Nursing practice with hospitalised older people: Safety and harm

Abstract

Background Nursing teams work with hospitalised older people in institutions, which prioritise a biomedical model of care. This model does not fit the needs of older people because it emphasises efficacy and a narrow definition of patient safety, but does not prioritise functional needs. Nursing care is provided around the clock within the context of fiscal restraints as well as negative societal and nursing perspectives about ageing and old people. Yet, nursing perceptions of managing safety and potential harms to older patients within these hospital institutions are not well understood. Methods An integrative review was conducted to examine nursing perspectives of safety and harm related to hospitalised older people. Results The majority of included papers focused on restraint use. Findings reveal that nurses are using restraints and limiting mobility as strategies to manage their key priority of keeping older patients safe, reflecting a narrow conceptualisation of safety. Policy, administrative support and individual nurse characteristics influence restraint use. Safety policies that nurses interpret as preventing falls can encourage the use of restraints and limiting mobility, both of which result in functional losses to older people. Conclusions This complex issue requires attention from clinical nurses, leaders, policy makers and researchers to shift the focus of care to preservation and restoration of function for older people in hospital as a safety priority. Implications for Practice Clinical leaders and nursing teams should engage in developing processes of care that incorporate maintaining and restoring older people's function.

How nurses’ use of language creates meaning about healthcare users and nursing practice

“…Dahlke et al () integrative review of nursing practices related to safety revealed that nurses often chemically and/or physically restrain, or limit older healthcare users’ mobility under the guise of keeping them ‘safe’. Moreover, in healthcare institutions where the emphasis is on zero falls, nurses are more likely to either restrain or limit the mobility of healthcare users (Dahlke et al, ).…”

“…Dahlke et al () integrative review of nursing practices related to safety revealed that nurses often chemically and/or physically restrain, or limit older healthcare users’ mobility under the guise of keeping them ‘safe’. Moreover, in healthcare institutions where the emphasis is on zero falls, nurses are more likely to either restrain or limit the mobility of healthcare users (Dahlke et al, ). One explanation for these nursing practices might be that nurses are protecting their position as a subordinate within the healthcare institution and thus treating the healthcare user as an object to be manipulated in order to avoid the negative consequences of a fall, which would be seen ‘unsafe’.…”

“…Through their use of language, nurses are perpetuating societal perceptions, perhaps even unknowingly. Moreover, the valuing of technical tasks, management of narrowly constructed safety risks, and promotion of efficiencies influence nurses’ practice with vulnerable populations, who often require time and have fundamental needs are greater than the system permits (Dahlke, Hall, & Baumbusch, ; Dahlke et al, ). If healthcare users’ needs are outside of nursing unit routines, more effort is required to meet those needs.…”

“…Nurses’ language exposes their paradox of being both disempowered employees, who must choose their lines of action within the available resources and institutional values, and of being in a position of power over healthcare users. Nurses are employees within healthcare organizations that privilege efficiency, the biomedical model, technology, and a prescribed view of patient safety (Aiken, Sloane, Bruyneel, Heede, & Sermeus, ; Baumbusch, Leblanc, Shaw, & Kjorvin, ; Parke & Chappell, ; Clarke & Aiken, ; Dahlke et al, ; Dixon‐Woods et al, ; Lucero, Lake, & Aiken, ; Parke & Hunter, ; Storch, ). Scholars have identified that structural constraints (e.g., skill mix, access to resources) within hospital environments influence nurses’ practice (Aiken et al, ) and healthcare system processes endorse nurses attend to medical treatments over person‐centered care (Long et al, ).…”

“…A meta‐synthesis of person‐centered studies reveals routinized and ritualistic care processes that provide few opportunities for healthcare providers to enact person‐centered care, despite many healthcare institutions espousing high value of this ideal (McCormack, Karlsson, Dewing, & Lerdal, ). The emphasis on safety is also a priority in healthcare institutions, although safety is often constructed narrowly as fall prevention, or reduction in medication errors (as examples), but does not include preventable loss of healthcare users’ function, a serious harm, with negative consequences for vulnerable people (Dahlke, Hunter, & Negrin, ; Zisberg et al, ).…”