Edmonton Clinic Health Academy, 11405 87 Avenue, University of Alberta, Edmonton, Alberta, Canada T6G 1C9.
Int J Nurs Stud. 2013 Sep;50(9):1206-18. doi: 10.1016/j.ijnurstu.2012.11.005. Epub 2012 Dec 4.
Internationally, older adults visit the ED at a rate higher than other age groups. Little attention has been given to ED care for older people with dementia, although concern for such care is growing with the increasing number of individuals worldwide affected by this significant disabling problem. It is critical to understand ED transitional processes and consequences because the complexity of dementia care poses multiple challenges to optimizing safety, effectiveness and quality of care during admission, assessment, and treatment in this setting.
Using an interpretive, descriptive exploratory design with three iterative, interrelated phases, we conducted interviews, created a photographic narrative journal (PNJ), and finally held photo elicitation focus groups to identify factors that facilitate or impede safe transitional care for community dwelling older adults with dementia in two Canadian emergency departments, and to identify practice solutions for nurses. We purposively sampled to recruit ten older adult-family caregiver dyads, ten ED RNs, and four Nurse Practitioners. Data were analyzed using constant comparative analysis.
Four interconnected reinforcing consequences emerged from our analysis: being under-triaged; waiting and worrying about what was wrong; time pressure with lack of attention to basic needs; and, relationships and interactions leading to feeling ignored, forgotten and unimportant. Together these consequences stem from a triage system that does not recognize atypical presentation of disease and illness. This potentiated a cascade of vulnerability in older people with dementia and their caregivers. Nurses experienced time pressure challenges that impeded their ability to be responsive to basic care needs.
In an aging population where dementia is becoming more prevalent, the unit of care in the ED must include both the older person and their family caregiver. Negative reinforcing consequences can be interrupted when nurses communicate and engage more regularly with the older adult-caregiver dyad to build trust. System changes are also needed to support the ability of nurses to carry out best practices.
在国际上，老年人到急诊科就诊的比例高于其他年龄段。尽管人们越来越关注这一重大致残问题，但对痴呆老年人的急诊科护理关注甚少。由于痴呆症护理的复杂性给在该环境下的入院、评估和治疗期间的安全性、有效性和护理质量的优化带来了多重挑战，因此了解急诊科的过渡过程和后果至关重要。
我们采用了一种解释性、描述性的探索性设计，该设计具有三个迭代的、相互关联的阶段，我们进行了访谈、创建了摄影叙事日记（PNJ），最后进行了照片启发焦点小组，以确定在加拿大的两个急诊科中，促进或阻碍有社区居住的痴呆症的老年人安全过渡护理的因素，并为护士确定实践解决方案。我们采用了有目的抽样的方法，招募了 10 名老年患者-家庭照顾者对、10 名急诊科注册护士和 4 名执业护士。使用恒定性比较分析对数据进行分析。
我们的分析得出了四个相互关联的强化后果：分诊不足；等待和担心出了什么问题；时间压力导致基本需求得不到关注；以及关系和互动导致感觉被忽视、遗忘和不重要。这些后果共同源于一种不能识别疾病和疾病不典型表现的分诊系统。这使得痴呆症老年人及其照顾者更容易受到伤害。护士面临时间压力的挑战，这阻碍了他们对基本护理需求做出反应的能力。
在人口老龄化且痴呆症日益普遍的情况下，急诊科的护理单元必须包括老年人及其家庭照顾者。当护士更经常地与老年患者-照顾者对进行沟通和互动，以建立信任时，可以中断负面的强化后果。还需要进行系统更改，以支持护士实施最佳实践的能力。
