Journal of Gerontological Nursing

ALTERNATIVE NURSING ENVIRONMENTS: Do They Affect Hospital Outcomes?

Lillian R Clark, MSN, RN; Vicki Fraaza, LPN; Susan Schroeder, LPN; Michael E Maddens, MD

Abstract

The elderly population is projected to increase to 54 million by the year 2020 when approximately 1 in ó Americans will be elderly. As people live longer, chronic illness, disability and dependency become more likely. In 1 988, older people accounted for 33% of all hospital stays and 44% of all days of care in hospitals. It is anticipated that, by the year 2025, 63% of the U.S. health care budget will be devoted to services for the aged (Economics and Statistics Administration, 1993). Providing cost effective care while trying to meet the needs of this increasing geriatric population is a challenge on general medical floors in acute care settings. When faced with this dilemma at our hospital, a 921 -bed suburban teaching institution, a dayroom program which focused intensively on functional needs was implemented for confused, geriatric inpatients >65 years) who otherwise might have been restrained or required sitters. The dayroom was formerly a patient room on a 64-bed medical nursing unit. It was furnished with recliner chairs to accommodate a maximum of 4 patients. Nurses selected patients according to established criteria and guidelines. All nursing care was provided by one licensed practical nurse (LPN) for assigned patients from 7 AM to 7 PM. Other staff were assigned as needed to cover breaks. Informal data had suggested many positive results for the assigned patients, however, a formal evaluation was needed for this approach to continue or expand. Therefore a study was planned to evaluate this alternative nursing environment.

Abstract

The elderly population is projected to increase to 54 million by the year 2020 when approximately 1 in ó Americans will be elderly. As people live longer, chronic illness, disability and dependency become more likely. In 1 988, older people accounted for 33% of all hospital stays and 44% of all days of care in hospitals. It is anticipated that, by the year 2025, 63% of the U.S. health care budget will be devoted to services for the aged (Economics and Statistics Administration, 1993). Providing cost effective care while trying to meet the needs of this increasing geriatric population is a challenge on general medical floors in acute care settings. When faced with this dilemma at our hospital, a 921 -bed suburban teaching institution, a dayroom program which focused intensively on functional needs was implemented for confused, geriatric inpatients >65 years) who otherwise might have been restrained or required sitters. The dayroom was formerly a patient room on a 64-bed medical nursing unit. It was furnished with recliner chairs to accommodate a maximum of 4 patients. Nurses selected patients according to established criteria and guidelines. All nursing care was provided by one licensed practical nurse (LPN) for assigned patients from 7 AM to 7 PM. Other staff were assigned as needed to cover breaks. Informal data had suggested many positive results for the assigned patients, however, a formal evaluation was needed for this approach to continue or expand. Therefore a study was planned to evaluate this alternative nursing environment.

Functional morbidity during acute illness is a major problem for older patients (Hirsch, Sommers, Olsen, Mullen, & Winograd, 1990; Lamont, Sampson, Matthias, & Kane, 1983; McVey, Becker, Saltz, Feussner, & Cohen, 1989). Thus maximizing functional starus is often the focus for studies of patients on geriatric units (Meissner, Andolsek, Mears, & Fletcher, 1989). Meissner and colleagues (1989) compared functional status outcomes in acutely ill patients on a general medical unit and demonstrated improved outcomes with the geriatric focused care, however cost and length of stay were increased in this group. Jackson (1989) found no differences in patients' abilities to manage personai care and activities of daily living (ADL) based on the type of ward (geriatric or general) after discharge. Other studies have supported intensive geriatric-focused assessments and care provided on specialized units, however improved function was usually attributed to identification of new diagnoses, attention to rehabilitation and increased time for recovery (Lefton, Bonstelle, & Frengley, 1983; Rubenstein, Abrass, & Kane, 1981; Teasdale, Shuman, Snow, & Luchi, 1983).

Functional status outcomes have long been recommended as important measures of the outcomes of illness in the elderly (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963). However few studies have provided insight about effective nursing interventions to enhance function when confronted with elderly mentally impaired patients. One study did report that nursing interventions implemented by geriatric clinical specialists were three times as likely to improve functional status of patients irrespective of age, admitting diagnosis, severity of illness or presence of delirium or dementia. However, these interventions were described as "intricate, intense, and comprehensive" (Wanich, SullivanMarx, Gottlieb, & Johnson, 1992).

No studies have described simple, effective management techniques for confused, elderly patients who required sitters or restraints to maintain safety. The purpose for this study was to determine if there was a benefit for either the elderly, often confused patients or the hospital, in providing nursing care utilizing this alternative nursing environment. To evaluate this approach, a formal study was designed to investigate the following questions.

Do elderly patients who participate in the dayroom improve or maintain their functional ability more than those who are not assigned to the dayroom?

Do patients experience fewer complications from hospitalization, require fewer sitters and receive more discharge teaching?

For purposes of this study, the following definitions applied. Complications of hospitalization were defined as injuries, problems, or untoward results of procedures required during a hospital stay. They include:

1) pressure ulcers that develop during the hospital stay,

2) patient inadvertently pulling out intravenous catheters which required restarting,

3) patient pulling out a urinary catheter or nasogastric tube needed for treatment,

4) infection occurring that was directly related to a hospital procedure and not present on admission (nosocomial infection),

5) patient fall as documented on a variance report, and

6) any other patient injury that was documented on a variance report.

Discharge instruction/ teaching was defined as a documented record of teaching/instructions provided by the nursing staff or physician caring for the patient at discharge. The teaching may be recorded on the Nursing Patient Teaching Documentation Form, Discharge Summary Form, or Physician Discharge Form. Teaching includes information provided about medications, treatments, diet, special therapy, disease process or follow-up instructions regarding medical care. The nursing documentation focuses on individualized patient needs and the patient's understanding of the information provided. Sitters are individuals, either hired by family or provided by hospital, for reasons of delirium or agitation, enlisted to protect the patient from harm or injury during their hospital stay.

The dayroom is a hospital room on a medical nursing unit used exclusively for patients selected according to the admission criteria. It is staffed by an LPN who is assisted by a nurse's aide. It is furnished with comfortable reclining chairs. The program objectives are to:

1) prevent functional decline during hospitalization,

2) decrease patient injury rates/

3) decrease cost of caring for highrisk elderly patients, and

4) to facilitate orientation in an unfamiliar environment.

The LPNs assigned to the dayroom were chosen from unit nursing personnel by me nursing manager based on their interest and experience in caring for geriatric patients. Inservice training was provided for the unit nursing staff by the hospital geriatrician prior to implementing the dayroom program. There was no increase in staffing for the program.

THEORETICAL FRAMEWORK

Levine's Conservational Model of Nursing (1967) is used as the conceptual framework for this study. Levine (1969) views a person as an everchanging organism in constant interaction with an ever-changing environment. Adaptation is defined as the process of change whereby the individual retains integrity and wholeness within the realities of one's environment. Levine's four principles guided this study, in particular, the conservation of personal and social integrity. Conservation of personal integrity directs the nurse to address the person by name, treat people with dignity and include the person in decision making and teaching. Conservation of social integrity directs the nurse to facilitate contact with family, religion and community. Elderly patients need to share life experiences and receive love and respect from others. The nurse participates actively in every patient's environment and much of what she does supports the predicament of illness. Accurate assessment of the individual's unique needs determines nursing interventions (Pieper, 1989). It is on this premise that the dayroom program was conceived.

METHOD

An experimental design was used to compare the outcome of hospitalization of two groups of elderly patients. The dayroom admission and exclusion criteria were used to select patients for the study. Patients could be included if they were:

1) 65 years of age or older,

2) confused but able to respond to verbal direction,

3) able to participate in activities to maintain or improve self-care skills, or

4) at risk for falls, therefore needing a sitter or restraints for safety.

They were excluded if they displayed uncontrollable, disruptive behavior, had an infectious disease, draining wounds, if they refused, or if their discharge was anticipated within 48 hours.

Patients who met this criteria were randomized by the last digit of their inpatient identification number (even or odd) to either the experimental (dayroom) or control group (usual care in hospital room). The experimental group received their basic care in their room by the LPN assigned to the dayroom. In addition, they spent from 2 to 8 hours (average 5 hours) in the dayroom where they received meals and participated in crafts, puzzle solving, reminiscing, music, reading papers, and simple exercises. In addition, dayroom patients were toileted and ambulated by the LPN caring for mem.

The investigators obtained a daily computer-generated unit census which provided die patient's name, diagnosis, inpatient number and age. Potential subjects who had been admitted with mental status changes or other diagnoses often associated with confusion (e.g., electrolyte imbalance, dehydration, faint/fall) were approached. The study was explained to either the patient or family and written consent obtained. The family was contacted when the patient was unable to give consent. Mental status, functional assessment, demographic and clinical data were recorded upon admission to the study. These measures were repeated 3 days later. This time frame was used because past experience had shown that dayroom patients displayed the most improvement within that period of time. Patients admitted to the dayroom program remained in it until their hospital or unit discharge (per program guidelines). Discharge teaching documentation was obtained by chart review after the patient's discharge. Hospital length of stay (LOS) was obtained from the hospital computer system.

INSTRUMENTS

Two instruments with established reliability and validity in geriatric research were employed in the study (Spector, 1990). The Index of Activities of Daily Living (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963) was used to assess functional status. This instrument evaluates independence in the performance of six functions (bathing, dressing, toileting, transferring, continence and feeding), resulting in an overall grade. Tests of this instrument in various settings found that 96% of patients could be categorized accurately by the Index of ADL.

According to the Index, performance (independent, needing some assistance, or dependent) is summarized as grades A, B, C, D, E, F or G, with A being the most independent and G the most dependent grade. In this study, these grades were converted to numerical scores to facilitate data analysis with a score of 1 being totally independent and 7 being completely dependent. The Index is scored by the individual observing the behaviors based on what the patient actually did.

The patient's degree of intellectual impairment was assessed with Pfeiffer's (1975) Short Portable Mental Status Questionnaire (SPMSQ). The SPMSQ is a standardized ??-item instrument used to assess several aspects of intellectual functioning in elderly people (Pfeiffer, 1975). SPMSQ scores correlate well with mental functioning. There is a high level of agreement between SPMSQ scores and the diagnosis of organic brain syndrome (moderate to severe). In addition, levels of intellectual functioning are thought to relate to a person's ability for self-care with those individuals who are the most severely impaired, the least able to handle self-care (Pfeiffer, 1975). The instrument is reported to be valid and reliable when used to detect intellectual impairment in the elderly (Pfeiffer, 1975). A score of 3 or more errors is indicative of some impairment of intellectual functioning with a score of 8+ being severely impaired. In this study, the SPMSQ was used to describe and compare the groups.

Demographic and clinical information was recorded on an instrument developed by the investigators. The instrument was tested for completeness and ease of documentation on 10 patients. Data were collected about the presence of a pressure ulcer, an infection, an intravenous catheter, a urinary catheter, falls, variances, sitter use, incontinence, toileting, medications and dietary intake (percentage of meals eaten). The final form was used by the three investigators to record data from the same patient and recorded responses were compared to establish uniformity in documenting information on the form. In addition, a sample form with documentation instructions was accessible in a binder for reference. Approval for conducting the study was granted by the hospital's Human Investigation Committee which adheres to federal guidelines.

RESULTS

Eighty patients completed the study (40 in each group). The most common admission diagnoses were mental status change, cardiac, syncope / fall, sepsis /infection, pulmonary disease and cerebral ischemia. Half the patients had multiple diagnoses and over one-third had a history of dementia. There were no statistical differences between the groups in age or gender. The mean age of the experimental group was 85.8 years with a range of 66 to 100 years. The mean age of the control group was 83.8 years with a range of 67 to 96 years. It was a predominantly white, female sample and the majority had graduated from high school. The most frequently documented reasons for admitting patients to the dayroom other than obvious management problems due to confusion were to increase activity, assure safety without using restraints, to monitor effects of medications, to increase socialization, and to provide toileting.

Mental status scores and functional ability differed between the experimental and control groups. On admission to the study, the experimental group (dayroom) was significantly more mentally impaired (SPMSQ mean was 5.95) than the control group (SPMSQ mean=3-75, p=<.05). They were also more functionally dependent (Index of ADL mean=6.7, p=<.05) man the control group (mean=6.2). On discharge from the study, subjects in both groups had maintained or improved their functional ability. The mean Index of ADL on discharge from the study for the dayroom group was 5.7 and for the control group was 5.2. Forty-eight percent of the dayroom patients demonstrated improvement in their Index score compared to 40% in the control group. However, the dayroom group remained more mentally impaired at discharge from the study than the control group (SPMSQ mean=5.65 and 3.42 respectively, p=<.05). Nevertheless, dayroom patients had a decreased length of stay (LOS) in the hospital. The mean LOS for the dayroom group was 9.8 days and for the control group was 11.3 days.

Dayroom patients had required more sitters at admission to the study, however at discharge from the study, the control group sitter hours had doubled and the experimental group had decreased hours by more than half (Table 1).

Patients in the experimental group (dayroom) received twice as much discharge teaching. The mean number of patient teaching documentation entries was 2.5 for the experimental group and 1.4 (significant at p=<.05, p=0.0122) for the control group. Almost half of the dayroom patients had improved dietary intake as compared to a third of the control group. In addition, they were more likely to have urinary catheters discontinued, be continent at discharge and be placed on a toileting schedule (Table 2).

There were fewer complications from hospitalization documented for dayroom patients. They experienced two pressure ulcers versus five in the control group. One patient in each group developed a nosocomial infection while in the study and one patient in the dayroom had a fall recorded as compared to two falls in the control group.

Table

TABLE 1Sifter Use by Group

TABLE 1

Sifter Use by Group

Table

TABLE 2Comparison of Continence

TABLE 2

Comparison of Continence

DISCUSSION

Several factors impacted the results of this study. The difference in mental status, the method chosen for randomizing patients, the limited time for collection of complication data and the instrument used to measure functional ability need to be considered when interpreting results. However, the unexpected difference in LOS was a significant finding that warrants further attention. Although one patient was excluded from the control group LOS computation due to an extended hospital stay while awaiting guardianship appointment, LOS was a day and a half less for the experimental group. This is even more remarkable in view of the difference in mental impairment between the groups. In contrast with what Meissner and colleagues (1989) reported, our patient outcomes and LOS improved with only limited environmental and staffing changes. We can only speculate as others have done (Wanich, Sullivan-Marx, Gottlieb, & Johnson, 1992) that the most influential factors were the dayroom interventions and the nurse who provided stability in what otherwise would have been a complex, frequently changing environment.

During the study, it became evident that by randomizing patients by their inpatient number the investigator was able to determine which group the patient was in before approaching the patient. Although only patients who met the admission criteria were included in the study, using a table of random numbers may have eliminated this potential bias. The dayroom could only accommodate four patients. Once patients were selected for the dayroom they remained until discharge. This may have prohibited another patient's selection for the dayroom program. However those patients whose inpatient numbers predicted they would be in the control group could be approached for the study inclusion since dayroom space would not be required. This randomization method may have precipitated some of the differences in mental status between the groups.

Studies have reported that the more confused a patient is, the more likely untoward results of hospitalization will occur (Lamont, Sampson, Matthias, & Kane, 1983). Patients who were provided care in the dayroom environment had fewer complications within the limited span of data collection. One can only speculate if the incidence of complications would have been higher had the control group been as mentally impaired as the dayroom group, or if data had been collected for a longer period of time. In a review of control patient records, complications did occur that were not included in study data because they did not occur during the previously determined study parameters. However, examination of the research data revealed that the pressure ulcers which developed in the control group patients were more serious. Three (of the five) pressure ulcers that developed in the control group patients were Stage ? within the 3 days of data collection. Although there were two pressure ulcers recorded in the experimental group, one was a Stage I and one had redness due to diarrhea.

The Index of ADL may not accurately reflect the acute care patient's functional ability since it measures observed behaviors, however it was sensitive when comparing the differences between the two groups. Hospitalized patients expect and are provided assistance with almost all of their ADLs even when, with encouragement, they may be able to accomplish a task for themselves. Nurses may actually promote dependence thus precipitating functional decline by their zeal to care for the patient. Within Levine's framework, it behooves a nurse to accurately assess an individual's need, then determine appropriate nursing interventions. For geriatric patients, it means encouraging them and enabling them to care for themselves. In the study by Hirsch and colleagues (1990), functional ability was rated using a "Care Needs Assessment" which is a scale partially adapted from the Index of ADL for use in an acute care setting. This scale uses report of ability by patient or caregiver to determine the level of function score in seven domains. It was reported to accurately reflect the individual's functional level in their setting.

Finally, at this institution, restraints are being used less frequently, however sitters are obtained for mentally impaired patients who present nursing management problems. Specific outcomes for study patiente who had sitters were not examined or compared in this study. Patients assigned to the dayroom were constantly observed, therefore sitters were discontinued (except for the midnight shift). Sitters do not provide the intensive functional care often required by these patients and may be considered an expensive, ineffective alternative for meeting the needs of a geriatric patient.

NURSING IMPUCATIONS

Results of the study indicate that patients who are 85+ years, admitted with mental status change, syncope not specifically cardiac, a fall history or with sepsis or infection, could benefit from care provided in an environment designed to meet their specific needs. Presently, there is a continual influx of different personnel into patient rooms and the patient is transported away from familiar surroundings for physical therapy, occupational therapy, x-rays, etc. This seems to cause distress for patiente. Also, noise from intercoms, talking in halls, infusion devices and phones may increase confusion and may lead to attempts to respond by climbing out of bed too quickly thereby increasing fall incidence or use of restraints. The dayroom program provided more consistency and nonrestrictive supervision for patiente in this complex hospital environment.

The study suggests that complications do occur in this patient population. They are at risk for skin breakdown and falls; however, incontinence can be avoided with adequate toileting schedules. Cost effective care can be provided in an environment that supports the elderly person's adaptive process. Nurses need to provide teaching that assures a patient is capable of self care when discharged. Personal and social integrity is conserved when nurses acknowledge losses that elderly patiente are experiencing. Patiente realize that their memory is affected, that they have lost function, lost family, spouses, children, home and friends. It is important to note that inservice training and geriatric rounds were provided for unit nurses by the geriatrician for 6 months prior to implementing the dayroom program. The decreased LOS in dayroom patients suggests that nurses, familiar with the needs of elderly patients, provide for these needs more adequately.

There is a need for further study about nursing interventions that would enable elderly patients to maintain function and remain active when hospitalized. Replication of this study with a more ethnically diverse populations and in different hospital settings is also warranted.

In summary, at this institution and with this patient population, the following outcomes were achieved. First, mere was a decreased LOS and decreased adverse events, which were achieved without additional staffing requirements in a group of elderly patients who were more impaired at baseline and in whom one would have expected to have worse outcomes. Secondly, a decrease in restraint and sitter use was achieved while providing more adequately for the patient's functional needs. Finally, there was an increase in family satisfaction regarding the nursing care provided for patients in this alternative environment.

REFERENCES

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TABLE 1

Sifter Use by Group

TABLE 2

Comparison of Continence

10.3928/0098-9134-19951101-07

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