Want to improve health outcomes of older adults in hospital? – Ask a nurse

Researchers conduct focus groups with nurses on how to prevent the decline of hospitalized older people. They discover some communications strategies that will be of interest to hospital administrators and health-care practitioners.

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Individuals 65 years of age and older often have multiple comorbidities – that is, secondary diseases that are related to a primary disease. For example, older patients with coronary artery disease may also have diabetes or depression. Simply put, these individuals experience complex and acute health issues.

In health-care facilities, such as hospitals, these vulnerable patients require numerous different professionals to communicate well and work seamlessly together to support them and prevent their decline. This process has been the subject of many research endeavours but, to date, one key expert voice is missing: the nurse’s perspective.

New research from York University, led by postdoctoral visitor Jeffrey Butler, under the supervision of Faculty of Health Professor Mary Fox and funded by the Ontario Ministry of Health and Long-Term Care and the Ontario Ministry of Research and Innovation, fills this important gap. Through focus groups with nurses, Butler and Fox identified novel approaches in interprofessional (IP) communication to improve the health outcomes of older adults in hospital.

“Our research offers new insight into nurses’ assessments of the usefulness of various modes of communication surrounding care for acutely ill or injured older people,” said Butler. “Our recommendations may inform the implementation of initiatives to improve IP communication more generally.”

The findings were published in Health Communication (2018).

Aging population is pressing policy issue

Given the aging population – arguably, one of the most important policy issues of our time – information about high users of hospital services is of great interest and importance.

Statistics are compelling:

• Canada’s older (65+) population is growing so much so that, by 2036, it is expected to make up 25 per cent of the population – this, compared to 14 per cent in 2010 (Canadian Medical Association).
• Last year, Canada spent $242 billion on health care, and hospital expenditure comprised a very large share of this (Canadian Institute for Health Information [CIHI]).
• Older adults are frequent users of health-care services, with the system spending more on them than on any other segment of the population (CIHI).
• Health-care costs increase with age: At 65 to 69 years of age, the annual per person cost is $6,298. By age 80+, this number jumps to $20,917 (Canadian Medical Association).

A more complete understanding of high users of health care could lead to both improved health outcomes of this population and a reduction of hospital costs. That’s why Butler and Fox’s research is so relevant.

Researchers conducted 13 focus groups with 57 nurses in Ontario

Given nurses’ key role in caring for older patients in hospital, Butler realized what could be gained through qualitative research with nurses. In his study, 57 nurses, including registered nurses (RNs) and registered practical nurses (RPNs), working in acute-care hospitals in Ontario participated in 13 focus groups.

Nurses shared knowledge about best ways to communicate

Via this qualitative research, nurses passed on knowledge from their lived experiences. Two categories emerged: direct and indirect communications.

Category 1: Direct, face-to-face communication

Study participants favoured face-to-face communication with other professionals because it provided context for the patient’s health, on-the-spot elaboration and further explanation or clarification. They emphasized that this was particularly important since older people’s health status can quickly deteriorate.

“Care promoting older people’s functioning requires more frequent direct communication than younger patient populations to keep other professionals up to speed regarding older people’s functional states and prevent further decline,” Butler explained.

Importance of huddles and rounds

Nurses in emergency departments underscored the importance of bedside dialogues, hallway huddles and quick chats at the nurses’ station. One RN mentioned the success of five-minute “safety huddles” pertaining to falls prevention.

Nurses in medical-surgical units and coronary care units (CCUs) said that they valued IP rounds as great opportunities to share information. (Patient rounds, led by attending physicians, involve several health-care professionals. Here, all parties coordinate care.)

This revealed a weakness in the system: “One recurring criticism was that nurses’ presence at IP rounds has been increasingly de-prioritized or eliminated altogether. Many believed that this allows crucial information to fall through the cracks,” said Butler.

Participants also said that more frequent, daily rounds were the most effective way to communicate. (This is not always possible or feasible – for example, on weekends.)

One RN said: “Daily rounds … really heighten your ability to care for the patient.”

Category 2:  Indirect communication

The study also looked at indirect communication – for example, computerized information technology (IT) tools that centralize a patient’s progress and status. This often backfired. “Numerous participants described portable computers that froze and batteries that did not last,” Butler explained.

Analogue tools seen as useful, cost effective

Rather than advocating IT solutions, the study participants said that simple, low-tech, cost-effective analogue tools, such as bedside whiteboards, were very useful for sharing information in a timely fashion. Hand-written “summary sheets,” housed in patients’ files, were cited as beneficial by a few CCU nurses.

Research offers communication tips for administrators and practitioners

In summary, this new research makes three key findings:

1. Direct face-to-face communication, huddles in the hallway etc. are successful ways to communicate, given the vulnerability of this population.
2. Nurses’ attendance in IP rounds and the frequency of the rounds (daily) are key to positive health outcomes.
3. Low-tech modes of communication, such as summary sheets and whiteboards, could improve communication and, in turn, lead to better health outcomes.

These findings could help to guide future communication strategies across numerous health-care contexts – not just hospitals, and not only in the care of older patients.

To read the Health Communication article, visit the website. To learn more about Butler, visit the York University Centre for Aging Research and Education (YU-Care) website. For more on Fox, see the YU-Care website or her faculty page.

To learn more about Research and Innovation at York, follow us at @YUResearch, watch the York Research Impact Story and see the snapshot infographic.

By Megan Mueller, manager, research communications, Office of the Vice-President Research and Innovation, York University, muellerm@yorku.ca