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\begin{document}

\title{``Older people aren't my real patients'': qualitative evaluation of
barriers and enablers to older person friendly hospitals}



\author[1]{Alison Mudge}%
\author[1]{Adrienne Young}%
\author[1]{Prue McRae}%
\author[2]{Frederick Graham}%
\author[3]{Elizabeth Whiting}%
\author[4]{Ruth E. Hubbard}%
\affil[1]{Royal Brisbane and Women's Hospital}%
\affil[2]{Princess Alexandra Hospital}%
\affil[3]{Metro North Hospital and Health Service}%
\affil[4]{The University of Queensland Faculty of Medicine}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
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\selectlanguage{english}
\begin{abstract}
Background, aims and objectives: With ageing global populations,
hospitals need to adapt to ensure high quality hospital care for older
inpatients. Older person friendly hospital (OPFH) principles and
practices to improve care for older people are recognised, but many
remain poorly implemented in practice. The aim of this study was to
understand barriers and enablers to achieving OPFH from the perspective
of key informants within an academic health system. Methods:
Interpretive phenonomenological study, using open-ended interviews
conducted by a single researcher with experienced clinicians, managers,
academics and consumers who had peer-recognised interest in care of
older people. Initial coding was guided by the Promoting Action on
Research Implementation in Health Services (PARIHS) framework. Coding
and charting was cross checked by three researchers, and themes
validated by an expert reference group. Reporting was guided by COREQ
guidelines. Results: Twenty interviews were completed (8 clinicians, 7
academics, 4 clinical managers, 1 consumer). Key elements of OPFH were:
older people and their families are recognized and respected; skilled
compassionate staff work in effective teams; and care models and
environments support older people across the system. Valuing care of
older people underpinned three other key enablers: empowering local
leadership, investing in implementation and monitoring, and training and
supporting a skilled workforce. Conclusions: Progress towards OPFH will
require genuine partnerships between clinicians, consumers, health
system managers, policy makers and academic organisations, and reframing
the value of caring for older people in hospital.%
\end{abstract}%



\sloppy


``Older people aren't my real patients'': qualitative evaluation of
barriers and enablers to older person friendly hospitals

Running title: Enabling older person friendly hospitals

Alison M Mudge, PhD

Department of Internal Medicine and Aged Care, Royal Brisbane and
Women's Hospital;

University of Queensland School of Clinical Medicine

Alison.Mudge@health.qld.gov.au 61 7 36460854

Internal Medicine Research Unit, 6\textsuperscript{th} floor block 7,
Royal Brisbane and Women's Hospitals, Butterfield St Herston Queensland
4019 Australia

Adrienne Young, PhD

Department of Nutrition and Dietetics, Royal Brisbane and Women's
Hospital.

Prue McRae, MPhil

Department of Internal Medicine and Aged Care, Royal Brisbane and
Women's Hospital.

Frederick Graham, RN

Department of Internal Medicine, Princess Alexandra Hospital.

Elizabeth Whiting, FRACP

Metro North Hospital and Health Services.

Ruth E. Hubbard, MD

PA-Southside Clinical Unit, School of Clinical Medicine, The University
of Queensland.

ABSTRACT

Background, aims and objectives: With ageing global populations,
hospitals need to adapt to ensure high quality hospital care for older
inpatients. Older person friendly hospital (OPFH) principles and
practices to improve care for older people are recognised, but many
remain poorly implemented in practice. The aim of this study was to
understand barriers and enablers to achieving OPFH from the perspective
of key informants within an academic health system.

Methods: Interpretive phenonomenological study, using open-ended
interviews conducted by a single researcher with experienced clinicians,
managers, academics and consumers who had peer-recognised interest in
care of older people. Initial coding was guided by the Promoting Action
on Research Implementation in Health Services (PARIHS) framework. Coding
and charting was cross checked by three researchers, and themes
validated by an expert reference group. Reporting was guided by COREQ
guidelines.

Results: Twenty interviews were completed (8 clinicians, 7 academics, 4
clinical managers, 1 consumer). Key elements of OPFH were: older people
and their families are recognized and respected; skilled compassionate
staff work in effective teams; and care models and environments support
older people across the system. Valuing care of older people underpinned
three other key enablers: empowering local leadership, investing in
implementation and monitoring, and training and supporting a skilled
workforce.

Conclusions: Progress towards OPFH will require genuine partnerships
between clinicians, consumers, health system managers, policy makers and
academic organisations, and reframing the value of caring for older
people in hospital.

Key words: health services; capacity building; health workforce; patient
care team

``Older people aren't my real patients'': qualitative evaluation of
barriers and enablers to older person friendly hospitals

INTRODUCTION

Longer life expectancy and expectations of ``baby boomer'' consumers
bring challenges for modern health systems as they adapt to the changing
face of patient care. Increasing frailty and disability mean that older
people are vulnerable to hospital-associated complications and poor
outcomes\textsuperscript{1,2}. Pioneering models of geriatric care can
reduce harm and deliver more efficient, patient-centred care for older
people \textsuperscript{3}. The principles developed in these models
must be expanded beyond small specialist units to all acute care
settings caring for older adults to realise the benefits for patients
and the healthcare system \textsuperscript{4-6}.

This challenge led to the concept of the Older Person Friendly Hospital
(OPFH), and several authors have proposed supporting frameworks and
practices\textsuperscript{7-11} ( Table 1). Common principles espoused
by these frameworks include senior organisational leadership that
addresses institutional ageism; a system that respects older patients'
choices about care and care delivery; staff equipped with geriatric
knowledge and skills; evidence-based practices (EBP) to reduce
hospital-associated complications such as delirium and falls; a
well-designed physical environment to promote function; and connections
to promote smooth transitions across care settings.

The Queensland Statewide Older Person's Health Clinical Network is a
multidisciplinary network linking clinicians interested in care of older
people across Queensland, Australia. In 2016, this group led a
state-wide survey assessing older person friendly principles in hospital
care, adapting a Canadian survey\textsuperscript{11}. The
self-assessment survey was completed by clinical and executive leaders
(e.g. directors of geriatrics, nursing, allied health and facility
managers) in 23 hospitals across Queensland, demonstrating several
consistent areas of strength and weakness (Table 2). Weaknesses included
poorly coordinated clinical and executive leadership; limited engagement
of older consumers; limited geriatric education and training across
disciplines; limited recognition and prevention of functional decline
and delirium; and poor integration of design principles outside
specialist geriatric wards \textsuperscript{12}\emph{.}

The current research aimed to gain an in-depth understanding of why
these weaknesses occurred and how they might be addressed, by describing
the experience of delivering, supporting or receiving hospital care for
older people. Our objectives were to engage stakeholders with personal,
clinical, management and academic experience in hospital care for older
people, articulate a comprehensive vision of challenges and
opportunities in achieving OPFH, and inform continuing system
improvements.

METHODS

The study was conducted in hospitals within two publicly-funded health
services in Brisbane and their associated universities. The project
steering committee consisted of clinicians and academics from within
these organisations with an interest in hospital care of older people.
Steering committee members identified potential key informants within
their clinical, consumer and academic networks, who in turn identified
colleagues as additional participants. Potential participants were known
by peers for their interest in care of older people, providing informed
experiences about challenges and successes in improving older person
hospital care. Participants included individuals from a range of
backgrounds (clinical care delivery, clinical management, clinical
research, teaching and training, and health consumer representative) to
construct a multi-faceted understanding of the phenomenon of caring for
older people in hospital, aligning with our constructivist worldview,
i.e. a knowable world mediated by an individual's conceptual
lens\textsuperscript{13}. Participants were purposively selected for
maximum variation with respect to position, discipline, setting and
experience level, and invited to participate via personalised email from
AY. A sample size of 20 participants was pre-specified pragmatically for
this time-limited project. Multi-site ethics committee approval was
received (HREC/16/QRBW/485) and written consent provided by all
participants.

Interviews were conducted by AY, a postdoctoral researcher with
qualitative research experience. She had worked as an allied health
professional (AHP) in one participating hospital, providing background
to OPFH care, and was known to three participants. Interviews were
undertaken at a time convenient to participants, in a private office
space in each participant's workplace. Each participant was provided
with the previous survey report\textsuperscript{12} as context. The
interview began with a verbal and written summary of practice gaps
identified (Table 2), inviting the participant to discuss their
experiences with care of older people in acute settings related to these
gaps. Beyond this opening statement, there were no set interview
questions. Probing questions were used if required to elicit further
information.

All interviews were digitally recorded using a dictaphone and
transcribed verbatim by a professional transcription service, and
cross-checked by AY. Field notes were taken during the interview for
reference during debriefing sessions with the research team and during
coding. Written transcripts were emailed to all participants for member
checking; five participants provided clarification.

A hybrid deductive-inductive approach was taken to thematic analysis of
interview data using an interpretive phenomenological approach (Fereday
\& Muir-Cochrane, 2006). In the first instance, a deductive approach
used the \emph{Promoting Action on Research Implementation in Health
Services} (PARIHS) framework \textsuperscript{14,15} as the analytical
framework, to allow consideration of barriers and enablers to older
person friendly care with an implementation focus. The first three steps
of analysis were informed by the Framework Method \textsuperscript{16}:

\begin{enumerate}
\tightlist
\item
  Familiarisation: review of field notes, audio-recording and
  transcription, noting initial thoughts and impressions
\item
  Identifying an analytical framework: pre-defined codes and explanatory
  notes developed based on PARIHS framework (Table 3).
\item
  Indexing: first four interviews coded independently by AY and AM,
  compared for consistency and framework refined with two additional
  codes generated from the data. Remaining interviews were coded
  independently by AY using the final framework. Indexing was completed
  using NVivo for Mac (version 10, QSR International).
\end{enumerate}

An inductive approach was then taken to identify themes within and
across data indexed under each code. AY, AM and RH independently
reviewed data indexed at three representative codes and summarised
themes. These were compared for consistency and discussed until
consensus was achieved. AY and AM independently reviewed and summarised
data indexed at the remaining codes, and identified themes within and
across codes. Theme summaries, exemplar quotes and five transcripts each
were provided to the other four authors for review to ensure that themes
and selected quotes adequately represented the data.

Rigour was ensured through discussions within the project steering
committee during data collection and analysis, and reporting using COREQ
guidelines. Trustworthiness was supported by presenting preliminary
themes back to participants (via email), and in workshop style at
meetings of the Statewide Older Person's Health Clinical Network and the
Statewide General Medical Network (each attended by approximately 40
participants, including clinicians, managers, and consumers), with
participants invited to provide feedback.

RESULTS

We identified 42 potential key informants from eight institutions; 26
were invited to participate, of whom only one declined. Interviews were
completed with 20 participants between October 2016 and February 2017.
Participants were mostly female (n=16, 80\%), and came from a range of
discipline backgrounds as shown in Table 4. Mean duration of interviews
was 50 minutes (SD 16). One participant was an appointed consumer
representative, but several other participants discussed their health
care experiences as carers of older family members, augmenting the
consumer perspective. Participants also drew on previous experience
working in other health services, community settings or or
organisations.

We identified seven major themes for the OPFH (Figure 1).Three core
elements for achieving systematic, high quality care were:

\begin{itemize}
\tightlist
\item
  Older people and their families are recognised and respected
\item
  Skilled compassionate staff work in effective teams
\item
  Care models and environments support older people across the system
\end{itemize}

Four system enablers were identified to achieve these goals:

\begin{itemize}
\tightlist
\item
  Empower local leadership in older person friendly care
\item
  Train and support a workforce skilled in care of older people
\item
  Invest in implementing and monitoring evidence-based practices
\item
  Value care of older people
\end{itemize}

The latter enabler underpinned all other elements and enablers, and
required challenging an ageist and efficiency-driven culture.

\emph{Older people and their families are recognised and respected}

Participants articulated that older patients need to be recognised as a
group with particular and often complex care needs requiring specific
knowledge and skills, and as legitimate and deserving recipients of
acute care. There was a perception that many staff viewed older patients
negatively, due to ageism, false expectations set during training,
complex care that disrupts and delays hospital processes, and nihilism
about outcomes.

``I think there is still a very strong\ldots{}belief of `older people
aren't my real patients. They're the exception. They're the difficult
ones''' P4, geriatrician, clinician ``We need to generate more positive
attitudes to ageing. People say they're not working with older people,
they're acute care therapists, but that's who they'll end up working
with'' P11, AHP, academic

Older people needed to be recognised as individuals, with variation in
their care needs, expectations, and life experience. Ageist stereotypes
contributed to homogenisation of older people, reducing their individual
value.

``I think {[}it's often said that{]} `older people like this, older
people like that'. Older people are actually more individual than you or
me. Because over the lifespan, if you think about it, we just keep
differentiating, don't we?'' P4, geriatrician, clinician

Some respondents noted that older people may be unable to advocate for
their needs, due to generational characteristics or cognitive
impairment. Family and carers of older people were recognised as
important sources of information, providing advocacy and supporting
individualised care. However, many participants reported a transactional
approach to engagement e.g. information exchange rather than genuine
partnership in decision making and care.

``We certainly had conversations and they were very respectful and
polite and all that but it wasn't shared decision making really.'' P12,
AHP, clinician (reflecting on consumer experience) ``The carers are
often so involved and really good advocates for those people but that's
not what you want when you're trying to look after a patient\ldots{}You
probably don't want someone telling you how that person likes their cup
of tea or likes to eat their breakfast or take their shower.'' P9,
nurse, academic

In contrast, some respondents had poignant reflections about their
personal experience as care-givers, recognising that family are often
invisible and require confidence and health literacy to initiate
engagement.

``It changed once they knew I was a nurse and it made me think `What
happens to people who don't have medical knowledge and can't ask the
questions?'\ldots{}.Up until then they'd walk into the room and ignore
me.'' P15, nurse, academic (reflecting on consumer experience)

\emph{Skilled compassionate staff work in effective teams}

Knowledge and skills in care of older patients, particularly those with
cognitive impairment, were seen as important for all hospital staff.

``Even from the people who work in the ward who are going to handle an
older person, who are going to transfer an older person; how are they
going to deal with an older person if he has dementia when he needs to
move from A to B or he needs to have his meds? So everyone needs to have
some sort of training.'' P17, geriatrician, academic

Compassion was identified as an important attribute in caring for older
people. Experiential learning could enhance compassion, while entrenched
ageism, lack of knowledge and mentorship, negative experiences and
competing values and demands could erode it.

``I do think that people start with a degree {[}of compassion{]} and it
can be eroded over time, through experiences of lack of
interdisciplinary teamwork, you know, lack of what they see as being
important, not being valued.'' P3, nurse, manager ``They probably don't
think about it\ldots{} It's so easy when you work in that environment
all the time. You become immune to what goes on'' P9 nurse, clinician

Teamwork was discussed as a critical component of care of older
inpatients. Respondents identified value and challenges working in
multidisciplinary teams (MDT). Good teamwork provided opportunities for
sharing information, prioritising workload, mutual learning and peer
support.

``Different people bring the different skill mix to the
situation\ldots{}. I actually love the interaction of the team because
it really allows us to talk about the aspects of the older person care
in a really MDT approach. We know the view of the doctors, the doctors
are able to learn the view of ours and I believe that we learn from each
other.'' P10, AHP, clinician

However, when multiple team members were involved in care there was a
risk of overwhelming patients and families with poorly coordinated
interactions. Within teams, professional silos could limit communication
of important information, create duplication, and prevent individual
providers taking responsibility beyond a limited scope.

``I would hear the nutrition assistant or the dietitian come around to
the patient\ldots{}just saying `how'd you go with your {[}breakfast{]}
this morning'. And I thought, what a missed opportunity, because the
nurse was there, you didn't ask the nurse, you walked straight past
them.'' P3, nurse, manager ``I think nurses are very quick to go `this
is not something I know a lot about so I'll flick it off sooner than I
really need to because I know that there's somebody more expert in
that.''' P12, nurse, academic

Important enablers for promoting effective teamwork included
face-to-face meetings, working together over time to develop trust and
shared values, and open discussion of role boundaries.

``{[}These medical staff{]} don't have any rapport with the allied
health team\ldots{} in comparison to teams that might meet three time a
week so you've got a bit of rapport. You get to understand how they
work, and they get to understand how you work\ldots{} I think with teams
that don't meet and don't really know each other, that's really
difficult.'' P1, AHP, clinician

\emph{Care models and environments support older people across the
system}

There was broad recognition that improving care practices required a
systematic and system-wide approach. This was challenged by existing
professional and governance structures, which are based around
``organs'', disciplines and acuity, leading to siloed practices and
disjointed systems within and beyond the hospital.

``Why is it that cardiology isn't also a good place for an older person
and why is it age that determines whether you go to cardiology or not?''
P4, geriatrician, clinician ``This team comes and looks at X, and this
team comes and looks at Y, but how are we all sort of pulling it
together?'' P14, nurse, academic

Respondents recognised the need for better relationships and
communication beyond the hospital, particularly with residential aged
care. Respondents admitted to poor mutual understanding, leading to
assumptions and conflict in transitions between providers.

``People in both sectors are throwing their hands up in the air, saying
``we're just not being told what we need to be told.'' P11, AHP,
academic

There was tension between care of older people being a specialty versus
being usual care, including some tension between geriatricians and
general physicians. Staff with specialist skills could provide
mentorship and support for generalist staff, but could also increase
complexity, and the concept of specialist care models was challenged by
the large number of older patients.

``Maybe all older people need a geriatrician just to look at, to watch
over them, not necessarily be the primary carer but to actually have
input into their care.'' P2, nurse, manager ``Sometimes {[}emergency
department outreach service{]} is involved, {[}community interface
service{]} is involved, the geriatrician's involved and throw in the
Older Persons' Psychiatrist as well and then there's a lot of varying
opinions sometimes. I think we need to look at who is owning the
patient.'' P19, geriatrician, clinician

Respondents valued comprehensive screening and assessment for older
inpatients, but recognised that screening could be inconsistent, and did
not always translate into care practices. Reasons included professional
boundaries and expectations, limited support systems, and balancing time
spent between screening and delivering actions.

``Even the new care plans that we've got in place, it talks about
cognition but it's not clear. It's just another ticked box. It refers to
using the CAM {[}Cognitive Assessment Method{]}, but then they don't
have the CAM and they don't have that training.'' P20, nurse, clinician
``Most of the time, you do the assessment, you do the discharge
planning, and there's so little time left for the really proper targeted
goal-oriented therapy'' P10, AHP, clinician

There was a developing awareness of evidence-based environmental design
features for older people, particularly by respondents with experience
in residential aged care and specialist older person's wards. However,
staff were often circumspect about their influence over decision makers,
and whether the principles would be realised in practice.

``We don't actually think about what we do in these hospitals. We think
about colour combinations as being something that is pleasant, whereas
it's not necessarily that functional from an older person point of
view.'' P2, nurse, manager ``We are fighting to get that ACE {[}Acute
Care of Elders{]} ward\ldots{} It is being constructed, but it's the
colour code and the dining area and the toilet design\ldots{} Hopefully
it's going to be the way we have planned.'' P5, geriatrician, clinician

\emph{Empower local leadership in older person friendly care}

There was a recognised need for multi-level leadership to provide
strategic and practical support for older person friendly practices.
However, there was a lack of confidence in executive leadership and
accountability, and challenges with governance structures which support
existing organisational silos.

``I think it's in the back of everyone's mind but no-one's had the
ability, if you like, to move it forward.'' P6, nurse, manager ``We're
going to have to have a new way of thinking about how we structure our
governance. Even though I might have a service line to look after, my
remit for the older person might have to be across the organisation and
if that's the case then the other services have to be prepared for me to
paddle in their place a little bit.'' P2, nurse, manager

As a result, change and advocacy were driven predominantly by passionate
informal leaders, limited by time constraints of their `real job' and
their individual capacity to galvanise action. Poor role recognition and
slow progress often led to frustration, but establishing alliances
across traditional discipline and department boundaries helped gain
momentum. There was also strong reliance on local champions,
particularly nurse unit managers. They provided local leadership through
motivating staff, setting expectations, coaching and modelling, but
required continuing support.

``Unfortunately he's a one-man band\ldots{} This is a huge organisation
and as enthusiastic as one person is, there are still real limits around
how quickly you can start.'' P12, nurse, academic ``I would go to
geriatric things and come back all keen and try to get basic age
friendly principles into place, basic signage, and I had no traction.''
P20, nurse, clinician

\emph{Train and support a workforce skilled in care of older people}

Respondents articulated the need for both a formal gerontology
curriculum and opportunities for interacting with older people from
early undergraduate years. Limited undergraduate training in care of
older people was recognised across all professions, attributed to low
priority by teaching institutions. Gerontology content was generally
delivered as elective rather than core curriculum, clinical placements
were limited, and there were minimal opportunities for post-graduate
study in gerontology.

``Part of the challenge in preparing a workforce is that you need to
develop {[}teamwork{]} skills just as much as the development of the
technical and know-how skills that fascinate accrediting authorities but
actually don't really serve people well in terms of being work-ready.''
P18, AHP, academic

Consequently, most training was occurring in the workplace. The
importance of experiential learning was well articulated, but exposure
to training was generally ad hoc, depending on early placements on
geriatric wards or exposure to passionate champions. There was a
recognised lack of skilled teachers and mentors with dedicated time to
provide training and support, and reliance on individually-sought
external conferences and courses.

``If you don't go through a geriatric unit or work with a geriatrician
who is maybe working as a general physician, other than that, I don't
think they will get formal geriatric training.'' P5, geriatrician,
clinician ``It's just where you end up working. You're provided with
on-the-job training\ldots{} There's lots of external courses and
conferences but there's nothing specific here.'' P6, nurse, manager

There were challenges in delivering hospital-based education including
multi-level learning needs, competing mandatory training, limited
education time, high staff numbers and turnover, and the limited value
of traditional `in-service' approaches for complex education and skills
training. External agencies provided some educational opportunities, but
there was a need for continuing support and `hands-on' training,
particularly in caring for people with cognitive impairment.

``If the skill mix is poor and you haven't got those other people with
experience, then how do you actually get that?'' P13, nurse, clinician
``It's educating staff\ldots{} coaching them and mentoring them is the
difference. It's constant follow-up. All this in-service and interest
groups and stuff like that, it's great. It's not enough. It's not enough
to create change and keep motivating people.'' P16, nurse, clinician

\emph{Invest in implementing and monitoring evidence-based practices}

Evidence-based practices (EBP) to achieve better outcomes for older
people were well recognised, but poorly translated into practice.
Barriers included lack of staff knowledge, lack of prioritisation by
teaching and service organisations, resistance to change, and lack of
investment in implementation and change management methods.

``It was interesting hearing all the research out there and all the
money that's been invested into research. It stops there and that's the
thing. There is so much stuff out there saying how we should be doing
things. Then the next step is investing into implementing into
practice.'' P16, nurse, clinician

Translational efforts included credible experts from other
organisations, local adaptation of guidelines and standardised orders,
education and mentoring, and local data to prioritise issues and
highlight gaps in EBP. These efforts were driven largely by informal
leaders. Progress required champions willing to change practice, and
continuing support and monitoring within the local context.

``I think in {[}ward name{]} the model works better because they've got
such passionate and enthusiastic staff so they're actually wanting to
change the culture of how they care for older people.'' P19,
geriatrician, clinician ``I think people {[}staff{]} will fall unless we
really monitor, I think they'll fall back to their old pattern.'' P2,
nurse, manager

Although several respondents appeared confident that organisational
audits, incident monitoring and benchmarking processes provided
appropriate data for monitoring care and outcomes of older patients,
others were sceptical about data quality and use, and identified a lack
of age-stratified reporting. They articulated that investment in
targeted measurement was essential, needing staff with skills and
dedicated time for reliable data collection and interpretation.

``They'd tell you how wonderful all their data is and how they collect
all this data. To me it's all smoke and mirrors. It's a bit like quality
and safety data\ldots{} there's not a lot of rigour in how it's
collected.'' P12, nurse, academic

\emph{Value care of older people}

Most respondents believed that staffing and resourcing to support care
of older people was inadequate, because it was a low organisational
priority. The powerful competing demand of throughput, with an emphasis
on emergency department wait times, length of stay and patient
discharge, was a major disincentive to person-centred and
quality-focussed resource allocation. At the same time, care for older
people was reported as more difficult and complex, requiring more
resources and disrupting task-driven care pathways. This created
challenges articulating the value proposition for investing in care of
older people.

``Everything's about NEAT {[}National Emergency Access Targets{]}. They
don't realise that it's actually what happens in between that effects
NEAT'' P19, geriatrician, clinician ``The problem is that {[}geriatric
interventions{]} are often quite expensive and how do we make them cost
effective and show our bean counters that they're actually of value?''
P6, nurse, manager

Many respondents felt they were constantly arguing for resources for
older patients, which were often secured in an ad hoc manner.
Participants attributed successes to networking with other champions to
pool resources and energy, and alignment with accreditation standards or
other strategic policy. The consumer highlighted the under-utilised
influence of politically aware older consumers.

``{[}Older consumers{]} are the guys that have the money, we've got the
influence, and there's lots of us, and we're just starting to wake up to
the fact that we've got to start making things a lot better for
ourselves.'' P7, consumer

DISCUSSION

Using in-depth interviews with key informants, we propose an
action-focussed model for hospitals to improve the experience and
outcomes of older people (figure 1). This model emphasises intersections
between how older patients and families are seen and involved in care,
how staff are trained and connected, and how the care environment is
created. Our respondents highlighted substantial challenges and
opportunities in leadership, workforce development, and implementation
of EBP required to support these elements, and combat an ageist and
efficiency-driven culture.

The central importance of patient and family involvement supports and
extends previous OPFH frameworks (table 1). Engagement must go beyond
eliciting patient preferences and sharing information with
families\textsuperscript{9,10}, to valuing older patients and their
families as legitimate partners in care decisions and
provision\textsuperscript{17}. This is congruent with a systematic
review of acute care experiences from the perspective of hospitalised
older people and their carers\textsuperscript{18}, which concluded that
genuine engagement requires recognition, reciprocity, and involvement.

Previous frameworks have recognised the need for staff geriatric
competencies, but our study indicates that compassion and teamwork are
essential to complement geriatric knowledge, and require experiential
learning. Consistent with other reports \textsuperscript{19,20}, our
respondents reported lack of dedicated gerontology teaching time, and
lack of expert teachers and mentors in undergraduate and graduate
training across all disciplines. They identified that traditional
teaching methods must be supported by opportunities for
interdisciplinary training, and positive mentored experiences to
demonstrate skills and values in practice. Creating such opportunities
will require leadership\textsuperscript{11} and cooperation between
education and health care sectors to prioritise gerontology curriculum
and support effective mentors.

Respondents recognised the central importance of geriatric care
principles (e.g. comprehensive risk assessment linked to integrated
multi-disciplinary care planning) and how teamwork and the physical care
environment could enhance or challenge delivery of this evidence-based
care\textsuperscript{7,10}. Many respondents were frustrated by
perceived failure to translate EBP into everyday practice. This
challenge has been recognised internationally, with poor uptake of
effective demonstration models into other settings \textsuperscript{3}.
Effective implementation of EBP for older people requires leadership
support \textsuperscript{21} but our findings illustrate the complexity
of providing leadership in a system traditionally organised along
disciplines and organ-based specialties. This leads to reliance on
motivated individuals forced to build their own skills and networks.
Strategic collaborations which empower and connect these individuals,
encourage cross-disciplinary partnership, create legitimate capacity for
role modelling for other staff, and advocate for investment in
implementation of EBP could enhance organisational capability in care of
older people. Robust systems for measuring and monitoring outcomes would
support visibility and facilitate improvements\textsuperscript{7}.

Our three key enablers of leadership, training and investment (Figure 1)
are similar to the concepts of authority, awareness and resources
identified in a review of successful dementia-friendly hospital
practices \textsuperscript{22}. Clearly identifying the value of caring
for older people in hospital is essential to activate these enablers,
but remains challenging in a context which prioritises efficiency and
throughput \textsuperscript{23}. In a time-driven system, staff can feel
helpless and frustrated by complex care needs (e.g. due to cognitive
impairment or disease complexity), and older patients can become
isolated and ignored. Powerful social discourses about ageing support
this behaviour \textsuperscript{6}. Our respondents recognised that
these additional needs could not be convincingly framed within the
prevailing efficiency paradigm, and that progress requires aligning with
other powerful policy incentives such as quality standards and consumer
expectations. Strong collaboration with older consumers, reliable data
for monitoring outcomes and benefits, and networking between champions
and policy and practice leaders are potential strategies to shape a
persuasive case for the OPFH\textsuperscript{10}. Careful selection of
communication strategies is critical to ensure thoughtful discourse and
avoid perpetuating ageist and negative stereotypes of health system
``burden'' rather than recognition of legitimate and specific healthcare
needs \textsuperscript{24,25}.

Strengths of our study include a multidisciplinary steering group and
diverse respondents from varied setting and disciplines. Informants
engaged enthusiastically and provided a comprehensive view from multiple
perspectives. Internal and external validity were supported by several
researchers coding and checking themes, member checking with
participants, and discussion with expert groups from inside and outside
the participating organisations. Our hybrid approach using a recognised
implementation framework helped us move beyond descriptions to
actionable themes to inform improvement. We also recognise some
limitations. Participants for this study were deliberately selected as
knowledgeable advocates for older person care, who may not recognise
barriers and enablers experienced by other staff and consumers. Despite
a diversity of disciplinary and practice backgrounds, most participants
were female. The stimulus (survey report) provided to frame interviews,
and snowball methods of recruitment, mean that participants may have
been aware of the perspectives of the research team, which may have
influenced their responses. Pragmatic constraints on sample size mean we
cannot be certain that data saturation was reached, although consistent
themes were voiced across diverse settings and disciplines. Our settings
were metropolitan, and we did not sample policy makers, which may have
under-represented codes related to the outer setting. We only had one
consumer representative participant, but other participants drew on
their personal consumer and carer experiences, and findings are
congruent with studies of consumer and care
perspectives\textsuperscript{18,23}.

Our findings inform actionable opportunities for clinicians, managers,
consumers, academics and policy makers to work together to create
hospitals which value care of the older person. Universities and
training institutions should encourage access to gerontology curricula
for all disciplines, and collaborate with services to provide mentored
training experiences and practice teamwork skills. Clinicians and
consumers must identify ways to engage older people and their families
respectfully and meaningfully in care, and advocate for EBP. Hospital
managers should recognise and promote local champions as key resources
for training and translation, and invest in interdisciplinary teams and
EBP, with age-stratified measurement of outcomes to monitor
effectiveness. Policy makers must recognise that prioritising efficiency
can create perverse cultural incentives with serious consequences for
vulnerable older patients. Researchers can work collaboratively with all
stakeholders to identify effective leadership structures for OPFH,
implement EBP at scale, and validate reliable, feasible and responsive
measures of care and outcomes that matter to older patients. Multi-level
collaborative leadership is required to challenge ageism and truly value
older people if we are to deliver OPFH.

ACKNOWLEDGEMENTS:

This work was supported by a Strategic Research Grant from Brisbane
Diamantina Health Partners. The authors acknowledge Professor Len Gray
and Professor Elizabeth Beattie for their contribution to the project
expert reference group.

DECLARATION OF CONFLICT OF INTEREST:

The authors have no conflict of interest to declare

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Table 1: Examples of previously described older person friendly hospital
(OPFH) frameworks, including definitions and key constructs\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Definition of OPFH (country)\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Key constructs of OPFH framework\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
``An age-friendly hospital is a hospital promoting health, dignity and
participation of persons of older ages'' \textsuperscript{8}
(Taiwan)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Management policies Communication and services Physical environment Care
processes\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
``Core components of a system-wide, acute care program designed to meet
the needs of older adults'' \textsuperscript{7} (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Guiding principles Leadership Patient- and family-centred approaches
Geriatric staff competencies Interdisciplinary resources and processes
Aging-sensitive practices Organisational structures Physical
environment\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
``To promote excellence in hospital care for acutely ill older adults
through the provision of evidence-based service delivery and
patient-family focussed care\ldots{}'' \textsuperscript{10}
(Canada)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
A favourable physical environment Zero tolerance towards ageism at all
organisational levels Comprehensive services using principles of the
geriatric approach Assistance with appropriate decision-making Fostering
links between the acute care hospital and the community\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
``An evidence-informed framework applied organization-wide to help
hospitals achieve better outcomes for frail
seniors''\textsuperscript{11} (Canada)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Organizational support Emotional and behavioural environment Processes
of care Ethics in clinical care and research Physical environment\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
``An age-friendly health system is based on patients' goals and values,
and on improved outcomes and lower costs of care within the walls of the
hospital and beyond'' \textsuperscript{9} (USA)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Leadership committed to addressing ageism A strategy to identify,
coordinate with and support family caregivers A clear process for
eliciting patient goals and preferences Clinical staff specifically
trained in expert care of older adults Care teams that are high
performing and can show measurable results for care of older adults A
geriatric care prototype specific to older adults A systematic approach
for coordinating care with organizations beyond the walls of the
hospital\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 2. Summary of findings from previous state-wide survey of older
person friendly care\textsuperscript{12}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.48\columnwidth}\raggedright\strut
Clinical and executive leadership\strut
\end{minipage} & \begin{minipage}[b]{0.48\columnwidth}\raggedright\strut
Developing clinical leadership Limited executive leadership Limited
coordination (e.g. planning, monitoring, linkages)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Respected and involved consumers\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Established systems for protecting decision making and advance care
planning Limited involvement of older person in care planning and
feedback\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Skilled and compassionate staff\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Limited training of hospital staff in care of older people Limited
graduate education across all disciplines\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Evidence-based assessment and management\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Established systems for recognising and preventing pressure injuries,
falls, adverse drug reactions and malnutrition Developing systems for
integrated assessment, care planning and discharge planning Limited
systems for recognising and preventing functional decline and
delirium\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Connected systems\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Established systems for referral to subacute and post-acute care Poor
communication between emergency department and residential care
facilities\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Well-designed physical environments\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Developing use of older person friendly design principles in specialist
units Limited use at organisational level\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 3. Analytical Framework based on the
\emph{PARIHS}framework\textsuperscript{14,15}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Codes & Explanatory Notes\tabularnewline
\midrule
\endhead
\textbf{Evidence} & \textbf{Evidence}\tabularnewline
Clinical experience and local information & Experience of individuals,
teams, services that influences decision making; outlook to other
service models/initiatives\tabularnewline
Patient experience & Patient or family engagement in service delivery or
design (formal or informal)\tabularnewline
Research & Research evidence (e.g. papers, guidelines, conferences),
data sources or processes (e.g. local or state-wide databases, audits),
evaluation of service delivery\tabularnewline
\textbf{Recipients} & \textbf{Recipients}\tabularnewline
Capability & Knowledge, skills, memory, attention and decision
processes, behavioural regulation\tabularnewline
Motivation & Social/professional role and identity, values, beliefs
about capabilities, optimism, beliefs about consequences, intentions,
goals, reinforcement, emotion\tabularnewline
\textbf{Inner Context (ward and organisation)} & \textbf{Inner Context
(ward and organisation)}\tabularnewline
Adequate resources\textsuperscript{1} & Time, personnel, equipment,
education materials\tabularnewline
Culture & Specific to care of older people and factors influencing this
(e.g. teamwork, interdisciplinary care, innovation), ward/service
line/organisation level\tabularnewline
Experience with change & Past implementation/change experiences:
positive/ negative, factors associated with success/
failure\tabularnewline
Leadership & Formal and informal leaders, ward/service line/executive,
across disciplines\tabularnewline
Organisational priorities & Specific to care of older people and factors
influencing this (e.g. teamwork, interdisciplinary care,
innovation)\tabularnewline
Structure & Hospital organisational structure (reporting, governance,
service lines), physical structure (physical space, layout of
wards/hospital), structure of university courses and
curriculum,\tabularnewline
Systems and processes & Models of care, processes for screening,
referral, discharge planning, communication processes,\tabularnewline
\textbf{Outer context (health service district, state, national)} &
\textbf{Outer context (health service district, state,
national)}\tabularnewline
Environmental (in)stability & Change in political or social environment
which may affect older people and/or health care\tabularnewline
Incentives and mandates & External funding, restrictions,\tabularnewline
Policy drivers, priorities & Broad political agenda relating to older
people and/or health care\tabularnewline
Inter-organisational networks and relationships & Networks and
relationships with community (aged care, GPs, community service
providers), universities, other health care organisations\tabularnewline
Regulatory frameworks & Health care (i.e. accreditation standards) and
university (i.e. competency standards for new graduates)\tabularnewline
Society values and expectations\textsuperscript{1} & Society perceptions
related older people and/or health care\tabularnewline
\bottomrule
\end{longtable}

\textsuperscript{1}these codes were generated inductively from the
interview data

Table 4 Characteristics of interview participants. Position and
workplace were the primary setting identified by the participant; four
participants identified themselves as academics and clinicians with
joint positions between the university and health service.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
& n (\%)\tabularnewline
\midrule
\endhead
\vtop{\hbox{\strut Position
Clinician}\hbox{\strut Academic}\hbox{\strut Manager}\hbox{\strut Consumer
representative}} & 8 (40) 7 (35) 4 (20) 1 (5)\tabularnewline
\vtop{\hbox{\strut Discipline Nurse}\hbox{\strut Allied health
professional}\hbox{\strut Geriatrician}\hbox{\strut Consumer}} & 10 (50)
5 (25) 4 (20) 1 (5)\tabularnewline
\vtop{\hbox{\strut Workplace Health service 1}\hbox{\strut Health
service 2}\hbox{\strut University 1}\hbox{\strut University 2}} & 10
(50) 5 (25) 3 (15) 2 (10)\tabularnewline
\vtop{\hbox{\strut Gender Female}\hbox{\strut Male}} & 16 (80) 4
(20)\tabularnewline
\bottomrule
\end{longtable}

Figure 1. The older person friendly hospital (OPFH): summary of
interview themes. Interlocking circular rings represent the central
elements of high quality OPFH, ovals represent system enablers, and the
rectangle represents the foundation value underpinning all other system
enablers.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/OPFH-figure-1-updated-2020-july/OPFH-figure-1-updated-2020-july}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

