c Admission to hospital wards

A named nurse
The Charter for patients and clients also states that every patient admitted to hospital should have a named nurse, that is, a particular nurse who is responsible for co-ordinating the patient’s nursing care during the hospital stay (EHSSB, 1999). Almost three-quarters of the patients (44 out of 61) did not have a named nurse when they were in hospital. Previous research carried out in a hospital in Northern Ireland into the care of patients in elderly care and rehabilitation wards also showed that three-quarters of the older patients in their survey did not have a named nurse in hospital (SHSSC, 2002).

Using a patient’s first name or surname
Almost a fifth of the patients (12 out of 56) were asked by the staff if they wanted to be called by a first name or a surname. The National Service Framework states that staff should use the older person’s preferred name (DOH, 2001a).

Involving patients in nursing care plans
Involving patients in developing their care plans (written plans for their nursing care) is helpful to both patients and staff (Davies and others, 1999). However, after admission to hospital, only a small number of the older patients interviewed (4 out of 60) had talked to the nurses about their care plans. As a result, very few older patients knew what was written in their nursing care plans.

Whether patients knew the staff nurses
The patients were asked if they could tell the staff nurses (the qualified nurses) from the rest of the nursing staff (student nurses and auxiliary nurses). Less than half of the patients (24 out of 58) knew the staff nurses on the wards who were responsible for their nursing care in hospital. Most of the patients from two of the hospitals, but only a few patients from the other hospitals, knew the staff nurses on the wards.

Getting up and going back to bed
The British Geriatrics Society, the Royal College of Psychiatrists and the Royal College of Nursing recommended that older patients in hospital should decide themselves what time to get up or go to bed (BGS, RCP and RCN, 1993). Indeed, the interviews with the patients showed that they were not usually expected to get out of bed very early unless they wanted to themselves. However, it appeared to be the custom in some cases to waken patients early to allow staff to start the ward routines. A fifth of the patients (12 out of 62) were wakened early between 6am and 7am by staff turning on lights, giving out basins for patients to wash and making beds. Previous research carried out in a hospital in Northern Ireland showed that a quarter of the older patients who had stayed in the elderly care and rehabilitation wards felt they had been wakened too early in the morning (SHSSC, 2002), compared with only a fifth of the patients in this research.

Moving patients in hospital
The patients were asked if they were moved to another ward (or another bed in the same ward) after they were first admitted to a hospital bed. Almost half of the patients (29 out of 62) had stayed in the same wards and in the same beds in the wards during their time in hospital. Patients who were moved about in hospital had been moved one-and-a-half times, on average. One patient who was moved five times said she did not like being moved about in hospital:

Some of the moves were probably carried out to make sure that patients stayed in wards or bays for women-only or men-only. However, moving patients a number of times makes it difficult to make sure they get good quality care during the hospital stay.

d Having and operation

Patients who had hip operations carried out
Most of the surgical patients who had operations carried out during their hospital stay were fracture patients (patients with broken bones) (7 out of 11). The standard for emergency hip operations written in the National Service Framework for Older People is that they should be carried out within 24 hours of admission (DOH, 2001b). However, the Department of Health, Social Services and Public Safety has recommended that these operations should be carried out within 48 hours of attending an Accident and Emergency Department (2002b). Four of the seven patients who needed hip operations waited between three and five days for their operations to be carried out.

e Getting help from staff

Help needed with walking
Two-thirds of the patients (41 out of 62) needed help from staff with walking or moving about during part of (or all of) the hospital stay. By the time they were ready to be discharged from hospital, a third of the patients still needed help to walk or were not able to walk at all.

Using call bells
Most of the patients (54 out of 56) had call bells at their beds. However, 19 of these patients had never used their call bells - instead, these patients had called for a nurse or waited for a nurse to pass by whenever they wanted help.

Getting help to go to the toilet
The patients who needed help from the nurses usually said the staff came quickly or fairly quickly when they were called. However, five patients had some difficulties getting help to go to the toilet. In particular, on one occasion in a hospital, the night nurses did not see to a patient at all when she needed help to go to the toilet. When a complaint was later made to the Ward Sister, the nurses involved spoke to the patient to make sure that she did not make any more complaints to the Ward Sister.

Getting help with washing
About half of the patients (30 out of 62) needed no help with washing when they were in hospital, although some of these patients were only able to wash themselves in bed with a basin. The rest of the patients needed help from the staff with washing, either in bed or with a shower or bath, for part of the hospital stay or all the time they were in hospital. Most of the patients said the staff had helped them whenever they needed any help with washing. However, a couple of patients said they had to wait to get help with washing. In addition, a patient’s wife said her husband had been washed every day in one ward, but when he was moved to another ward he was not washed or had his pyjamas changed for three days.

Getting help at mealtimes
Only eight patients needed help with their meals. However, three of the eight patients had to wait for the help or they did not get the help they needed. For example, a patient who was served soup had poor eyesight and did not know that the soup had been given to her.

f Privacy and dignity

Women-only and men-only wards
The National Service Framework states that mixed-sex wards can be particularly embarrassing for older people (DOH, 2001a). However, although patients admitted to hospital for planned treatment are entitled to women-only or men-only accommodation, patients admitted in an emergency via Accident and Emergency Departments may be admitted to mixed-sex wards (Health and Social Services Executive, 1997).

Almost three-quarters of the patients interviewed for this research were cared for in wards or bays (sections of wards) for women-only or men-only all the time they were in hospital. However, only half of the patients in one hospital were cared for in wards or bays for women-only or men-only all the time they were in hospital, compared with most of the patients from the other hospitals. In addition, two patients who were cared for in women-only or men-only wards or bays used toilet or bathroom facilities (or both) which were also being used by patients of the opposite sex. Previous research carried out by the EHSSC (2001) showed that all the Health and Social Services Trusts have some mixed-sex wards or bays. Most Trusts also have a number of wards where the washing and toilet facilities are used by both women and men.

Five patients did not have enough privacy when using toilet or bathroom facilities because of poor hospital facilities or staff routines (or both). A patient in one hospital experienced a loss of dignity when the staff did not see to her when she needed help to go to the toilet.

Wearing hospital gowns
All the patients who had to wear hospital gowns when going for tests or operations said they were adequately covered by the gowns.

g Medications

Most of the patients (47 out of 62) were given at least one new medication (tablets or injections) when they were in hospital. The reasons for the new medications were explained to nearly two-thirds of these patients. In addition, five patients had their usual medications changed while they were in hospital and the reasons for the change of medication were explained by the staff. For example, a patient was given a few types of antibiotics and the staff explained why she needed these:

However, over a third of the patients who were given new medications (18 out of 47) were not sure about the reasons for the new medications because these were not explained, or adequately explained, by the staff. The review of community care in Northern Ireland also showed that older people are often confused about their medicines. As a result, the Department of Health, Social Services and Public Safety recommended that better medicines information should be given to patients before they are discharged from hospital (DHSS&PS, 2002a).

After they were admitted to hospital, over half of the patients (38 out of 61) had some pain which needed to be treated with medication. Four of the eleven patients who had operations had pain afterwards which was not fully relieved by the medication they got.

h Cleanliness of wards and quality of food

Cleanliness of wards
Nearly all the patients said the wards and ward facilities were clean. Some patients mentioned the drab surroundings in old hospitals or old parts of hospitals.

Meals in hospital
Most of the patients were satisfied with the meals they got in hospital. The patients who had to eat special diets in hospital usually got their correct meals. A couple of the comments made about the food were as follows:

i Nursing and medical procedures

Explaining procedures to patients
The patients were asked if the staff had explained what they were going to do before they carried out any basic nursing or medical procedures, such as giving intravenous injections (into a vein), putting in or taking out a drip or catheter (in the bladder) or dressing a wound. Most of the patients who had such procedures carried out got a brief explanation from the staff before they started the procedure. However, in a fifth of the cases (11 out of 57), the staff did not explain beforehand what they were going to do or the explanation given was not adequate. In particular, it appeared that the staff sometimes assumed that the patients understood what was being done to them without this needing to be explained to them. Guidance from the Department of Health, Social Services and Public Safety states that consent must be sought from patients before carrying out an examination or giving care or treatment (2003)

j Handling of death on wards

Over a quarter of the patients who were interviewed (18 out of 62) said another patient had died in the ward during the hospital stay. The patients had noticed changes in the ward which made them think that other patients were about to die or had died. Moving very ill patients to a side room made other patients think that the individuals were close to death. A change in the ward atmosphere, curtains being pulled around the beds and beds later becoming vacant also made patients think that other patients had died.

The Dignity on the Ward campaign in England showed that some older people felt the death of another patient was the most upsetting thing that had happened to them during their time in hospital (Davies and others, 1999). Although most of the patients who were interviewed for this research were not upset by the deaths of other patients (17 out of 18), nurses need to be more sensitive to how the death of a patient on the ward can affect other patients in hospital.

k Attitudes of staff

It is very important to older patients that staff are kind and friendly (Davies and others, 1999). Most of the patients interviewed for this research said the nursing staff were always pleasant. However, seven patients (mostly surgical patients) spoke about the poor attitudes of one or more members of the nursing staff in four of the hospitals. Seven patients also said that some nurses and doctors need to improve their attitudes to older patients. In particular, they said the staff should always treat older patients with respect.

l Satisfaction with care

Most of the patients were satisfied with the nursing staff who looked after them (50 out of 57) and with the care they got in hospital (54 out of 60):

However, over a quarter of the patients (17 out of 60) mentioned improvements that are needed in the care that older patients get in hospital.

m Discharge from hospital

Help needed after discharge
Most of the patients needed some help after discharge, for example, with washing and dressing. The hospital staff usually made sure that the patients got this help at home (for example, a home help) or were admitted to a residential home or that they would be staying with a relative who could give the help needed. Where help was organised at home, the staff had nearly always turned up as arranged.

Equipment needed at home
Where the patients needed equipment provided, for example, a hospital bed, or needed installations carried out at home (such as a door rail), these were usually in place before the patients were discharged from hospital.

Care settings after discharge
Eight patients were admitted to residential homes or a community hospital after they were discharged from hospital. Where the patients were admitted to residential homes, most of them stayed there for one to three weeks only.
Patients who were admitted for short periods had little choice over the homes, although when one patient told his social worker that he did not want to go into a particular home, he was admitted to a different home instead. Only one patient moved into a residential home permanently.

She was not admitted to her first choice of home because there was no room available. However, the social worker informed her that if a room later became available she could still move, although she liked her current home.

One patient who appeared to have been admitted to a home as an alternative to continuing hospital care was told that she would have to pay for the admission if she stayed in the home for more than two weeks. However, guidelines from the Eastern Health and Social Services Board state that patients should not be charged for short stays in homes that are organised as an alternative to continuing hospital care (letter sent to Trusts in 2002)

n Making a suggestion or complaint

The Charter for patients and clients states that every Health and Social Services Trust should have a procedure in place for patients to make complaints, if problems occur (EHSBB, 1999). The patients were asked if they knew how to make a suggestion or complaint in hospital. However, almost a third of the patients (18 out of 60) did not know how to go about making a suggestion or complaint. Only a few patients (5 out of 60) would have been willing to make written complaints if the need arose. A small number of patients (3) would have been unwilling to make complaints at all.

o Summary of quality of care in hospital

The standard of care given to older people in hospitals in the Eastern Health and Social Services Board area was usually satisfactory. However, the care given to a small number of patients was not always adequate. To make sure that a high standard of care is given to older people in hospital, the length of time they have to wait to be admitted to beds should meet the standard listed in the Charter for patients and clients and the waiting time for emergency hip surgery should meet the standard recommended by the Department of Health, Social Services and Public Safety (EHSSB, 1999; DHSS&PS, 2002). Each patient should also have a named nurse and be involved (with relatives) in planning the nursing care, and consent should be always be sought from patients before nursing or medical procedures are carried out. The staff should always be pleasant to older patients and treat them with kindness and respect. Older patients should be moved about in hospital as little as possible and they should be given help in staying continent and in coming to terms with the death of another patient on the ward. Lastly, patients who are discharged to residential or nursing homes for short periods, where they would normally be kept in hospital, should not be charged for the admissions to the homes.

There were some differences in the care given to medical patients (patients with long-term illnesses) and surgical patients (patients who may need operations carried out). As there is often a shortage of medical beds, most of the patients who waited over two hours in Accident and Emergency Departments for hospital beds were medical patients. More medical patients than surgical patients were moved about in hospital. Most of the older people who had experienced the death of another patient in the ward during the hospital stay were medical patients.

It was usually surgical patients who had difficulties getting help with personal care (including eating) and who had experienced negative attitudes from some of the nursing staff. A few surgical patients had pain after their operations which was not fully relieved by the medication they got. Lastly, the small number of patients who did not get adequate help after discharge were surgical patients. Therefore, it was usually surgical patients who had experienced problems with getting their basic care needs met in hospital and with getting adequate help after discharge.