Elsevier

Collegian

Volume 25, Issue 4, August 2018, Pages 377-383
Collegian

The ‘unworthy’ patient with dementia in geriatric rehabilitation hospitals

https://doi.org/10.1016/j.colegn.2017.10.002Get rights and content

Abstract

Background

The number of people presenting to hospital with dementia is escalating worldwide. Hospitals are inadequately prepared leading to a poor patient experience.

Aim

To explore the perspectives of nurses caring for people with dementia to critically evaluate the reasons behind the widely reported poor care received by such patients. The study examined what was privileged in the care of patients with dementia in geriatric rehabilitation facilities.

Method

The study used critical ethnography. Data were obtained from interviews with 29 nurses working with patients with dementia in geriatric rehabilitation hospitals. The interviews were audio-recorded and transcribed verbatim.

Findings

The theme of the ‘unworthy’ patient was supported by sub-themes of people with dementia and hospital performance targets, risk, nurse workload and acute care issues.

Discussion

Hospitals have increasing pressure to conform to tight budgets and must justify all expenditure, increase patient throughput and minimise risk. Patients with dementia can have a longer hospital stay complicated by frailty, complications and social problems. The focus on rapid discharge influences the mind-set of nurses and nurse habitus. Patients with multiple chronic co-morbidities are unpopular and considered low priority and less worthy of resources. Privileging care for certain patients and tasks is supported by organisational cultural beliefs. Nurses require support to maintain empathetic caring practices in the face of managerial priorities.

Conclusion

The research found that patients with dementia were considered unworthy in the geriatric rehabilitation hospital setting. The difficulties caring for patients with dementia are considerable. Nurses need education and support to improve practice.

Introduction

Globally there has been an increase in the number of people who have dementia, which is a phenomenon related to the advancing age of the population and the subsequent rise in chronic diseases (Knapp et al., 2007). It is estimated that approximately 35.6 million people across the world currently have dementia and the rate of diagnosis is accelerating, with 7.7 million new cases identified each year (WHO, 2012). In Australia it is estimated that at least 354,000 people currently have dementia although this is a conservative approximation as dementia is often unrecognised or under-reported (Australian Institute of Health and Welfare, 2016). As a consequence, the number of people presenting to hospital with dementia as a comorbidity is escalating worldwide; however it has been demonstrated that hospitals are inadequately prepared (Prince et al., 2015). To date, addressing the specific needs of people with dementia which are related to cognition have not been a high priority of hospitals however since the turn of the century a greater focus has been directed to dementia in the United Kingdom, Scandinavia and parts of Europe (Alzheimer Europe, 2014). In Australia, clinical practice guidelines have recently be released which aim to improve the quality and consistency of care in community, residential and hospital settings (Laver et al., 2016).

The economic burden of caring for people with dementia in the community, in institutional care and in hospital is enormous with an annual worldwide cost estimated in 2012 to be US$ 604 billion (WHO, 2012). Cost containment is a priority both globally and in Australian hospitals, where expenditure is closely monitored to ensure that maximum benefit is provided to the community (Adams & Nelson, 2009). The valid concern about the cost of hospital care has led to an intense focus on efficient service management, with the aim of reducing risk to patients, staff and the public, and at the same time increasing patient turnover, maintaining occupancy targets and adhering to budgets (Sorensen, Paull, Magann, & Davis, 2013). However this focus has had consequences for the nurse-patient relationship which is based on caring and does not readily adapt to the rapid movement of patients through the system. People with dementia require time and nursing resources which may not be adequately provided in this fast-paced environment. Hospitals often do not provide additional resources to support nurses when there is an increase in the workload related to the cognition of the patients, leaving the nurses ill-equipped and compromising care (Edberg, Anderson, Orrung Wallin, & Bird, 2015; Sanchez, Mahmoudi, Moronne, Camonin, & Novella, 2015). There is a dichotomy between what is affordable in these circumstances and what is required by patients with dementia and the nurses caring for them.

This paper examines the findings of a study indicating that nurses view some patients are more deserving of resources, or more worthy, than others and the underlying issues which have led to this devaluation of people with dementia in hospital.

The purpose of the study was to explore the perspectives of nurses caring for people with dementia to critically evaluate the reasons behind the widely reported poor care received by such patients. The study examined what was privileged in the hospital care of patients with dementia in geriatric rehabilitation facilities.

Section snippets

Study design

A qualitative design makes it possible to form an understanding of the way that people recognize and construct meaning in their world (Liamputtong & Ezzy, 2005). In this study the experiences of nurses caring for patients with dementia in geriatric rehabilitation hospitals were investigated using critical ethnography in order to build a cultural critique of the contributing forces which shaped care. Ethnography shares epistemological foundations with constructionism in which people create

Results

A major theme identified during analysis of the data was the ‘unworthy' patient. The focus of this paper is the nurses’ perspective on patients with dementia who were deemed less worthy of care and resources than others. Sub-themes include people with dementia and hospital performance targets, risk, nurse workload and acute care issues.

Discussion

The nurses faced considerable challenges in managing care with the time and resources allocated to them. The privileging of certain patients and tasks was a highly subjective process and could be related to the concept of worthiness; nonetheless the nurses must inevitably make choices in providing care because of the increasing workload. Making decisions about what nursing duties received priority could easily become judgemental and hamper the nurses in a core part of their role which is to

Conclusion

This research provided insight into the reasons behind the sub-optimal care and outcomes experienced by people with dementia in geriatric rehabilitation hospitals. The nurses in this critical ethnographic study displayed a number of attitudes towards the patients which were influenced by the culture of budgetary restraint and risk mitigation which dominates Australian health services. The habitus which was engendered by the focus on rapid discharge influenced nurses to see the patient with

Conflict of Interest

There are no conflicts of interest.

Acknowledgments

Robin Digby acknowledges the support of Monash University Maxwell King PhD scholarship and Postgraduate Publications Award and wishes to thank the hospitals and nurses who participated in this research.

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