ORIGINAL ARTICLE
Prehospital emergency care for patients with suspected hip fractures after falling – older patients’ experiences Kenneth Aronsson, Ida Bj€ orkdahl and Birgitta Wireklint Sundstr€ om
Aims and objectives. To describe and explain older patients’ lived experiences of prehospital emergency care in cases of suspected hip fractures after falling. Background. Falls among the elderly is an issue internationally and a public health problem that seems to be on the increase. In the emergency medical services, older people are frequent patients after having suffered a fall, but there is little information on how older patients experience prehospital emergency care in cases of suspected hip fractures after falling. Design. Qualitative interview study. Methods. Ten older patients were interviewed. These depth interviews were taperecorded, transcribed verbatim and analysed for meanings. Results. The comprehensive understanding of the phenomenon is: ‘Glad to have been rescued, despite bad experiences as well as good’. The older patient is offered care in an open and friendly atmosphere concurrently with feeling anxiety about the treatment. Intervention with streamlined care and treatment can thus simultaneously be beneficial as well as doing harm. Patients experience confusion and the need to ask questions about what really happened in the ambulance. Bad experiences remain unexplained. These findings are based on three themes with relevant subthemes: efficiency, concerned encounters and suffering from care. Conclusions. Our study shows that prehospital emergency care when hip fracture is suspected – from patients’ point of view – is insufficient and unsatisfying. Prehospital emergency care for these vulnerable patients could be improved through more compassion being shown towards older patients’ existential needs and their increased participation. Furthermore, alternative methods of prehospital pain relief need to be developed. Relevance to clinical practice. Responsibility for patients’ safety regarding pain relief is emphasised. Pain relief in the emergency medical services should be individualised. This development should focus on care that is already good and gradually eradicate compassionless care. Key words: ambulance, care pathway, caring science, emergency medical services, hip fracture, lived experiences, phenomenology, prehospital emergency nurse
What does this paper contribute to the wider global clinical community?
• On the topic of care for older
•
•
patients with suspected hip fractures, this study contributes the following: The prehospital emergency care and pain relief given by the emergency medical services should be individualised for each patient. Prehospital emergency nurses need to develop more compassion towards older patients’ existential needs and increased patient participation.
Accepted for publication: 5 December 2013 Authors: Kenneth Aronsson, MSc, RN PEN, Emergency Medical € Service System at S€ odra Alvsborg Hospital, Bor as; Ida Bj€ orkdahl, € MSc, RN PEN, Emergency Medical Service System at S€ odra Alvsborg Hospital, Bor as; Birgitta Wireklint Sundstr€ om, PhD, RNAN, Associate Professor, School of Health Sciences, Research Centre PreHospen, University of Bor as, The Prehospital Research Centre of Western Sweden, Bor as, Sweden
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123, doi: 10.1111/jocn.12550
Correspondence: Birgitta Wireklint Sundstr€ om, Associate Professor, School of Health Sciences, University of Bor as, SE-501 90 Bor as, Sweden. Telephone: +46 33 435 47 77. E-mail: [email protected]
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Introduction and Background Falls among the elderly is an issue internationally (Bergeron et al. 2006) and a public health problem that seems to be on the increase (Olsson et al. 2007). The high risk of injury from falling for older people is caused by deterioration in balance, reduced muscular strength, medication, impaired vision, poor nutrition, impaired reflexes and the environment (MSB 2012). In Sweden, approximately 270,000 falls annually (MSB 2005) lead to at least 1400 deaths, more than 70,000 cases needing hospital treatment and about 18,000 hip fractures (Lundin-Olsson & Rosendahl 2008). Pain following suspected hip fracture has been associated with delirium, depression, sleep disturbance and decreased response to interventions for other illness (Abou-Setta et al. 2011). Therefore, it is important to treat and manage complaints of pain adequately during acute treatment for hip fracture. Patients with suspected femur or hip fractures are often difficult to evaluate. The prehospital analgesics administered often provide insufficient pain relief or cause serious side effects (Abou-Setta et al. 2011). In the emergency medical services (EMS), older people are frequent patients after having suffered a fall (Halter et al. 2011). Patients with suspected hip fractures are often rated as a high-risk patient group, particularly on account of their immediate need for pain relief (NBHW 2003, SIGN 2009). Integrated care pathways (ICP) for suspected hip fracture patients have been constructed according to prehospital emergency care protocols (Olsson et al. 2007, Larsson & Holgers 2011). Via streamlined, standardised management with multidisciplinary medical, nursing and paramedic teams, a ‘fast track’ for patients with hip fractures has been established (Hommel 2007, Olsson et al. 2009). When a hip fracture is suspected, the prehospital emergency nurse (PEN) follows the treatment protocol for ‘fast € 2011). This means that the patient goes tracks’ (SAS straight into the X-ray ward and, when the diagnosis for hip fracture is settled, straight to the orthopaedic ward without further delay. For pain relief, the drugs given are morphine [opioid] and Ketalar [ketamine]. Benzodiazepines are administered as a preventative measure to minimise the side effects, dreams and confusion, of ketamine (Belfour 2004, Pai & Heining 2007). From a healthcare science perspective, it is import to make patients’ own experiences visible and take each unique experience to account (Dahlberg et al. 2008). In hospital, patients’ experiences of hip fracture, consisting of coping with pain (Archibald 2003) and waiting for surgery, are experienced as stressful and may develop into confusion (Hommel et al. 2012). Pain decreased during the hospital
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stay, but several patients had moderate or severe pain (Hall-Lord et al. 2004). Preventative pain relief would decrease patients’ suffering (Hallstr€ om et al. 2000). However, older patients’ experiences of prehospital emergency care in cases of suspected hip fractures after falling is an unexplored and unknown area.
Aim The aim of the study was to describe and explain older patients’ lived experiences of prehospital emergency care in cases of suspected hip fractures after falling.
Methods Design and settings A qualitative interview study with a reflective lifeworld research (RLR) approach (Dahlberg et al. 2008, 2009) was adopted, characterised by openness and searching for the meanings of a phenomenon. The intention of such an approach is to adopt a reflective stance to things taken for granted, for example integrated care pathways for hip fracture patients in the EMS, and to describe this phenomenon as experienced by the patients. This method is based on phenomenological epistemology and Husserl’s theory of the lifeworld, that is understanding human lives, health, suffering and well-being as they are experienced in daily life. In this approach, the ‘bridling’ of past knowledge is one of the most critical aspects. This means avoiding earlier interpretations and understandings of a phenomenon. The interview study was conducted in cooperation with an EMS in a rural area of western Sweden. This EMS has nine ambulance stations operating in an area of approximately 13,000 square kilometres, providing emergency healthcare services for a population of 325,000 people. The participants came from four municipal areas in southern Sweden. The settings for the trauma varied between urban, rural and agricultural and between indoors (e.g. at home) and out-of-doors (e.g. in the street).
Participants The study consisted of 10 older patients (seven female and three male, mean age 80 years, age span 68–91 years old). These participants were selected in the EMS electronic patient care record (ePCR) system for a period of three months, from the beginning of December 2010–the end of February 2011. Following keywords were used: ‘Pathways for hip fracture patients’, ‘Fast track – suspected © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123
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hip fracture’ and ‘Collum fracture’. The inclusion criteria were: (1) Patients with suspected hip fractures after falling who received prehospital emergency care by ICP, (2) Age 65 years or older, (3) Living in private residences. The exclusion criteria were: (1) Alcohol or other drug influence, (2) Dementia or other disorientation conditions, (3) Living in any sort of community-based residence. Forty patients met the inclusion criteria. Of the 40 possible patients who met the inclusion criteria and were still alive, 23 were excluded, four did not answer and three declined to participate.
Data collection Data were collected in the participants’ own homes through depth interviews, January 2010–April 2011. Two of the authors (KA, IB) carried out the interviews as a dialogue to give the participants an opportunity to recall and reflect on their experiences of prehospital emergency care. The interviews started with the open question: ‘Could you please tell me what happened the day you fell and were given care by the ambulance staff?’ This was followed by other questions, depending on what emerged from the patients’ narratives, for example, ‘Could you please tell me more about your experience?’ and ‘Could you please develop that?’ The interviews lasted 40–60 minutes, were tape-recorded and transcribed verbatim.
Data analysis In line with Dahlberg et al. (2008), the interview data were analysed for meanings. Such analyses were characterised by a tripartite structure and described as a movement between the whole to the parts and back to the whole. This entailed understanding the data as a whole, dividing it into parts and finally returning to a new whole. The authors then moved between different abstract levels during the analysis process but always with the interview data as their reference point. All three authors read through the data independently. When an overall understanding of the text was reached, the first preparation began and the data were divided up into units. Units of meaning were then marked and compared for differences and similarities. Clusters of meanings that related to each other were identified. By comparing the clusters to each other, themes and subthemes of meaning gradually emerged. The phenomenon ‘prehospital emergency care when a hip fracture is suspected, as experienced by the older patients’, consists of three themes of meaning. The meanings of the themes should be seen as being on a © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123
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more abstract level than the subthemes. Furthermore, each of these themes has its own characteristics with a distinctive meaning in relation to the others. Thus, each theme can be ‛isolated’ in the description of prehospital emergency care, but at the same time, prehospital emergency care is a complex phenomenon so that the meanings of the three themes overlap. For deeper perception of the phenomenon, a comprehensive meaning was formulated, constituting the most abstract meaning of the phenomenon. The results present the comprehensive meaning followed by brief descriptions of the three themes and of the subthemes. Quotations from the participants (P1–P10) are included to back up and provide more detail for the individual subthemes.
Ethical considerations The phenomenological emphasis on openness entails an ethical approach throughout the entire research process. Extra attention was paid to ensure that the encounters with the participating patients as well as their relatives were respectful, especially as the interviews took place in their homes. In connection with the interviews, every informant was given plenty of time to ask questions if anything was unclear about the way the study was conducted. This study was designed to meet the ethical principles for research procedures as put forward by the International Council of Nurses (2006), ensuring that the principles of anonymity, integrity and confidentiality are maintained. We emphasised awareness of and consideration for the older patients’ vulnerability as well as that of their relatives. Prior to data collection, contact was taken with the Swedish civil registration, which includes all inhabitants, to make sure that participants were alive and to obtain their current residential addresses. This first step in selecting participants was a fundamental assurance in applying and making possible an ethical approach in this study. After this, it was emphasised that participation was voluntary, that responses would remain anonymous and that participants could withdraw from the study at any point without repercussions. They were informed orally and in writing about the study, and they signed up to participate. Despite the fact that with Swedish legislation and demands, ethical approval from a research committee was not necessary for this study, all corresponding strict ethical demands have been applied. This mode of procedure may differ from other countries regarding ethical approval.
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Results Prehospital emergency care in cases of suspected hip fracture is described as ‘Glad to have been rescued, despite bad experiences as well as good’. The older patient is offered care in an open and friendly atmosphere concurrently with feeling anxiety about the treatment. Intervention with streamlined care and treatment can thus simultaneously be beneficial as well as doing harm. Patients experience confusion on account of impaired or failed memory and the need to ask questions about what really happened in the ambulance. Bad experiences remain unexplained. The older patients’ questions are left unanswered. The meaning of the phenomenon will be explicated using the following three themes, which should be seen as variations of the phenomenon: efficiency, concerned encounters and suffering from care (Table 1).
functional and efficient caring. One patient says: ‘Everything happened very quickly, the stretcher had already been fetched. They worked methodically’ (P9). In rational treatment, the PENs are seen to distribute the tasks among themselves in a practical way, although they are careful with lifts and transportations. Being meaningfully treated Patients visualise care as being meaningful treatment. When patients are offered different interventions and several tasks are performed on site as well as in the ambulance, the treatment feels meaningful. One patient describes what happened: Everything they did was useful. I didn’t think they could do so much. I was given pain relief, he [PEN] called the hospital and informed me about what he was doing. (P7)
Efficiency
Concerned encounters
Prehospital emergency care appears efficient, structured and rational. It is characterised by working smoothly, with a number of measures being taken. The equipment of the ambulance contributes to functionality, and the carers use different techniques innovatively and methodologically, based on what is needed to solve the situation and perform complex care. This theme is presented through two subthemes: Being rationally cared for and being meaningfully treated.
The meeting between a PEN and a patient seems to be a personal encounter involving positive feelings to create a sense of well-being. Dialogue and touching are of vital importance as well as the carers’ ability to combine empathy and medical knowledge. This theme is presented through its subthemes: Someone to talk to, someone with feelings and someone to hold on to.
Being rationally cared for Being rationally cared for occurs when the ambulance is on site and measures are taken. Patients experience this as Table 1 Older patients’ lived experiences of prehospital emergency care
Theme
Subtheme
Efficiency
Being rationally cared for Being meaningfully treated Someone to talk to Someone with feelings Someone to hold on to Being excluded Having hallucinations Being confused
Concerned encounters
Suffering from care
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Comprehensive understanding Glad to have been rescued, despite bad experiences as well as good
Someone to talk to Dialogue is experienced to be important for the patients’ sense of well-being. One patient describes a conversation as follows: ‘What a pleasure it was. Someone who just sat there and talked to me’ (P9). Experiences of pain can clearly also be diminished by small talk about everyday tasks and events. Patients describe that they have been met by a friendly atmosphere. Someone with feelings Patients experience the empathy of the PEN as a sense of well-being during caring. One patient says: ‘Whatever you do out of love can only be good’ (P6). They describe the very humane impression made by the nurses. One patient was struck by these feelings: They can help you and make it easier for you. They really are emotional; they can understand how you’re feeling. (P5)
Patients compare the caring and the medical aspects as follows: ‘It’s not just medical knowledge; it has to be a little more’ (P6). A PEN who shows empathy is described as touching. One patient describes this feeling: ‘Everything © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123
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they did felt so right’ (P1). Another patient also describes how agreeable the PENs seemed: They were so friendly all the time.//They asked if I was lying com-
Prehospital emergency care for older patients Not until we were in the ambulance did I hear that we were going to another hospital, but I was so tired I didn’t have the strength to argue. (P5)
fortably on the stretcher…//… nothing was a problem for them.
The patients’ questions go unanswered, and they feel that the PENs
(P7)
are so busy with different tasks that they do not want to bother them. It seems that there are situations where patients avoid
Someone to hold on to Touching is experienced to have different meanings, both in care situations and those concerning lifts. One patient says: ‘They were so nice to me. They held my hand and I wasn’t scared’ (P9). Patients also describe how important touching becomes when concluding prehospital care. One patient describes ‘the good-bye’: When they were handing me over, the girl came up to me and took my hand. I don’t remember what she said, but they were very good people indeed. (P2) There is also a sort of touch that seems to create feelings of wellbeing: ‘I was lying there in bed, so they took hold of me gently and laid me down on the carpet’. (P9)
contact with the nurse. One patient describes such an experience: ‘She just wrote and wrote; we made no real contact’. (P8)
Having hallucinations Auditory hallucinations occur in patients’ experiences. Care seems to be associated with strange sounds and white noise. One characteristic is that the volume is set to maximum and out of the patient’s control. One male patient describes a suffering that still lingers with him. He says: ‘I can remember that sound at any time’ (P10). Patients experienced visual phenomena, feelings of movement and dramatic images of the caring situation: And then I saw all these colours, mostly red and white. I also saw myself lying on the stretcher that moved by itself, I didn’t see anyone moving the stretcher. Incredible experience, really. (P4)
Suffering from care Suffering as a result of care appears to be an aspect of the patients’ situation. One characteristic is that patient participation is lacking. Instead, information is gathered from relatives, and decisions are made without the patients’ involvement. Moreover, pain relief sometimes seems to result in undesirable side effects. Unclearness and blurriness resulting from memory failure are features that become conspicuous, especially when no explanations are given as to what has happened, what is going to happen and what care implies. Prioritising tasks over and above the caring encounter is shown to result in loneliness for the patient and lack of contact with the PEN. This theme is presented through its subthemes: Being excluded, having hallucinations and being confused. Being excluded Patients feel that the PENs sometimes withhold information about their care from them. They experience exclusion from the intervention and not knowing anything, as expressed in the following: ‘Actually, they didn’t inform me about what they were doing’//‘they did not talk to me, I did not know. Just hung on, I suppose’ (P3). Another patient describes how he, after a long time, happened to overhear what was planned for him:
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123
Patients express varying knowledge about the medical treatment. One patient who was given information about possible side effects of pain relief still describes the situation as ‘a death experience’: ‘I saw myself on the stretcher, inside the ambulance. Then the experience of being dead was very strong’. (P2)
Being confused The patients’ situation is characterised by impaired memory and lack of insight into their situation, especially in terms of what has happened and what is about to happen. Thus, they experience confusion. For lack of explanations, they try to understand the context on their own. One patient tested different explanations in the search for clarity: My thoughts went like this: ‘Did I faint?’ ‘Did I fall?’ ‘Which came first?’ ‘Have they checked my brain?’ Of course, I thought, ‘TIA’ [Transient Ischemic Attack]. (P1)
Another patient describes how he feels in relation to what had been done to him: I don’t remember that bloody much, you see. I asked where they put the needle, what the hell had I done, what injury did I have? (P10) The patients may feel that there are no carers present, resulting in loneliness. One patient describes how it felt: ‘Very strange, I would
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Discussion The main findings of this study are that the older patients’ experiences were often contradictory as they experienced both concerned encounters with engaged PENs and side effects of medical treatment. Care pathways and streamlined treatment protocols, especially the use of ketamine with its documented side effects (Belfour 2004), create unpleasant experiences for the patients. It emerges that from the patients’ perspective, prehospital emergency care is about enduring both pain and the side effects of pain relief in terms of visual and auditory hallucinations. This is confirmed by Archibald (2003), who writes about a lack of knowledge about pain relief in practice. Andersson (2002) also reports states of confusion where the patients do not know whether their experiences are fantasy or reality. Nurses in the ambulances must pay attention to patients’ experiences of pain and distress, trying to minimise the patient’s problems (Hall-Lord et al. 2004). Earlier studies also show that older patients describe their pain in a nuanced and detailed way in their everyday speech, not merely as intense pain (Bergh et al. 2005a,b). Our findings thus draw attention to the fact that well-being involves more than just pain relief, at least from a caring science perspective. The patients also experienced prehospital emergency care as being routinely cared for. The suffering demonstrated in these findings can be related to ICPs for hip fracture patients. The intervention is described by these patients as a journey starting in despair, continuing in hope, turning into a terrifying feeling of unreality and ending in confusion about the whole experience. This cannot be called either care or medicine but appears more to be inhuman treatment (Vicente et al. 2013). Inhuman treatment caused by neglecting a person’s existential dimension is experienced as being left to one’s own devices, being alone and feeling worried. Patients’ feelings of anxiety also seemed to extend into anxiety about their very survival. Our findings show that the patients’ vulnerability and existential dimensions do not receive sufficient attention. These findings must be regarded as surprising in a healthcare field such as the ambulance services and the EMS. However, and even worse, these findings confirm previous research about suffering resulting from care (Berglund et al. 2012), characterised by feelings of fragmentisation and objectification. Therefore, we need to underline strongly the
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need for a lifeworld-led care approach (Dahlberg et al. 2009) and nurses who pay more attention to individual patients’ resources and motivations (Olsson et al. 2009). The results of this study show moreover that patients experienced lack of participation in their own care. Unclear dialogues between patients and PENs evoked insecurity and confusion. Complementing the findings of Nystr€ om et al. (2002), one remarkable fact is that patients are reluctant to ask their carers anything, not wanting to risk bothering them. Being given recognition by a PEN is described as essential. Being seen by the nurse and being respected for who you are creates a sense of participation in one’s care. When the PEN clearly describes the intentions and the effects, the patients’ worries and stress are diminished. Noncaring experiences are described as feeling neglected and excluded, and lacking information. Present findings show the opposite to Foss (2011), that is the importance of participation for older patients. We emphasise that without this awareness there is a risk that the treatment will hinder rather than improve the health of patients. In spite of the findings discussed above, the study also shows that standardised treatment with ICP for hip fracture patients offers a hopeful and calming atmosphere. This complements the findings of Larsson and Holgers (2011), who show that this method benefits patients. These findings should be noted, especially against the background of the risks of generalised treatment. More specifically, there is a risk that the unique aspects of every caring encounter, where the individual’s needs are taken into account, tend to be regarded as less important, at the expense of efficiency. In line with Olsson et al. (2009), we argue for combining ICP with individualised care as the best method for improving efficiency, even in prehospital settings. Finally, the results point to the need for PENs, who encounter patients with suspected hip fractures, to adopt a reflective stance. Therefore, we argue for compassion towards the patients’ existential needs, participation and well-being to prevent suffering as well as insufficient and unsatisfying care.
Limitations and trustworthiness Time constraints for the study limited the number of interviews that could be held. However, the data collected can be described as rich as it consisted of older patients’ lived experiences in varying life situations and represented different scenarios for falls resulting in hip fractures. The RLR approach (Dahlberg et al. 2008) makes great demands on the researcher to be observant to the
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Prehospital emergency care for older patients
participants’ world of experiences throughout the entire research process. This is an approach in which the researcher endeavours to present a phenomenon and its meanings in all their complexity, without applying preconceived understanding too soon. Therefore, we practised a form of restraint by being ‛uninformed’ and ‛unknowing’ during interviews as well as during the analysis process. The authors continuously discussed the meaning units they had found and reminded each other not to let their preunderstanding interfere with the analysis. There was an ongoing struggle to maintain this awareness, especially for two of the authors (KA, IB), who are professional PENs. The phenomenological approach applied involves being open to whatever the participants say or imply. However, a qualitative researcher must recognise that one can never completely capture another person’s experiences in the same way as they have been experienced by that person. Nevertheless, qualitative research has been neglected when it comes to patients’ experiences of prehospital emergency care in cases of suspected hip fracture. This fact underlines the value of these findings.
Conclusion Our study shows that prehospital emergency care when hip fracture is suspected – from the patients’ point of view – is insufficient and unsatisfying. The prehospital emergency care for these vulnerable patients could improve with more compassion being shown towards older patients’ existential needs and patients’ increased participation. Additional research is required to develop alternative methods of prehospital pain relief in cases of suspected hip fracture. Regional fascia-iliaca blocks may constitute one example (Monz on et al. 2010). Furthermore, research will be needed to develop a protocol that takes individuals’ existential needs into account, in order to develop a more
humane approach towards care for older people than has been available up to now.
Relevance to clinical practice Responsibility for patients’ safety regarding pain relief is emphasised. Prehospital emergency care and pain relief for older patients with suspected hip fractures should be individualised in the EMS, even when pathways with standardised protocols are used. This development should focus on care that is already good and gradually eradicate compassionless care. We stress the responsibility of the prehospital emergency nurse to balance carefully between generalised guidelines and the needs of each unique patient. Furthermore, before leaving the hospital ward, patients should be encouraged to ask questions about their experiences of care. PENs should support them in such follow-up dialogues.
Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethi cal_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.
Funding The study was conducted with support from the Southern € Alvsborg Hospital.
Conflict of interest No conflict of interest has been declared by the authors.
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Prehospital emergency care for older patients
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© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123
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Prehospital emergency care for patients with suspected hip fractures after falling – older patients’ experiences Kenneth Aronsson, Ida Bj€ orkdahl and Birgitta Wireklint Sundstr€ om
Aims and objectives. To describe and explain older patients’ lived experiences of prehospital emergency care in cases of suspected hip fractures after falling. Background. Falls among the elderly is an issue internationally and a public health problem that seems to be on the increase. In the emergency medical services, older people are frequent patients after having suffered a fall, but there is little information on how older patients experience prehospital emergency care in cases of suspected hip fractures after falling. Design. Qualitative interview study. Methods. Ten older patients were interviewed. These depth interviews were taperecorded, transcribed verbatim and analysed for meanings. Results. The comprehensive understanding of the phenomenon is: ‘Glad to have been rescued, despite bad experiences as well as good’. The older patient is offered care in an open and friendly atmosphere concurrently with feeling anxiety about the treatment. Intervention with streamlined care and treatment can thus simultaneously be beneficial as well as doing harm. Patients experience confusion and the need to ask questions about what really happened in the ambulance. Bad experiences remain unexplained. These findings are based on three themes with relevant subthemes: efficiency, concerned encounters and suffering from care. Conclusions. Our study shows that prehospital emergency care when hip fracture is suspected – from patients’ point of view – is insufficient and unsatisfying. Prehospital emergency care for these vulnerable patients could be improved through more compassion being shown towards older patients’ existential needs and their increased participation. Furthermore, alternative methods of prehospital pain relief need to be developed. Relevance to clinical practice. Responsibility for patients’ safety regarding pain relief is emphasised. Pain relief in the emergency medical services should be individualised. This development should focus on care that is already good and gradually eradicate compassionless care. Key words: ambulance, care pathway, caring science, emergency medical services, hip fracture, lived experiences, phenomenology, prehospital emergency nurse
What does this paper contribute to the wider global clinical community?
• On the topic of care for older
•
•
patients with suspected hip fractures, this study contributes the following: The prehospital emergency care and pain relief given by the emergency medical services should be individualised for each patient. Prehospital emergency nurses need to develop more compassion towards older patients’ existential needs and increased patient participation.
Accepted for publication: 5 December 2013 Authors: Kenneth Aronsson, MSc, RN PEN, Emergency Medical € Service System at S€ odra Alvsborg Hospital, Bor as; Ida Bj€ orkdahl, € MSc, RN PEN, Emergency Medical Service System at S€ odra Alvsborg Hospital, Bor as; Birgitta Wireklint Sundstr€ om, PhD, RNAN, Associate Professor, School of Health Sciences, Research Centre PreHospen, University of Bor as, The Prehospital Research Centre of Western Sweden, Bor as, Sweden
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123, doi: 10.1111/jocn.12550
Correspondence: Birgitta Wireklint Sundstr€ om, Associate Professor, School of Health Sciences, University of Bor as, SE-501 90 Bor as, Sweden. Telephone: +46 33 435 47 77. E-mail: [email protected]
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Introduction and Background Falls among the elderly is an issue internationally (Bergeron et al. 2006) and a public health problem that seems to be on the increase (Olsson et al. 2007). The high risk of injury from falling for older people is caused by deterioration in balance, reduced muscular strength, medication, impaired vision, poor nutrition, impaired reflexes and the environment (MSB 2012). In Sweden, approximately 270,000 falls annually (MSB 2005) lead to at least 1400 deaths, more than 70,000 cases needing hospital treatment and about 18,000 hip fractures (Lundin-Olsson & Rosendahl 2008). Pain following suspected hip fracture has been associated with delirium, depression, sleep disturbance and decreased response to interventions for other illness (Abou-Setta et al. 2011). Therefore, it is important to treat and manage complaints of pain adequately during acute treatment for hip fracture. Patients with suspected femur or hip fractures are often difficult to evaluate. The prehospital analgesics administered often provide insufficient pain relief or cause serious side effects (Abou-Setta et al. 2011). In the emergency medical services (EMS), older people are frequent patients after having suffered a fall (Halter et al. 2011). Patients with suspected hip fractures are often rated as a high-risk patient group, particularly on account of their immediate need for pain relief (NBHW 2003, SIGN 2009). Integrated care pathways (ICP) for suspected hip fracture patients have been constructed according to prehospital emergency care protocols (Olsson et al. 2007, Larsson & Holgers 2011). Via streamlined, standardised management with multidisciplinary medical, nursing and paramedic teams, a ‘fast track’ for patients with hip fractures has been established (Hommel 2007, Olsson et al. 2009). When a hip fracture is suspected, the prehospital emergency nurse (PEN) follows the treatment protocol for ‘fast € 2011). This means that the patient goes tracks’ (SAS straight into the X-ray ward and, when the diagnosis for hip fracture is settled, straight to the orthopaedic ward without further delay. For pain relief, the drugs given are morphine [opioid] and Ketalar [ketamine]. Benzodiazepines are administered as a preventative measure to minimise the side effects, dreams and confusion, of ketamine (Belfour 2004, Pai & Heining 2007). From a healthcare science perspective, it is import to make patients’ own experiences visible and take each unique experience to account (Dahlberg et al. 2008). In hospital, patients’ experiences of hip fracture, consisting of coping with pain (Archibald 2003) and waiting for surgery, are experienced as stressful and may develop into confusion (Hommel et al. 2012). Pain decreased during the hospital
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stay, but several patients had moderate or severe pain (Hall-Lord et al. 2004). Preventative pain relief would decrease patients’ suffering (Hallstr€ om et al. 2000). However, older patients’ experiences of prehospital emergency care in cases of suspected hip fractures after falling is an unexplored and unknown area.
Aim The aim of the study was to describe and explain older patients’ lived experiences of prehospital emergency care in cases of suspected hip fractures after falling.
Methods Design and settings A qualitative interview study with a reflective lifeworld research (RLR) approach (Dahlberg et al. 2008, 2009) was adopted, characterised by openness and searching for the meanings of a phenomenon. The intention of such an approach is to adopt a reflective stance to things taken for granted, for example integrated care pathways for hip fracture patients in the EMS, and to describe this phenomenon as experienced by the patients. This method is based on phenomenological epistemology and Husserl’s theory of the lifeworld, that is understanding human lives, health, suffering and well-being as they are experienced in daily life. In this approach, the ‘bridling’ of past knowledge is one of the most critical aspects. This means avoiding earlier interpretations and understandings of a phenomenon. The interview study was conducted in cooperation with an EMS in a rural area of western Sweden. This EMS has nine ambulance stations operating in an area of approximately 13,000 square kilometres, providing emergency healthcare services for a population of 325,000 people. The participants came from four municipal areas in southern Sweden. The settings for the trauma varied between urban, rural and agricultural and between indoors (e.g. at home) and out-of-doors (e.g. in the street).
Participants The study consisted of 10 older patients (seven female and three male, mean age 80 years, age span 68–91 years old). These participants were selected in the EMS electronic patient care record (ePCR) system for a period of three months, from the beginning of December 2010–the end of February 2011. Following keywords were used: ‘Pathways for hip fracture patients’, ‘Fast track – suspected © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123
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hip fracture’ and ‘Collum fracture’. The inclusion criteria were: (1) Patients with suspected hip fractures after falling who received prehospital emergency care by ICP, (2) Age 65 years or older, (3) Living in private residences. The exclusion criteria were: (1) Alcohol or other drug influence, (2) Dementia or other disorientation conditions, (3) Living in any sort of community-based residence. Forty patients met the inclusion criteria. Of the 40 possible patients who met the inclusion criteria and were still alive, 23 were excluded, four did not answer and three declined to participate.
Data collection Data were collected in the participants’ own homes through depth interviews, January 2010–April 2011. Two of the authors (KA, IB) carried out the interviews as a dialogue to give the participants an opportunity to recall and reflect on their experiences of prehospital emergency care. The interviews started with the open question: ‘Could you please tell me what happened the day you fell and were given care by the ambulance staff?’ This was followed by other questions, depending on what emerged from the patients’ narratives, for example, ‘Could you please tell me more about your experience?’ and ‘Could you please develop that?’ The interviews lasted 40–60 minutes, were tape-recorded and transcribed verbatim.
Data analysis In line with Dahlberg et al. (2008), the interview data were analysed for meanings. Such analyses were characterised by a tripartite structure and described as a movement between the whole to the parts and back to the whole. This entailed understanding the data as a whole, dividing it into parts and finally returning to a new whole. The authors then moved between different abstract levels during the analysis process but always with the interview data as their reference point. All three authors read through the data independently. When an overall understanding of the text was reached, the first preparation began and the data were divided up into units. Units of meaning were then marked and compared for differences and similarities. Clusters of meanings that related to each other were identified. By comparing the clusters to each other, themes and subthemes of meaning gradually emerged. The phenomenon ‘prehospital emergency care when a hip fracture is suspected, as experienced by the older patients’, consists of three themes of meaning. The meanings of the themes should be seen as being on a © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123
Prehospital emergency care for older patients
more abstract level than the subthemes. Furthermore, each of these themes has its own characteristics with a distinctive meaning in relation to the others. Thus, each theme can be ‛isolated’ in the description of prehospital emergency care, but at the same time, prehospital emergency care is a complex phenomenon so that the meanings of the three themes overlap. For deeper perception of the phenomenon, a comprehensive meaning was formulated, constituting the most abstract meaning of the phenomenon. The results present the comprehensive meaning followed by brief descriptions of the three themes and of the subthemes. Quotations from the participants (P1–P10) are included to back up and provide more detail for the individual subthemes.
Ethical considerations The phenomenological emphasis on openness entails an ethical approach throughout the entire research process. Extra attention was paid to ensure that the encounters with the participating patients as well as their relatives were respectful, especially as the interviews took place in their homes. In connection with the interviews, every informant was given plenty of time to ask questions if anything was unclear about the way the study was conducted. This study was designed to meet the ethical principles for research procedures as put forward by the International Council of Nurses (2006), ensuring that the principles of anonymity, integrity and confidentiality are maintained. We emphasised awareness of and consideration for the older patients’ vulnerability as well as that of their relatives. Prior to data collection, contact was taken with the Swedish civil registration, which includes all inhabitants, to make sure that participants were alive and to obtain their current residential addresses. This first step in selecting participants was a fundamental assurance in applying and making possible an ethical approach in this study. After this, it was emphasised that participation was voluntary, that responses would remain anonymous and that participants could withdraw from the study at any point without repercussions. They were informed orally and in writing about the study, and they signed up to participate. Despite the fact that with Swedish legislation and demands, ethical approval from a research committee was not necessary for this study, all corresponding strict ethical demands have been applied. This mode of procedure may differ from other countries regarding ethical approval.
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Results Prehospital emergency care in cases of suspected hip fracture is described as ‘Glad to have been rescued, despite bad experiences as well as good’. The older patient is offered care in an open and friendly atmosphere concurrently with feeling anxiety about the treatment. Intervention with streamlined care and treatment can thus simultaneously be beneficial as well as doing harm. Patients experience confusion on account of impaired or failed memory and the need to ask questions about what really happened in the ambulance. Bad experiences remain unexplained. The older patients’ questions are left unanswered. The meaning of the phenomenon will be explicated using the following three themes, which should be seen as variations of the phenomenon: efficiency, concerned encounters and suffering from care (Table 1).
functional and efficient caring. One patient says: ‘Everything happened very quickly, the stretcher had already been fetched. They worked methodically’ (P9). In rational treatment, the PENs are seen to distribute the tasks among themselves in a practical way, although they are careful with lifts and transportations. Being meaningfully treated Patients visualise care as being meaningful treatment. When patients are offered different interventions and several tasks are performed on site as well as in the ambulance, the treatment feels meaningful. One patient describes what happened: Everything they did was useful. I didn’t think they could do so much. I was given pain relief, he [PEN] called the hospital and informed me about what he was doing. (P7)
Efficiency
Concerned encounters
Prehospital emergency care appears efficient, structured and rational. It is characterised by working smoothly, with a number of measures being taken. The equipment of the ambulance contributes to functionality, and the carers use different techniques innovatively and methodologically, based on what is needed to solve the situation and perform complex care. This theme is presented through two subthemes: Being rationally cared for and being meaningfully treated.
The meeting between a PEN and a patient seems to be a personal encounter involving positive feelings to create a sense of well-being. Dialogue and touching are of vital importance as well as the carers’ ability to combine empathy and medical knowledge. This theme is presented through its subthemes: Someone to talk to, someone with feelings and someone to hold on to.
Being rationally cared for Being rationally cared for occurs when the ambulance is on site and measures are taken. Patients experience this as Table 1 Older patients’ lived experiences of prehospital emergency care
Theme
Subtheme
Efficiency
Being rationally cared for Being meaningfully treated Someone to talk to Someone with feelings Someone to hold on to Being excluded Having hallucinations Being confused
Concerned encounters
Suffering from care
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Comprehensive understanding Glad to have been rescued, despite bad experiences as well as good
Someone to talk to Dialogue is experienced to be important for the patients’ sense of well-being. One patient describes a conversation as follows: ‘What a pleasure it was. Someone who just sat there and talked to me’ (P9). Experiences of pain can clearly also be diminished by small talk about everyday tasks and events. Patients describe that they have been met by a friendly atmosphere. Someone with feelings Patients experience the empathy of the PEN as a sense of well-being during caring. One patient says: ‘Whatever you do out of love can only be good’ (P6). They describe the very humane impression made by the nurses. One patient was struck by these feelings: They can help you and make it easier for you. They really are emotional; they can understand how you’re feeling. (P5)
Patients compare the caring and the medical aspects as follows: ‘It’s not just medical knowledge; it has to be a little more’ (P6). A PEN who shows empathy is described as touching. One patient describes this feeling: ‘Everything © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123
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they did felt so right’ (P1). Another patient also describes how agreeable the PENs seemed: They were so friendly all the time.//They asked if I was lying com-
Prehospital emergency care for older patients Not until we were in the ambulance did I hear that we were going to another hospital, but I was so tired I didn’t have the strength to argue. (P5)
fortably on the stretcher…//… nothing was a problem for them.
The patients’ questions go unanswered, and they feel that the PENs
(P7)
are so busy with different tasks that they do not want to bother them. It seems that there are situations where patients avoid
Someone to hold on to Touching is experienced to have different meanings, both in care situations and those concerning lifts. One patient says: ‘They were so nice to me. They held my hand and I wasn’t scared’ (P9). Patients also describe how important touching becomes when concluding prehospital care. One patient describes ‘the good-bye’: When they were handing me over, the girl came up to me and took my hand. I don’t remember what she said, but they were very good people indeed. (P2) There is also a sort of touch that seems to create feelings of wellbeing: ‘I was lying there in bed, so they took hold of me gently and laid me down on the carpet’. (P9)
contact with the nurse. One patient describes such an experience: ‘She just wrote and wrote; we made no real contact’. (P8)
Having hallucinations Auditory hallucinations occur in patients’ experiences. Care seems to be associated with strange sounds and white noise. One characteristic is that the volume is set to maximum and out of the patient’s control. One male patient describes a suffering that still lingers with him. He says: ‘I can remember that sound at any time’ (P10). Patients experienced visual phenomena, feelings of movement and dramatic images of the caring situation: And then I saw all these colours, mostly red and white. I also saw myself lying on the stretcher that moved by itself, I didn’t see anyone moving the stretcher. Incredible experience, really. (P4)
Suffering from care Suffering as a result of care appears to be an aspect of the patients’ situation. One characteristic is that patient participation is lacking. Instead, information is gathered from relatives, and decisions are made without the patients’ involvement. Moreover, pain relief sometimes seems to result in undesirable side effects. Unclearness and blurriness resulting from memory failure are features that become conspicuous, especially when no explanations are given as to what has happened, what is going to happen and what care implies. Prioritising tasks over and above the caring encounter is shown to result in loneliness for the patient and lack of contact with the PEN. This theme is presented through its subthemes: Being excluded, having hallucinations and being confused. Being excluded Patients feel that the PENs sometimes withhold information about their care from them. They experience exclusion from the intervention and not knowing anything, as expressed in the following: ‘Actually, they didn’t inform me about what they were doing’//‘they did not talk to me, I did not know. Just hung on, I suppose’ (P3). Another patient describes how he, after a long time, happened to overhear what was planned for him:
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123
Patients express varying knowledge about the medical treatment. One patient who was given information about possible side effects of pain relief still describes the situation as ‘a death experience’: ‘I saw myself on the stretcher, inside the ambulance. Then the experience of being dead was very strong’. (P2)
Being confused The patients’ situation is characterised by impaired memory and lack of insight into their situation, especially in terms of what has happened and what is about to happen. Thus, they experience confusion. For lack of explanations, they try to understand the context on their own. One patient tested different explanations in the search for clarity: My thoughts went like this: ‘Did I faint?’ ‘Did I fall?’ ‘Which came first?’ ‘Have they checked my brain?’ Of course, I thought, ‘TIA’ [Transient Ischemic Attack]. (P1)
Another patient describes how he feels in relation to what had been done to him: I don’t remember that bloody much, you see. I asked where they put the needle, what the hell had I done, what injury did I have? (P10) The patients may feel that there are no carers present, resulting in loneliness. One patient describes how it felt: ‘Very strange, I would
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Discussion The main findings of this study are that the older patients’ experiences were often contradictory as they experienced both concerned encounters with engaged PENs and side effects of medical treatment. Care pathways and streamlined treatment protocols, especially the use of ketamine with its documented side effects (Belfour 2004), create unpleasant experiences for the patients. It emerges that from the patients’ perspective, prehospital emergency care is about enduring both pain and the side effects of pain relief in terms of visual and auditory hallucinations. This is confirmed by Archibald (2003), who writes about a lack of knowledge about pain relief in practice. Andersson (2002) also reports states of confusion where the patients do not know whether their experiences are fantasy or reality. Nurses in the ambulances must pay attention to patients’ experiences of pain and distress, trying to minimise the patient’s problems (Hall-Lord et al. 2004). Earlier studies also show that older patients describe their pain in a nuanced and detailed way in their everyday speech, not merely as intense pain (Bergh et al. 2005a,b). Our findings thus draw attention to the fact that well-being involves more than just pain relief, at least from a caring science perspective. The patients also experienced prehospital emergency care as being routinely cared for. The suffering demonstrated in these findings can be related to ICPs for hip fracture patients. The intervention is described by these patients as a journey starting in despair, continuing in hope, turning into a terrifying feeling of unreality and ending in confusion about the whole experience. This cannot be called either care or medicine but appears more to be inhuman treatment (Vicente et al. 2013). Inhuman treatment caused by neglecting a person’s existential dimension is experienced as being left to one’s own devices, being alone and feeling worried. Patients’ feelings of anxiety also seemed to extend into anxiety about their very survival. Our findings show that the patients’ vulnerability and existential dimensions do not receive sufficient attention. These findings must be regarded as surprising in a healthcare field such as the ambulance services and the EMS. However, and even worse, these findings confirm previous research about suffering resulting from care (Berglund et al. 2012), characterised by feelings of fragmentisation and objectification. Therefore, we need to underline strongly the
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need for a lifeworld-led care approach (Dahlberg et al. 2009) and nurses who pay more attention to individual patients’ resources and motivations (Olsson et al. 2009). The results of this study show moreover that patients experienced lack of participation in their own care. Unclear dialogues between patients and PENs evoked insecurity and confusion. Complementing the findings of Nystr€ om et al. (2002), one remarkable fact is that patients are reluctant to ask their carers anything, not wanting to risk bothering them. Being given recognition by a PEN is described as essential. Being seen by the nurse and being respected for who you are creates a sense of participation in one’s care. When the PEN clearly describes the intentions and the effects, the patients’ worries and stress are diminished. Noncaring experiences are described as feeling neglected and excluded, and lacking information. Present findings show the opposite to Foss (2011), that is the importance of participation for older patients. We emphasise that without this awareness there is a risk that the treatment will hinder rather than improve the health of patients. In spite of the findings discussed above, the study also shows that standardised treatment with ICP for hip fracture patients offers a hopeful and calming atmosphere. This complements the findings of Larsson and Holgers (2011), who show that this method benefits patients. These findings should be noted, especially against the background of the risks of generalised treatment. More specifically, there is a risk that the unique aspects of every caring encounter, where the individual’s needs are taken into account, tend to be regarded as less important, at the expense of efficiency. In line with Olsson et al. (2009), we argue for combining ICP with individualised care as the best method for improving efficiency, even in prehospital settings. Finally, the results point to the need for PENs, who encounter patients with suspected hip fractures, to adopt a reflective stance. Therefore, we argue for compassion towards the patients’ existential needs, participation and well-being to prevent suffering as well as insufficient and unsatisfying care.
Limitations and trustworthiness Time constraints for the study limited the number of interviews that could be held. However, the data collected can be described as rich as it consisted of older patients’ lived experiences in varying life situations and represented different scenarios for falls resulting in hip fractures. The RLR approach (Dahlberg et al. 2008) makes great demands on the researcher to be observant to the
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3115–3123
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Prehospital emergency care for older patients
participants’ world of experiences throughout the entire research process. This is an approach in which the researcher endeavours to present a phenomenon and its meanings in all their complexity, without applying preconceived understanding too soon. Therefore, we practised a form of restraint by being ‛uninformed’ and ‛unknowing’ during interviews as well as during the analysis process. The authors continuously discussed the meaning units they had found and reminded each other not to let their preunderstanding interfere with the analysis. There was an ongoing struggle to maintain this awareness, especially for two of the authors (KA, IB), who are professional PENs. The phenomenological approach applied involves being open to whatever the participants say or imply. However, a qualitative researcher must recognise that one can never completely capture another person’s experiences in the same way as they have been experienced by that person. Nevertheless, qualitative research has been neglected when it comes to patients’ experiences of prehospital emergency care in cases of suspected hip fracture. This fact underlines the value of these findings.
Conclusion Our study shows that prehospital emergency care when hip fracture is suspected – from the patients’ point of view – is insufficient and unsatisfying. The prehospital emergency care for these vulnerable patients could improve with more compassion being shown towards older patients’ existential needs and patients’ increased participation. Additional research is required to develop alternative methods of prehospital pain relief in cases of suspected hip fracture. Regional fascia-iliaca blocks may constitute one example (Monz on et al. 2010). Furthermore, research will be needed to develop a protocol that takes individuals’ existential needs into account, in order to develop a more
humane approach towards care for older people than has been available up to now.
Relevance to clinical practice Responsibility for patients’ safety regarding pain relief is emphasised. Prehospital emergency care and pain relief for older patients with suspected hip fractures should be individualised in the EMS, even when pathways with standardised protocols are used. This development should focus on care that is already good and gradually eradicate compassionless care. We stress the responsibility of the prehospital emergency nurse to balance carefully between generalised guidelines and the needs of each unique patient. Furthermore, before leaving the hospital ward, patients should be encouraged to ask questions about their experiences of care. PENs should support them in such follow-up dialogues.
Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethi cal_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.
Funding The study was conducted with support from the Southern € Alvsborg Hospital.
Conflict of interest No conflict of interest has been declared by the authors.
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Original article
Prehospital emergency care for older patients
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