The majority of older adults will experience hospitalization at some point in later in life. Frequently, they are hospitalized for acute exacerbations of existing chronic conditions that cannot be treated on an outpatient basis. Unfortunately, the hospitalization experience may create other problems. Illness and hospitalization can create a crisis situation for many individuals regardless of age. However, elderly adults are perceived as the least likely to adapt successfully to hospitalization because they have fewer physiological energy reserves than younger adults and a declining capacity to adapt to unfamiliar environments (Eliopoulous, 1997; Girard, 1997).
A growing body of literature related to the negative effects of hospitalization on elderly individuals exists. Many studies have identified mental and physical impairments resulting from hospitalization in previously unimpaired elderly adults (Castle, 1996; Foreman, Theis, & Anderson, 1993; Rudberg, Pompei, Foreman, Ross, & Cassel, 1997). Other authors have demonstrated how physical problems can compound during hospitalization (Hirsch, Sommers, Olsen, Mullen, & Winograd, 1990). More recently, researchers have recognized the heterogeneity of delirium in hospitalized elderly patients (Rudberg et al., 1997). Others have recognized the high prevalence of malnutrition in hospitalized elderly patients. Malnutrition results in more hospitalization complications, longer hospital stays, more frequent readmission, higher in-hospital mortality, and increased mortality at 90 days and 1 year (Reuben, 2000).
These researchers have begun to identify the unique problems elderly patients must face in an acute care setting, but few researchers approach the problem from the patient's perspective. Yet, more than 20 years ago authors such as Mezey (1979) emphasized the need for further study of elderly individual's subjective response to hospitalization. The purpose of this study was to identify and describe the hospitalization process as perceived by elderly patients.
The study participants consisted of eight White, middle-class, elderly patients (ages 66 to 83 years; M = 73.5 years) in a 300-bed, acute care hospital in a large, western, metropolitan area. All patients were identified through purposive sampling and agreed to participate in the study. Inclusion criteria were:
* English speaking.
* Age 65 and older.
* Admission to a general medical or surgical unit for at least 24 hours.
* Conscious and cognitively intact as determined by nursing staff and documented in the medical record.
The four men and four women who comprised the patient group represented both medical and surgical diagnoses and the ethnic and socioeconomic older adult patient population of the hospital. Length of hospitalization varied from 1 to 33 days.
After Institutional Review Committee approval, data were collected during a 7-month time period, and patients from four separate hospital units were included. Qualitative rigor guidelines for the study were adapted from the work of Lincoln and Guba (1985). Sources of data included interviews, participant observation, and review of medical records. Data were generated until little or no new information surfaced for the study.
After patients meeting the selected criteria were identified, each was contacted and the purpose of the study was explained. After obtaining the participant's consent, an interview using ethnographic techniques (Hammersley & Atkinson, 1983; Spradley, 1979) was conducted with each of the informants in a convenient location preferred by the informant within the hospital. Every attempt was made not to disrupt the daily routine of the patients or hospital staff. Interviews used an unstructured format, and a broad opening statement, such as, "Tell me what your hospitalization experience is like..." was used to elicit the informant's perceptions. Additional prompting was used to elicit further information as needed, and all interviews were allowed to proceed until the individuals were satisfied they had nothing else to add.
The interviews were tape recorded and ranged from 20 to 75 minutes. One or two follow-up interviews with each participant served as a means to validate data categories and to obtain additional data informants wanted to express about their hospitalization experience. Interviews were identified by code numbers (i.e., Case 1 to 8) and transcribed by a secretary trained in transcription. All transcripts were subsequently read for accuracy by the investigator, and nonverbal observations noted during the interview were added.
Field notes were used to record nonverbal and analytical information during or after each interview. Personal impressions were also recorded at the completion of interviews. Participant observation with field notes occurred as older patients were receiving care during hospitalization. These observations included environmental arrangements, traffic to and from the patients' rooms, noise levels, location and activity of patients and visitors, and other unit activity.
All information from the different perspectives of patients, investigator observation, and medical records was considered during coding. Certain factors were considered as each informant's perceptions of the hospitalization experience was analyzed. These factors included:
* Patient's medical diagnosis and special gerontological problems.
* Length of hospital stay at the time of the interview.
* Demographic factors such as gender and age of the informant.
A microcomputer program, The Ethnograph (Seidel, Kjolseth, & Clark, 1985), was used to sort and organize investigator coded data. AU codes were compared against each other and additional data collected until categories began to emerge for this study.
Reliability and validity are important considerations of any research study. Aspects of rigor were assessed for this study. Evaluating the representativeness of the data, coding and categorizing data, verifying typical elements, and deliberately trying to discount conclusions by further data collection and analyses increased credibility. Credibility was further enhanced by triangulation of data collection methods (i.e., interviews, observations, record review). Congruence among these methods and informants was examined. In addition, the researcher checked with informants to validate categories emerging from the data. Using this technique, perceptions of the investigator were compared with those of the informants living the experience.
Consistency, or reliability, in quantitative studies is called "auditability'' in qualitative studies. This aspect requires researchers to provide a detailed description and justification of the data collection procedure, analyses, and interpretation provided. The degree of auditability is determined if others can follow a "decision trail" and come to a similar decision (Lincoln & Guba, 1985). In this study, the qualitative process used throughout the project was reviewed by five researchers with qualitative research expertise who confirmed the decision trail.
Thirty initial codes were identified as the data were broken into small pieces. A word or words similar to or exactly those used by the informants were attached to the data. As data collection and analyses occurred, initial codes were reevaluated and further condensed into seven categories.
Patient and Family Concerns
Patients described the difficulties they encountered during hospitalization. Their concerns were especially pronounced if the patient was discussing difficulties the hospitalization caused a spouse. Concern surrounded travel to and from the hospital for visits, bad driving conditions, and fear of spouse being alone. The patients' spouses often were older individuals with many health problems, who now faced being the sole decision-maker, maneuvering in new environments, and spending exhausting hours in the hospital setting to be with their spouses. The following patient comment reflected his concern for his spouse:
I'd be afraid of sending her home by herself and her not being well either... (Case 6).
Patients were also concerned they would not be able to manage care after hospital discharge.
This refers to problems patients had finding constructive activities to occupy their time. Patients and family members complained of idle time - as described by one patient:
You know the nervous waiting... Waiting for all the tests and it got on your nerves and the whole family too. (Case 8).
Others watched patient-billed television, or read books. However, many said they did not have anything to read and were unaware of any hospital library that would provide reading materials for them.
Independence and Dependence Struggle
The struggle between independence and dependence depicts the patients' level of ability to be responsible for and to actively participate in their care. Informants perceived the less mobile patients were, the more dependent they were. Comments relating to the patients' struggle to maintain independence are voiced in the following:
* I'm not used to being helpless and dependent on other peoplc.I'd do anything to avoid asking somebody to do something for me (Case 1).
* Well, everybody loses their independence when they come into the hospital... It's a very demeaning experience to be hospitalized (Case 2).
* I just told my doctor this morning, I said, "I will refuse another test like that" (Case 6).
This category captures the experiences of patients' previous illnesses and hospitalizations or those of loved ones. Patients compared these previous experiences with the current hospitalization. Past experiences appeared to influence heavily every patient's perception of the current hospitalization.
Patients described feeling that things would work out in their situations. The optimism described by patients often had stronger and weaker moments. Some comments referred to confidence in hospital staff, while others indicated prior events had made them strong, such as the following patient comment:
I won't be as weak this time I don't think and I feel better because I think maybe they're getting to the base of my problem.... I don't know whether it can be cured or not, but it can be kept under control and I feel confident that they are doing all they can to do it (Case 3).
Patients relayed their fears about hospitalization. Informants indicated changing states in their perceptions of threats, as well as in their reactions to the threats. Patients mentioned fear of what was happening to them more often than optimistic comments. Each informant made numerous comments about problems relating to:
* Concerns about tiring procedures that depleted their energy.
* Sleep disturbances.
* Noise levels.
* Side effects of medications.
* Transfer to other rooms.
* Food not perceived as appropriate for hospitalized patients.
Medical errors were of particular concern to some patients. For example, the blood one informant had given during a 5 -week period prior to surgery was mistakenly discarded (Case 1). Another informant experienced a problem with transferring from an out-of-state hospital - a problem resulting in many hours of confusion and exhaustion for the patient and his family (Case 8). Some patients expressed fears that their situation was overwhelming and that they lacked the energy to cope with it.
Perceptions of Care
Patients stated their views of hospital staff and the care they were receiving. These perceptions of care frequently revealed ambivalence. On one hand, patients were grateful to the staff and willing to comply with their medical regime. When asked specifically about medical and nursing staff, patients indicated confidence in the care they received, such as in the following excerpt:
Well, most of them [staff] have been really, really good. The nurse has been good. The doctors have been real good and I have been well satisfied (Case 2).
On the other hand, these informants expressed confusion, and sometimes anger, that they or their family members had to go through needless mental anguish, as well as physical suffering. One patient remarked angrily:
Some of them [staff] just try to tell you what to do instead of helping (Case 4).
Another patient stated, "The nurses aren't patient" (Case 1), and another patient stated she did not feel like anyone ever came into her room just to talk to her (Case 5).
In general, patients had fewer negative than positive perceptions of care. Although all informants expressed negative comments, most qualified their remarks by stating these situations were understandable. These informants seemed to accept the care they received, even though they realized, in some cases, it could be better. Informants expressing particularly angry comments indicated reluctance to accept such unsatisfactory care, and identified methods to circumvent such situations because they realized they were not likely to change. This is typified in the following statement:
Actually I ran into two nurses here that were really mean... Well I get that way back with them and they settle down a bit for awhile (Case 2).
Limitations exist to this qualitative study. The purposive sampling technique, small number of participants, and limited ethnic diversity of the sample do not allow generalization beyond the participants in this study. Different ethnic, economic, and geographically located groups are likely to have varying perspectives. In addition, the patients in this study ranged in age from 66 to 83 years. Older patients may have different perspectives, as those older than 85 are usually considered more frail and may experience additional stress during hospitalization.
Findings from this study indicate these eight older patients perceived hospitalization as a stressful event with many threatening factors. These perceptions are supported by existing literature on the hospitalization of older individuals. Fletcher (2000) reviewed several existing literature resources and stated, "hospitals are dangerous places for older persons" (p. 758). Palmer and Bolla (1997) agreed that during hospitalization, older individuals may develop functional dependency, cognitive dysfunction, mood disorders, and malnutrition. These conditions are thought to result from the interacting effects of aging, chronic disease, acute illness, and the physical environment.
Other authors have addressed iatrogenic illnesses that can affect all hospitalized patients, especially older patients. These illnesses or harmful occurrences may result from a diagnostic procedure or therapeutic intervention, and are not natural consequences of the patient's underlying illness (Palmer & Bolla, 1997). Older patients in this study were very concerned about hospital-related complications, and provided examples of errors occurring during their treatment at the facility.
Medication errors were of particular concern. These apprehensions are supported in a variety of studies examining adverse drug reactions, and are described in a recent report by the Committee on Quality of Health Care in America, Institute of Medicine (Kohn, Corrigan, & Donaldson, 2000). Moreover, Classen, Pestotnik, Evans, Lloyd, and Burke (1997) reported in their study of more than 22,000 hospitalized patients that patients having adverse drug reactions were nearly twice as likely to die. Additionally, Lazarou, Pomeranz, and Corey (1998) analyzed 39 studies of adverse drug reactions in hospitalized patients completed during a 32-year period and found adverse drug reactions among the top 10 causes of death.
The elderly patients in this study were influenced by unpleasant memories of previous illness and hospitalization. Fried, van Doom, O'Leary, Tinetti, and Drickamer (2000) also found that among older individuals interviewed 2 months after their hospitalization, one of the primary reasons they preferred home care over hospitalization was a previous bad hospital experience. Some participants cited a lack of nursing response or a sense their nurses did not care about them. Complications believed to result from hospitalization, bothersome hospital personnel in training, and problems with roommates were also identified as bad hospital experiences. These authors found that older patients who preferred hospitalization cited a sense of greater safety within the hospital as the primary reason for desiring hospitalization.
The participants in this study reflected comments similar to those found by Fried et al. The Perceptions of Care category contained a variety of comments indicating patients did not feel nurses cared about them, and that patients were put through needless mental and physical suffering. Yet, these patients provided excuses for staff behavior, believed most staff members were trying to help them, and felt confident about their hospital care. These positive perceptions were also reflected in the Optimism category, in which confidence related to hospital staff was expressed, as well as a belief that they would "get through it [hospitalization] . "
Concerns about family members and not knowing how they would be able to manage their care after discharge were echoed by participants in this study and reinforced in the literature. Numerous authors have identified discharge problems with elderly patients (Girard, 1997; Rosswurm & Lanham, 1998). One successful model incorporating advanced practice nurses has been described (Naylor et al., 1999); however, many hospitals have yet to adopt comprehensive discharge planning.
IMPLICATIONS FOR NURSING PRACTICE
Nurses can significantly help minimize stressors, help patients and their families understand the meaning of the hospitalization experience, and shorten hospitalization time when appropriate. Preventing "cascade iatrogenesis" (i.e., a sequence of two or more iatrogenic events) in hospitalized older patients has been identified as an important role for nurses. Interventions to alter this potentially negative sequence require nurses to encourage early assessment of potential problems and promote functional mobility (Jacelon, 1999). Recognizing patients at risk for functional decline and implementing strategies to decrease this risk is the goal of most special geriatric units. This goal also can be accomplished in acute care hospitals without special units.
Developing screening protocols that include assessment of functional risk and assessment of patient's perception of hospitalization at admission or early in the hospitalization experience may be useful in identifying the major stressors found in this study. These protocols should include an assessment of:
* Patient and family concerns.
* Desired activities to help "fill the time."
* Level of functioning and independence desired.
* Memories of past hospitalizations.
* Indicators of optimism.
* Perceived threats.
* Perceptions of care.
Interventions to facilitate functional ability, minimize recognized stressors and iatrogenic illnesses, reinforce optimism, and construct activities to fill the time could be implemented as appropriate. Tests of these and other interventions to facilitate supportive acute care environments are yet to be conducted. Phillips and Ayres' (1999) review of supportive and nonsupportive care environments for elderly individuals reinforces the need for research focusing on person-environment interactions in acute care settings.
Older patients face unique problems during hospitalization. The literature abounds with negative physical and cognitive consequences of hospitalization for elderly patients, yet few studies have examined the older patients' perception of the hospitalization experience. This study identified the perceptions of eight elderly, hospitalized patients. Further research studies with larger and more varied groups are needed to test interventions. These interventions should strive to maximize functional abilities, minimize iatrogenic illnesses and stressors, reinforce optimism, and construct activities to make better use the patient's time while hospitalized. Such research, combined with existing knowledge, may assist nurses in creating more positive hospitalization experiences for those older patients least able to withstand the negative consequences of hospitalization.
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