“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, 6th 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 outcomes1,2. Pioneering models of geriatric care can reduce harm and deliver more efficient, patient-centred care for older people 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 4-6.
This challenge led to the concept of the Older Person Friendly Hospital (OPFH), and several authors have proposed supporting frameworks and practices7-11 ( 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 survey11. 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 12.
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 lens13. 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 report12 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 Promoting Action on Research Implementation in Health Services (PARIHS) framework 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 16:
  1. Familiarisation: review of field notes, audio-recording and transcription, noting initial thoughts and impressions
  2. Identifying an analytical framework: pre-defined codes and explanatory notes developed based on PARIHS framework (Table 3).
  3. 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).
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:
Four system enablers were identified to achieve these goals:
The latter enabler underpinned all other elements and enablers, and required challenging an ageist and efficiency-driven culture.