Beaver, Jessica
(2021)
An exploration of older people who ‘call out’ repetitively in the acute hospital.
PhD thesis, University of Nottingham.
Abstract
Background
On acute Medicine for Older People hospital wards, staff often care for patients with cognitive impairment who ‘call out’ repetitively. This behaviour, combined with acute hospital admission and busy, unfamiliar staff, can cause serious effects on the quality of care provided for people who call out. Little is currently known about knowledge or beliefs surrounding this behaviour, and how hospital staff and carers respond to it.
Aim
The aim of this study was to explore calling out in the context of the acute hospital. This involved describing calling out, the people who display it (in hospital and after discharge), the way in which others react and respond to it, and people’s knowledge, beliefs, and experiences of calling out.
Method
An ethnographic case-series study was conducted across ten Medicine for Older People wards on two acute hospital sites. This utilised structured and unstructured observations of people who call out repetitively, and records of medical and nursing documentation. Baseline and ongoing measures of calling out, cognitive ability, activities of daily living, pain, depression, and behavioural and psychological symptoms of dementia were undertaken. Semi-structured interviews were conducted with patient participant’s relatives, and hospital staff members. Qualitative and quantitative data were analysed using inductive thematic analysis, and descriptive statistics.
Results
Thirty patient participants were recruited into the study. They scored highly for frequency and severity of calling out. They had poor mobility and functional ability, severe cognitive impairment, and were likely to have delirium. Most were in mild to moderate pain. Most displayed depression, agitation/aggression, anxiety, and apathy. Average length of stay was two and a half times more than for older patients in the United Kingdom in general. A third died within the three-month participation period.55% of the remaining patient participants were readmitted into hospital. Patient participants were described or observed exhibiting other challenging behaviours alongside their calling out, such as physical aggression. Calling out was considered by relatives and staff members to be often due to the presence of an unmet need. Many needs were identified, relating to medical and functional biological needs, mental distress, and social relationship needs. However, uninterpretable needs, and the concept of a patient participant having “no needs” also arose, causing staff to sometimes feel that no intervention was required. Many interventions were observed or discussed by staff or relatives. These were pharmacological (analgesia and psychotropic medication, including sedation) and non-pharmacological (activity, verbal distraction, reassurance, re-orientation, physical comfort, and environment). Barriers to intervention included the context of the acute hospital, staff knowledge and attitudes, and availability of individual patient information.
Conclusions
These findings allow for the better understanding of the cognitive and functional abilities of people who call out repetitively within the acute hospital, and provide a detailed description of the ‘problem’ of calling out. The study was feasible to conduct in terms of participation and retention rates; however, new or adapted measures for calling out are required, to be able to detect more subtle and immediate changes in calling out, should an intervention study be conducted
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