Research paper
Emergency nurses’ knowledge and self-rated practice skills when caring for older patients in the Emergency Department

https://doi.org/10.1016/j.aenj.2017.08.001Get rights and content

Abstract

Background

Older adults are high users of emergency department services and their care requirements can present challenges for emergency nurses. Although clinical outcomes for older patients improve when they are cared for by nurses with specialist training, emergency nurses’ knowledge and self-assessment of care for older patients is poorly understood.

Aim

To assess emergency nurses’ knowledge and self-rating of practice when caring for older patients.

Methods

A cross-sectional self-report survey of emergency nurses (n = 101) in Melbourne, Australia.

Results

Mean scores were 12.7 (SD 2.66) for the 25-item knowledge of older persons questionnaire, and 9.04 (SD 1.80) for the 15-item gerontic health related questions. Scores were unaffected by years of experience as a registered nurse or emergency nurse. More than 80% of nurses rated themselves as ‘very good’ or ‘good’ in assessing pain (94.9%), identifying delirium (87.8%), and identifying dementia (82.8%). Areas with a ‘poor’ ratings were identifying depression (46.5%), assessing polypharmacy (46.5%) and assessing nutrition (37.8%).

Conclusions

There was variation in knowledge and self-rating of practice related to care of older patients. The relationship between knowledge and self-ratings of practice in relation to actual emergency nursing care of older people and patient outcomes warrants further exploration.

Introduction

The projected increase in the number of persons ≥65 years in most developed countries is well documented [1], [2], [3] and accordingly demand for emergency healthcare amongst older persons is increasing [4], [5]. As experienced internationally, Australia’s ageing population has prompted the need to focus attention on how healthcare is delivered to older emergency department (ED) users [6], [7]. Older persons ≥65 years in Australia are high users of ED services, representing approximately 20% of ED presentations, and are more likely to be admitted to hospital or have repeated ED visits [2], [4], [5], [8], [9], [10]. As separate specialities, emergency nursing and gerontic nursing are complex and require highly specialised skills and knowledge. Emergency department care of older patients combines these two complex specialties in order to provide optimum emergency care to a vulnerable population. Compared to younger patients, older ED users and particularly ‘frail’ older patients (80+ years [11]), can have chronic and complex conditions, multifaceted healthcare needs [2], [12], are more often acutely ill on presentation [4], [5], [13], have longer lengths of stay in the ED [6], [14] and have increased rates of adverse outcomes post ED discharge [2], [5]. Therefore, older ED users require increased nursing resources, in particular time and specialised knowledge [12]. However, essential care needs for older patients are not always adequately managed within the unique context of the ED environment [7], [15].

Models of care that are not compatible with the needs of older patients can have an impact on older ED users as well as staff that deliver care [16], [17]. The provision of safe and quality care for older patients in the ED is a key concern for nurses [18], [19], [20], and requires emergency nurses to be informed, educated and supported to deliver interventions and use models of care demonstrated to be beneficial for older patients [20], [21]. Clinical outcomes for older patients improve when they are cared for by nurses with specialised training [19], [22], and staff knowledge is seen as important for improvements in older patients’ care [21], [22], [23], [24], [25].

A literature review highlighted that emergency nurses’ knowledge and attitudes were major influences on the therapeutic interaction between nurses and older ED patients [17]. However, there is a dearth of literature on emergency nurses’ gerontic knowledge and their perceptions of care delivery for older patients.

Section snippets

Aims

As part of a wider study we explored how emergency nurses manage the care of older patients in the ED. In this paper we focus on the outcomes of a survey to assess emergency nurses’ gerontic knowledge and their self-rated assessment of practice in delivering care to older patients in the ED.

Design

A cross-sectional self-report study design was used.

Setting

The study was conducted at three EDs in public hospitals in Melbourne, Australia. In 2013/2014 annual presentations in these EDs were approximately 200,000 and older persons aged 65 years and over comprised 18% of these presentations.

Data collection tool

Data were collected using a paper based 59-item questionnaire consisting of three sections: a) knowledge of older adults and ageing; b) gerontic health related questions; and c) self-rated practice assessment.

Participant characteristics

There were 101 participants and their characteristics are summarised in Table 1. Most participants were RNs (73.0%, n = 74), and approximately one-third of RNs (32.4%, n = 24) were working in senior clinical, education or management roles. The low number of EN participants (2.9%, n = 3) was consistent with the small number of ENs that worked in the three EDs. All participants had over five year’s clinical experience. Approximately 41% (n = 41) had a postgraduate qualification and the highest education

Discussion

This study had three key findings: i) there was variation in knowledge about older persons; ii) there was variation in participants’ self-rating of practice in caring for older patients and; iii) there was a lack of congruency between self-rating of practice and knowledge of some aspects of older patients’ care. Previous investigations into gerontic knowledge of acute care nurses, including emergency nurses, found significant gaps [17], [22], [31], [32], [34]. However, the mean percentage of

Conclusion

Emergency nurses provide care to large numbers of ED users of all ages in a complex environment. The provision of evidence-based, age-appropriate care for older patients in the ED is an essential part of meeting the health needs of an ageing population. Ensuring that emergency nurses are able to appropriately meet the care needs of this growing and increasingly complex population in the ED is a key imperative in improving healthcare for older patients. High quality emergency care for older

Author contributions

HR, PB and JC conceived and designed the study. HR and JC conducted the literature review. HR collected the data. HR, CO and JC analysed the data. HR, AMH and JC prepared the manuscript. HR, PB, CO, AMH and JC critically revised and edited the manuscript draft prior to submission.

Funding

This study was funded by a grant from the Centre for Quality and Patient Safety Research (QPS), Deakin University.

Role of funding source

The funding body were not involved in any aspect of the research including design, analysis, and contents of this manuscript, or the decision regarding where to publish.

Provenance and conflicts of interest

No authors have any conflicts of interest or provenance issues to declare. Professor Julie Considine is a Deputy Editor of the Australasian Emergency Nursing Journal but had no role in the peer review and editorial or decision-making process. This paper was not commissioned.

Acknowledgements

The development of this research was supported by a competitive grant from the Centre for Quality and Patient Safety Research (QPS), Deakin University. Our sincerest thanks to the health service and staff of the emergency departments, and Research Assistants Catherine Au and Tania Cossich.

References (52)

  • K.H. Todd et al.

    Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study

    J Pain

    (2007)
  • M. Palonen et al.

    Discharge education for older people and family members in emergency department: a cross-sectional study

    Int Emerg Nurs

    (2015)
  • C. Shanley et al.

    Caring for the older person in the emergency department: the ASET program and the role of the ASET clinical nurse consultant in South Western Sydney, Australia

    J Emerg Nurs

    (2009)
  • G. Arendts et al.

    Demography is destiny: an agenda for geriatric emergency medicine in Australasia

    Emerg Med Australas

    (2013)
  • 3222.0–Population Projections, Australia, 2012 (base) to 2101

    (2013)
  • C. Leonard et al.

    Demand for emergency department services in the elderly: an 11 year analysis of the Greater Sydney Area

    Emerg Med Australas

    (2014)
  • J.A. Lowthian et al.

    Demand at the emergency department front door: 10-year trends in presentations

    Med J Aust

    (2012)
  • M. Boltz et al.

    Care of the older adult in the emergency department: nurses views of the pressing issues

    Gerontologist

    (2013)
  • K.N. Shankar et al.

    Toward patient-centered care: a systematic review of older adults' views of quality emergency care

    Ann Emerg Med

    (2014)
  • D. Markham et al.

    Characteristics of frequent emergency department presenters to an Australian emergency medicine network

    BMC Emerg Med

    (2011)
  • M. Fry et al.

    Emergency department utilisation among older people with acute and/or chronic conditions: a multi-centre retrospective study

    Int Emerg Nurs

    (2016)
  • Australian Institute of Health Welfare

    Emergency department care 2015-16: Australian hospital statistics

    (2016)
  • C. Ferguson et al.

    Operationalising frailty definitions in the emergency department: a mapping exercise

    J Nutr Health Aging

    (2009)
  • A. Banerjee et al.

    The impact of very old patients in the ED

    Br J Healthc Manag

    (2011)
  • Johanna Briggs Institute

    Age-friendly nursing interventions in the management of older people in emergency departments

    Nurs Health Sci

    (2012)
  • M. Boltz et al.

    Hospital nurses' perception of the geriatric nurse practice environment

    J Nurs Scholarsh

    (2008)
  • Cited by (9)

    • Impact of emergency department length of stay on anxiety and comfort in older people

      2021, International Emergency Nursing
      Citation Excerpt :

      Being in the ED may be particularly distressing and anxiety provoking for older people who are more likely to have a longer ED stay [9,10], and more frequently have diagnostic imaging and pathology testing [13] than younger patients. Older ED users are a vulnerable population with complex healthcare needs and they are highly reliant on ED clinicians to ensure their emergency care is safe [28]. Older ED users are more likely to have cognitive impairment, anxiety, depression [29], and are at risk of unrecognised functional decline, cognitive impairment and delirium [11,30].

    • Knowledge, attitudes, clinical practice and perceived barriers with nutrition support among physicians and nurses in the emergency department: A national cross-sectional survey

      2021, International Emergency Nursing
      Citation Excerpt :

      This study found that a higher level of knowledge in nutrition support was evident in physicians and nurses who: worked in a higher level of hospital (i.e. tertiary hospital versus community hospital), were older in age, had more years of employment, employed as physician rather than nurse, had a higher education background, higher professional title, and had received some form of training through a nutrition related program. These findings differ, in part, to other research undertaken in three public hospital EDs in Australia where nutrition knowledge level among emergency nurses did not differ based on years of work experience and education level [24]. This discrepancy could be due to the nature of education delivery in Chinese EDs where staff may obtain nutritional education through their time working clinically rather than via formal educational opportunities [16].

    • Consensus-based clinical research priorities for emergency nursing in Australia

      2018, Australasian Emergency Care
      Citation Excerpt :

      These patient groups can be some of the most challenging to provide care for, and as such innovative, evidence informed ways to deliver safe, effective and holistic care is needed. Care of vulnerable populations is a defining feature of emergency nurses [49–51] and in Australia, emergency nurses are mandated to providing care for all Australians, irrespective of age, socio-economic status, or healthcare requirements [52]. Moreover, emergency nurses across Australia, and indeed elsewhere, have formal legal, professional and ethical obligation to care and advocate for vulnerable groups [53,54].

    View all citing articles on Scopus
    View full text