“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:
- Familiarisation: review of field notes, audio-recording and
transcription, noting initial thoughts and impressions
- Identifying an analytical framework: pre-defined codes and explanatory
notes developed based on PARIHS framework (Table 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:
- Older people and their families are recognised and respected
- Skilled compassionate staff work in effective teams
- Care models and environments support older people across the system
Four system enablers were identified to achieve these goals:
- Empower local leadership in older person friendly care
- Train and support a workforce skilled in care of older people
- Invest in implementing and monitoring evidence-based practices
- Value care of older people
The latter enabler underpinned all other elements and enablers, and
required challenging an ageist and efficiency-driven culture.