820)

the prospect of such work can be daunting, and if apprehension is coupled with a sense of loss and dislocation from a previous lifestyle and personal identity, then being discharged from hospital into a care home represents a life event with, potentially, a profound impact on older people, and one which requires some recognition and support from nurses. Moreover, previous studies by Johnson et al. (1994) and Retsinas (1991) suggest that moving into a care home is often accompanied or precipitated by major changes in health, social support and ability to cope.

The role of the nurse in supporting older people

A supportive role is advocated in much nursing literature where the nurse-patient relationship is discussed. While some, like Armstrong (1983), might suggest that this relationship has been a recent `fabrication' in nursing, the arguments for developing communication and interpersonal skills in nursing are difficult to refute. As Smith (1992) has argued, `emotional labour' is an important part of nursing care if patients are to receive more than cursory processing through the health service system, and if they are to have some of their emotional and psychological needs addressed. Moving away from a restricted physiological model of health to incorporate the psychological and social aspects of health and health care is a move which is gaining ground in many areas of nursing and health care, and which permits a more holistic view of the patient (Cooper et al. 1996). More specifically, Nolan et al. (1996) have argued that the nurse has an important role to play in the process of decision making when older people are considering moving into a care home, and that this role may involve advocacy to ensure that the interests of older people are addressed.

Implications of the literature

The literature, then, seems to indicate that the discharge of older people from hospital is something that is, by and large, poorly managed by nurses and other staff, with detrimental consequences for older people. This literature does not provide much information about the discharge of older people from hospital into care homes since much of it concentrates on discharge home. We can, however, extrapolate from the literature that exists on the impact of relocation and loss of home on older people to argue that, while these discharges may not present the administrative and organizational problems of ensuring that services are available which are attendant on a discharge home, that they present a different set of problems which are emotional and psychological. These problems may be primarily problems for the older people concerned, but there is also a strong argument in the nursing literature to suggest that they should also be the concern of nurses. The gap in the research literature therefore would seem to be in this area of support what older people need and want, and how nurses can meet these needs.

THE STUDY

Aims

This study explored the area of support for older people being discharged from hospital into a care home. The main aims of the study were to investigate the experiences of older people and to identify possible forms of support that might be needed. The study also sought comments from staff about how they saw the process, and what support they felt was needed or available. The study was funded by an National Health Services Executive (Northern and Yorkshire Region) research program which funded practice development studies in professions allied to medicine. The study has therefore adopted an action research approach to the development of nursing practice, based on the cyclical process of development, implementation and evaluation (Hart & Bond 1995). In accordance with this approach, the study has used a collaborative approach appropriate to the generation of ideas and observations which can inform the development of guidelines, and has therefore utilized data from interviews with a range of individuals involved in the process of discharge. The study does not, however, follow the action research cycle to the point at which change is implemented or evaluated, as resources were not available to allow the study to reach this point. What it represents therefore is the first stage of an action research study in which indications for practice development have been outlined but not tested out. It must also be said that the process of implementation would not simply be a matter of developing guidelines and then asking staff to adhere to them there may well be some reservations expressed by staff who did not identify a need for the study in the first place. The role of the research team was not therefore to reflect and act upon a staff initiative, but to direct a study as suggested by a reading of the available literature and research. The consequences of this position have been explored by some authors (see, for example Meyer 1993) and are likely to impact upon processes of change in the way that the staff who are asked to develop their practice do not see themselves as having ownership of the research study.

Methods and design

The data collection was carried out in two stages: first, interviews with older people and family members and secondly, focus groups with staff. The interviews with older people had a loosely structured interview agenda (end of page 821)

focusing on their experiences of discharge processes and any areas which they felt were problematic, or care that they found particularly helpful. This interview style was adopted in order to ensure that interviews were focused enough to avoid respondents becoming tired, but were flexible enough to allow respondents to introduce new topics or areas. The discussion groups to develop guide[1]lines adopted focus group techniques (Kitzinger 1995) to elicit opinions and ideas from the participants. Many focus group techniques assume that members have no previous contact with each other, and concentrate on eliciting spontaneous responses to questions and ideas. As members of the groups in this study were work colleagues, the interview format was designed to elicit general group perspectives in the context of professional roles and cultures (Reed & Payton 1997).

Stage 1: identifying user perspectives

Patients recently discharged from the study hospital (part of a large acute care Trust in the North East of England) to the independent sector within a 10-mile radius of Newcastle were identified from hospital records. They were visited by the researcher in the care home within 4 weeks of their discharge and invited to participate in the study. These patients and their significant others were interviewed to identify and describe their experiences of discharge. The interviews were conducted in the care home or in the respondent's own home, and followed a semi structured interview schedule which outlined the main areas of the study. Patients' case notes were also examined for information about discharge arrangements and plans, and to provide background material.

Stage 2: identifying professional perspectives

Care home staff and hospital staff were interviewed about discharge procedures and their satisfaction with them. Ideas about where improvements could be made were sought. Both individual and focus group interview techniques were used, and the interview agendas were informed by the data from the patient study. The information from these interviews was analyzed in order to identify areas in which practice can be developed.

Sample

The sample was purposively selected in order to maximize data collection. The concerns were to build up data on the experience of moving into a care home from the perspective of a range of different people involved in the process within a particular practice setting. Older people Forty-eight older people who had been discharged from five wards at the study hospital site into independent sector care homes were followed up within 1 month of discharge and invited to participate in interviews. The study wards were comprised of three wards which cared specially for older people (two acute/rehabilitation care and one rehabilitation ward) and two acute care/rehabilitation medical wards which cared for a range of patients across the adult age range. Of the 48 patients identified, 20 were found to be able and willing to participate 19 were excluded from the study because of frailty or cognitive impairment, as evidenced by their disorientation when they were approached to discuss the study, four older people had died soon after relocation to the care home, three older people declined to take part, and two people had moved out of the area. Family members or significant others who were identified by the older people were also approached and invited to participate in the study. It was anticipated that the study would generate 20 interviews with significant others, and 20 interviews with older people (40 interviews in total). In practice, the limited number of family members nominated by the older people in the study meant that only 17 were interviewed. This was a reflection of the lack of family and social support to which some older people in the study had access and, indeed, it may well have been this isolation which precipitated their move. This generated 37 interviews for Stage 1 of the study.

Staff

Nursing staff from the study wards were invited to participate in focus groups to explore the issues raised in discharging older people to care homes. Because of the nature of the study wards, the staff reflected practice in settings where a range of patient groups are cared for, as well as settings which specialized in the care of older people. Because of demands on the nursing staff's time, and because the study coincided with ward closures and relocations, only one acute care/rehabilitation ward was able to participate in focus groups. In order, therefore, to ensure that a range of nursing experiences within the hospital were included in the study, a semi structured questionnaire was issued to two further acute care of the elderly wards (five per ward) for qualified nursing staff to complete. In the medical wards it was only possible to carry out one semi structured interview with a ward nurse; however, it was not possible to dispatch questionnaires to the medical study wards as these wards had merged and no longer existed at that stage of the study. Social workers and medical staff were also invited to take part in single profession focus groups in order to explore practitioners' observations and ideas about the process of discharge. It was possible to conduct a focus group with three members of hospital medical staff of varying degrees of seniority, a focus group session with three social workers from the study hospital and a focus group with three members of qualified nursing staff. (end of page 822)

Staff from care homes were also invited to participate in the focus groups. A total of four focus groups with staff from nursing and dual registered care homes was con[1]ducted, comprising 14 members of staff. Overall seven focus groups were conducted, which included a total of 23 members of NHS and Independent Care Sector staff. Six written responses were received from NHS nursing staff, and one individual interview was conducted. This gives a participation total of 29 NHS staff.

Findings Older people's experiences

The experience of moving into a care home was described by many older people in the study as a profound change in their lives. Some had found the move distressing and their subsequent lifestyle uncomfortable or unpalatable, while others described the move as a relief from anxiety and uncertainty, and life in the home as unexpectedly pleasant. In the analysis of the data, however, it was important to distinguish between the feeling of the older people about the loss of their home, the process of moving, and their new life in the care home. Some people would be sad about the loss of their home but happy about life in the care home. Others would be happy about leaving their home, but would not like the care home. It was clear that there were many different views which depended on personal perspectives and attitudes, and the circumstances precipitating hospital admission and discharge to a care home. Among these individual stories, however, there was one theme which remained constant: the passivity of older people in the process of moving. They did not expect support from staff, and their coping strategies centered mainly on stoicism. As one person told us: Well, you just have to get on with it, I mean there's no point in making a fuss. Some older people expressed a concern to avoid being a burden to others, either staff or family members. These people `had better things to do' as one man put it, and for the staff this included looking after other people `with more sickness' than him. The idea that others needed staff time more than they did seemed to arise partly from their own judgement, but some older people made comments that suggested that these ideas had also come from nursing staff where they talked about nurses telling them that it was time to move on, or that they couldn't stay in the hospital for ever. For example one person argued that: They [the staff] said it was about time I was going, and they were right. It was also striking that they did not think of themselves as people with any choices or control over care decisions the older people in our study did not voice any objections to the verdicts of staff that they should move into a home, not did they seem to expect to exercise much choice over the home they moved to. The choice of home was delegated to family members or social workers, and this was explained as being the only way such a choice could be made, given that they were too frail to visit homes themselves. As one person told us: My daughter sorted all that out I couldn't go round those homes because I can't get about. I had to rely on her. It did not seem that any alternatives had been suggested, for example help in making a visit to the care home with transport and assistance. The older people had also expected to have to it in with care home regimes, and were surprised that the care home allowed them any choice or freedom. One lady, for example was surprised to be `allowed' to order a newspaper she had not expected to be able to do this. Their ideas about care homes had been vague and based on snippets of information gathered from friends, acquaintances and the media, rather than any clear information. As one person told us: It was like taking a step in the dark. I didn't know what to expect. Care home staff confirmed this saying that often older people seemed to have little idea about what life in a care home would be like.

Family perspectives

The idea that they were not needy enough to be in hospital seemed to be shared by staff and older people. Family members, however, seemed less convinced by this thinking, and expressed more concerns about the process being rushed. These concerns stemmed from anxieties over the health of their relative, but also because of the process of choosing a home for them to move into was more complex than they had imagined and some felt that they had not had enough time to choose carefully. As one family member told us: I had to go out and a place, quickly because she was coming out. I went to see a couple, but I didn't have time to work through the list. The `list' that this person talked about was a list of homes registered with the Registration bodies of the Local Authority and Health Authority, and as such contain no information beyond addresses and numbers of beds. For most people in the study this was not enough information they had very little guidance on what to look for in a home, or how to evaluate the care given. At the same time, family members felt a huge sense of responsibility for making the `right' decision. The decision to opt for care home services was often portrayed as a professional decision, but the selection of a specific home was fraught with dilemmas they did not feel themselves to be `informed consumers'. The views of the older people (end of page 823)

themselves did not seem to be always actively sought they were sometimes dismissed, or the older people themselves opted out of the process, and this resulted in a paradoxical situation of people wanting to and somewhere where their relative would be happy, yet not involving them in the process of decision-making

The staff view

The hospital nurses' responses indicated that there was no standardized approach to dealing with this process discussions, if they occurred, were ad hoc, fragmented and arose only if the older person initiated them. These initiations, however, did not seem to occur very often, with staff reporting that they did not welcome discussion or invite it one nurse described older people as having `made up their mind to accept their fate, and they don't see the point in discussing it they only become distressed'. One nurse did, however, indicate in a written response that older people might not openly invite discussion and that sometimes nurses have to encourage them to talk Sometimes patients don't openly ask for advice or support, but it's up to the nurse to spot the signs of anxiety and to approach the subject casually'. Where nurses did give examples of having talked to older people about their impending move they described these conversations as taking place while they were doing other things with the older person, such as helping them to dress. This approach avoided making a `big thing' out of discussions, but also seemed to involve a degree of superficiality nurses described the purpose of these discussions as being to `cheer up' older people. The nursing staff felt that they knew little about care homes, and could not offer much support. They were not clear, for example, about the difference between nursing and residential care, about processes of inspection and registration, or about how such care was financed. They also felt that this was not part of their job to know these things, as other staff (for example social workers) were in charge of the process. In addition, there was some degree of hostility or suspicion towards the independent sector, particularly privately run homes, which were described by one nurse as `just in it for the money'. Some nurses had worked in private homes as relief nurses and reported that the standards of care they had seen were low, and there was a reluctance to collaborate with staff from these homes. One nurse recounted a situation where a care home had asked for some information about a patient, but she had been reluctant to provide it:

. . . it seemed like laziness and shouldn't they be assessing them for themselves. As their care will be completely different from afterwards it seemed like a cop out.

Social workers had more contact with care homes, and more knowledge of the systems of regulation and funding care, but this expertise did not necessarily give them a feeling of control over the process. They felt that they were responding primarily to pressures from medical staff to organize discharges and did not have time to spend with patients discussing their choices and preferences. They talked about their professional skills in providing support as being eroded by their administrative role in processing assessments and arrangements for care. One social worker described her role as being driven by these demands:

I don't spend the time I used to it's just you get a message from the medical staff this one's to go out, and you just sort out the paperwork and maybe talk to the family. Sometimes I don't even get to see the client.

Medical staff, however, felt that their role was mainly in making discharge decisions and deciding the level of care required from a medical point of view. Their concern was that the move was made quickly, and that it was not governed by Social Service Department financial considerations. They talked of their concern with patients who were waiting to come into hospital, which had to over-ride their concern with those who had received treatment and who had no further need of acute care. When asked about providing support for older people moving into a care home they reported that they expected that social workers and nurses would provide the necessary support and advice to patients. This was partly because they felt that it was not their role to do so that treatment was their priority but also because of the way in which their time was managed and their contact with patients was organized. As one doctor put it:

We see people on a round or at appointments and then we go away. Once we've told them where they're going to go, we disappear, and if they want to think about it later or discuss it after they've had a think about it, we're not there, but the nurses and social workers are more around.

CONCLUSIONS

This study suggests that the apparent stoicism of older people moving into a care home can mask feelings of loss and anxiety. If nursing staff wish to support older people through this transitional process, then they may have to be proactive in initiating discussions rather than waiting for older people to do so. Such an approach, however, must be carefully negotiated with older people some may not wish to discuss their feelings when offered the opportunity to do so. Such discussions will need to be informed, and there is a need for nurses in hospitals to learn more about the care home setting, and to reflect on some of the assumptions that they may make about the independent sector. Understanding how care homes work may help nurses to encourage older people to think of themselves as people with choices, and working through their personal preferences for activities and lifestyles may well encourage this. We would suggest, therefore, that attention is (end of page 824)

paid to ways in which nurses can learn more about care homes, and how they can encourage older people to make active decisions about their move. This will need to be based on a systematic approach, such as formal assessment and review procedures, rather than rely on ad hoc initiatives. Developing a formal assessment schedule which is written with patients and which focuses on lifestyle preferences may go some way towards supporting older people in exercising and expressing preferences, and if this were to accompany them to the care home it would provide valuable information for staff there. An extension of this study would involve the development of such a schedule. In addition, the data suggest that there is some confusion between nursing staff, medical staff and social workers about who is responsible for which aspects of the discharge procedure, with each professional group assuming that another has chief responsibility or input. For the future development of discharge processes, multidisciplinary teams need to clarify exactly what responsibilities each group has, and ensure that contact with older people is documented to reflect this. As Penhale (1997) has argued, multidisciplinary working in discharge planning is fraught with problems which arise from different goals for practice, and different forms of organizational power across professional groups, but such negotiation is essential if older people are to be given the support that they need at a time of great change and potential stress in their lives.