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

By Megan Mueller

Individuals 65+ years of age 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 healthcare 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 endeavors but, to date, one key expert voice is missing: the nurse’s perspective.

New research from York University, led by Post-Doctoral Visitor Jeffrey Butler, under the supervision of Health Professor Mary Fox, and funded by the Ontario Ministry of Health and Long-Term Care and the Ontario Ministry of Research & Innovation, fills this important gap. Through focus groups with nurses, Butler and Fox identified novel approaches in interprofessional (IP) communications 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. Our recommendations may inform the implementation of initiatives to improve IP communication more generally,” says Butler.

Training perioperative nurses in their future work environment

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 healthcare, and hospital expenditure comprised a very large share of this (Canadian Institute for Health Information/CIHI).
  • Older adults are frequent users of healthcare services, with the system spending more on them than on any other segment of the population (CIHI).
  • Healthcare 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 healthcare 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) says that they valued IP rounds as great opportunities to share information. (Patient rounds, led by attending physicians, involve several healthcare 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,” says Butler.

Participants also says 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 says: “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.

Analog tools seen as useful, cost effective

Rather than advocating IT solutions, the study participants says that simple, low-tech, cost-effective analog 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 communications tips for administrators and practitioners

In summary, this new research makes three key findings:

  1. Direct face-to-face communications, 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 communications and, in turn, lead to better health outcomes.

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

Megan Mueller, Manager, Research Communications, Office of the Vice-President Research & Innovation, York University.