Improving the quality and safety of hospital care for older people, focusing on two geriatric syndromes: falls and pain

<p dir="ltr"><b>Background</b> In recent years, there has been an increase in the use of hospital services by older people. One in nine Australians visiting hospitals experience complications; this increases to one in four for those staying overnight. The increased vulnerability experienced by older people poses considerable challenges in their care, making some of them more susceptible to complications known as geriatric syndromes; for example, falls, delirium, and pain, all of which discernibly impacts the quality and safety of care and increases the risk of adverse outcomes. Falls are a major concern, accounting for 40% of injuries in acute care settings, despite preventive strategies. Similarly, pain is often under-recognised and undertreated, especially in older people with cognitive impairment.</p><p dir="ltr"><b>The Overall Aim of this PhD</b> This PhD aimed to improve the quality of care and safety of older people in acute care by addressing these two key issues: falls in older people and pain in older people with cognitive impairment. This PhD was conducted in the specific context of a hospital within a local health district in New South Wales (NSW), Australia.</p><p dir="ltr"><b>Specific Aims of the Two Studies</b><b><i> </i></b><b><i>Study 1:</i></b> This study aimed to explore nurses’ and patients’ perceptions of falls using a reflective model chosen by the nurses and to identify strategies to reduce falls among older people on the participating wards. <b><i>Study 2: </i></b>The aim of this study was to improve the assessment and management of pain in older people with cognitive impairment on the participating wards.</p><p dir="ltr"><b>Methods</b> The overarching methodology of this PhD was action research (AR). Study 1 employed a participatory action research (PAR) approach and involved quantitative and qualitative data collection and analysis. It comprised four phases, and two PAR cycles, with quantitative data on the number of falls and qualitative data gathered through focus groups and reflections from staff and patients. Information from the first phase informed the subsequent phase, fostering collaboration between nurses and patients to develop innovative preventive strategies. These solutions were then implemented and evaluated in conjunction with the participating ward staff.</p><p dir="ltr">Study 2 used AR and was guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, which is characterised by four primary constructs: facilitation, innovation, recipients, and context. Evidence was collected through audits, a knowledge survey, and focus groups conducted in participating wards. The data were analysed and collated according to the specific context of each ward. Facilitation played an instrumental role, an evidence-based educational intervention based on feedback from the nurses, and co-designed solutions were developed to enhance pain assessment and management in older people. These were then implemented and evaluated to enhance pain assessment and management.</p><p dir="ltr"><b>Findings</b> In Study 1, qualitative findings revealed key themes: "It was out of my control," "Falls could have been prevented," and "It was very sad" (Nurses); and "I thought I will be fine," "No one came for a long time," "I fell because...," "You can help me," and "I was hurt" (Patients). In cycle 1, initial interventions reduced falls rates in all wards, although the effects varied. Ward A showed notable decreases followed by a slight increase, Ward B consistently maintained the lowest rates, and Ward C showed fluctuating but reduced rates. In cycle 2, Ward A and Ward B demonstrated promising initial decreases, with slight increases in post-intervention, while Ward C had the highest and most variable rates. Fall-related injuries were minimal and stable across both cycles, with no deaths reported.</p><p dir="ltr">In alignment with the i-PARIHS framework, Study 2 underscored the significance of innovation, recipients, context, and facilitation in driving positive change among nurses. Data from audits, knowledge surveys and focus groups spotlighted the pivotal role of facilitation in the success of an educational intervention. Qualitative themes highlighted nurses’ perceptions: “inconsistencies in pain assessment and management”, “pain assessment is too hard”, and “ways to improve the pain assessment and management”. Tailored interventions were implemented successfully, e.g., pain champions, and development of a resource manual. This resulted in a considerable increase in the use of behavioural pain assessment tools and administration of analgesics post-assessment. There were notable increases in the nurses' knowledge and confidence in assessing and managing pain in older people with cognitive impairment.</p><p dir="ltr"><b>Conclusion</b> This study highlights the importance of collaborative, educational, and context-focused interventions for addressing falls prevention and pain management. The findings suggest leadership and facilitation are paramount for implementing solutions for these geriatric syndromes. These results can inform future research, clinical practice, and policy development to enhance care quality for older patients in hospital.</p>