To what extent are carers involved with care decisions regarding patients

admitted with fractured neck of femur?

M MacLeod, Prof J Hutchison, N Ruta, P Blackledge, Prof R Chesson

-----Carers Research PartnershipThe Robert Gordon University

Department of Orthopaedic Surgery, ARI

Carers ResearchPartnership

Policy Background

• Carers are valued partners in the provision of health and social care.

NHS Plan (2000)National Service Framework for Older People

(2001)

• At the time of discharge carers must feel fully informed and involved in the planning of future care of the patient, so that assumptions are not made about their ability or willingness to care.

The National Strategy for Carers (1999)

Aim of the Research

To examine the extent to which carers are involved in care decisions regarding patients admitted to the Orthopaedic Trauma Unit with hip fracture.

Literature

• Search carried out on Medline and Cinhal and supplemented by manual searching.

• 37 items reviewed

• None relating to carers of patients with hip fracture

• Problems identified re communication between carers and ward staff.

Study Setting

• 69 bed Orthopaedic Trauma Unit• Admits from extensive geographical area

including Orkney and Shetland• 2 wards, each divided into 2 distinct

clinical areas with separate nursing teams• The unit is admitting emergency patients

continuously and uses the highest proportion of agency / bank staff within the Trust.

Methods

• A convenience sample of 30 carers were recruited as participants.– Patients admitted from nursing home were excluded.

• They were invited to participate in an initial interview after the patient had been to theatre.

• A follow up interview was carried out 2 weeks after discharge.

• All interviews undertaken by Margaret Macleod

Profile of Patients• 22 women and 8 men

• Mean (average) age 86 (men) and 82 (women).

• 11 patients lived alone prior to fracture.

• 12 lived with the carer prior to fracture.

• In 12 cases a mental health problem was identified ranging from ‘forgetfulness’ to dementia, depression and schizophrenia.

• 5 patients died in acute care.

• 4 patients died after discharge from acute care.

Relationship of carer to patient

3

7

11

7

1

1

0 2 4 6 8 10 12

Sister

Spouse

Daughter

Son

Grand daughter

Niece

Profile of Carers (1)

Profile of Carers (2)

• 10 had other caring roles– 3 had 2 other caring roles– 3 had young children– 3 were caring for a terminally ill husband

• 13 described own health problems

• 16 carers lived outside the Aberdeen area.

• 6 carers were dependent on public transport or ‘lifts’ to visit hospital

Profile of Carers (3)

• 10 were in employment– 4 part time– 3 in health care

• 1 was a full time student

• 4 were retired health care workers

Living arrangements prior to admission

9

7

2

1

2

1

2

5

1

0 2 4 6 8 10

Alone

with carer

with spouse

with other relative

residential care

Cornhill hospital

Female patients n=22 Male patients n=8

The Patient’s Journey

Discharge from Trauma Unit

2

1

5

2

9

1

1

1

3

3

1

1

0 2 4 6 8 10

Died in acute care

Dome

BHU

Myrtle

Community Hosp

Roxburgh

Home

Nursing Home

Female n=22 Male n=8

Carers’ Role in Hospital (1)

• To do laundry (15)

• To ‘chat’ (14)

• To update family and local news (13)

• To provide emotional support (10)

• To provide food (9)

Carers’ Role in Hospital (2)

Frequency of visiting

5

12

8

3

1

1

0 5 10 15

every visiting

daily

most days

3-4 per week

every 3 days

weekly

Carers’ Role in Hospital (3)

• ‘I yap to him and let him yap to me. If he has a drink I will hold the straw for him - that’s about it.’

• ‘We generally talk about the family and what our friends are doing. All sorts of chat to keep her in touch with things and how she feels and that sort of thing. I do the washing too.’

Carers’ Role in Hospital (4)• ‘I sat and spoke to her - going through her mail

and doing the banking. She is treasurer of the pensioners association and I pass on messages to the president.’

• ‘The nurses don’t really have time to sit and make conversation and my Aunt needs conversation and she needs someone to help her look at the paper and see the relative bits of scandal about the royal family and the planning permission – she needs to know about the planning permission.’

Carers’ Role in Hospital (5)

• ‘Things are bound to be different when she is in hospital although I do everything anyway. When she is at home I do everything anyway –she is not able to cook or anything.’

• ‘Practical things – I know the nurses are busy on the ward. Little things that we notice that they probably don’t notice. Things that I notice because I am a nurse and her granddaughter.’

Carers’ Commitment

• Regular visiting

‘I had said that I would come in at lunchtime and tea times to try and get her to eat.’

• Concern for health of patient

‘I had a very anxious time when she was at ARI as I was very worried about her and had difficulty getting a doctor to explain.’

• Multiple caring role

‘Well it really couldn’t have come at a worse time to be honest. I have a terminally ill husband and I have a daughter who has just had a caesarean birth.’

Information Seeking

• Telephone (13)

• Carer asking staff (15)

• Via the patient (8)

• Listening/open ear (5)

• Assumptions made (11)

Information Receiving

• Details of surgery (8)

• Complications (9)

• Progress

• Discharge (17)

• 19 carers expressed a desire for more information

Communication with Hospital Staff

• Carers spoke to– Nurses (25)– Doctors (11)– Physiotherapist (5)– Discharge co-ordinator (4)

• Carers did not speak to– Chaplains– Social workers– Other carers

Overview of findings (1)

• High level of commitment by carers

• Complexity of carers’ roles

• High level of carers’ involvement in care activities in hospital

• Carers recognised high demands on nursing staff

Overview of findings (2)

• Little evidence of carers’ involvement in decision making

• Carers did not seek active involvement in (or express a desire for involvement in) decision making

• Different patterns of involvement when carer was health professional

The Future• Carers who are more involved will be more satisfied, feel

more prepared for discharge and have a better perception of care. (Bull et al, 2000)

• The challenge for the NHS is to find ways of enabling professionals to recognise carers at an early stage and to provide care which goes beyond the patient and treats the carer (Ward and Cavanah, 1997)

• Better awareness of the problems carers experience and attention to improving quality in these areas may facilitate family involvement in patient care and enhance carer and patient satisfaction. (vom Eigen et al, 1999)

Acknowledgements

• Carers who participated

• Nursing staff on the trauma unit

• Hip Fracture Audit Nurse