Westlake, Meri
(2025)
How do healthcare professionals recognise and respond to Hospital-Acquired Deconditioning?
PhD thesis, University of Nottingham.
Abstract
Background
Hospital-acquired deconditioning (HAD) in adults is associated with increased readmission, extended length of stay, discharge to institutional care, reduced quality of life, and higher ongoing health costs. In the context of quality targets to reduce LOS and to prioritise discharge to usual residence, preventing deconditioning is a regularly cited goal of acute hospital care. However, there is no formally agreed-upon definition of hospital-acquired deconditioning. From this stems a lack of specificity in what clinical presentations indicate that a patient is affected by HAD. This PhD study addresses the gap of what clinical features may constitute a diagnosis of HAD through the exploration of how healthcare professionals recognise and respond to it in adults.
Methods
An exploratory multi-method program was undertaken to develop insight into the recognisable clinical features of HAD and responses to it. A scoping review was used to seek established key characteristics and definitions of HAD. Focus groups, interviews and non-participant observation were used to explore healthcare professionals' experiences of recognising and responding to HAD. Moreover, organisational and environmental factors that may affect the ability of healthcare professionals to recognise and respond to HAD were solicited. Results from these studies were synthesised into a draft process model of the clinical decision-making process. This draft process model was presented to a group of stakeholders and refined using a modified nominal group technique to determine the core signs and symptoms of HAD required for a diagnosis.
Results
Evidence from 103 sources included in the scoping review showed a large and diverse literature base. Key findings included a lack of consistency and clarity on the core features of HAD, suggesting that a common definition of HAD had yet to be established. A qualitative inquiry featuring five focus groups, 18 interviews, and non-participant observations was illustrated using reflexive thematic analysis, which generated the understanding that there were three aspects that shaped the participants' process of recognising and responding to HAD. These were who is recognising and responding, what is being recognised and responded to and the interpretation of the situation. Across these inquiries, it was understood that determining the clinical features of the patient's presentation due to HAD was challenging and highly contextualised. A definition of HAD was derived from the data as an observable (negative) change in a person’s ability to care for themselves that is greater than anticipated. The scoping review and qualitative inquiry findings informed a draft process model, which outlined the potential interaction between HAD symptoms, contributory factors, consequences, and the context. Reviewing this process model in a modified nominal group technique with 10 stakeholders identified that important features of HAD may include greater dependence, impaired mobility, depression, impaired recovery, anxiety, increased fear or heightened sense of danger, weight loss, frailty, impaired personal care, and reduced engagement. Consensus on the definitive clinical features of HAD was not reached. The importance of simplifying the process model for a clinical and patient audience was highlighted.
Conclusion
This thesis has provided an exploration into the nature of the concept of HAD from the perspective of healthcare professionals. This viewpoint has been unrepresented in the evidence. A process model for HAD has been developed with adaptations for clinical and patient audiences. The absence of definitive criteria developed from the work suggests that further research is required to determine HAD's boundaries and clinical features. Alternatively, these findings may indicate that while the perceived outcomes and impact of HAD are important, the terminology of HAD is inappropriate for further inquiries. A third potential is that the fragile nature of the concept of HAD provides insight into the strategies that HCPs engage in to enact change in the current NHS context, affected by austerity-induced resource constraints and the governance of New Public Management.
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