Repetitive Vocalisation in the Hospital (Patients and Carers)
Research type
Research Study
Full title
Repetitive Vocalisation in Older People with Cognitive Impairment in the Hospital: A Feasibility and Characterisation Study (Patients and Carers Study)
IRAS ID
212966
Contact name
Sarah Goldberg
Contact email
Sponsor organisation
University of Nottingham
Duration of Study in the UK
1 years, 6 months, 1 days
Research summary
Summary of Research
Ward based staff (such as doctors, nurses, therapists and their assistants) can find it difficult caring for older patients with dementia or delirium who call out repetitively. Calling out can include screaming, groaning, and repetition of sentences or words. It is generally disruptive and thought of as one of the most problematic behaviours on acute geriatric medical wards. Ward staff report they do not know how to manage patients who call out. Research has been conducted in care home settings on people who call out repetitively, but there has been no research on how staff care for patients who call out on hospital wards.This study involves data collection and observation of 30 patients who call out repetitively and 15 interviews with the patient's carers to:
• Define and describe calling out repetitively on Healthcare of Older People (HCOP) wards.• Examine the natural history of calling out, both in the hospital and after discharge.
• Observe the way in which hospital staff interact or attempt to intervene with patients who call out repetitively.
• Study the feasibility of identification, recruitment, data collection, follow up, interview and observational studies in this population.
• Inform future cohort studies of associated and causal factors.
The study will last 18 months in total. Each patient participant will be in the study for 90 days, and each interview participant will be in the study for one interview, lasting up to an hour and a half.
This study is linked to a staff interview study which has been submitted for NHS ethical approval through the Health Research Authority system.
Summary of Results
Background On acute Medicine for Older People hospital wards, staff often care for patients with cognitive impairment who ‘call out’ repetitively. This behaviour, combined with acute hospital admission and busy, unfamiliar staff, can cause serious effects on the quality of care provided for people who call out. Little is currently known about knowledge or beliefs surrounding this behaviour, and how hospital staff and carers respond to it.Aim
The aim of this study was to explore calling out in the context of the acute hospital. This involved describing calling out, the people who display it (in hospital and after discharge), the way in which others react and respond to it, and people’s knowledge, beliefs, and experiences of calling out.Ethical Approval
The patient and relative study was approved by the Bradford Leeds Yorkshire and the Humber – Bradford Leeds NHS REC (IRAS Project ID 212966; REC Reference 16/YH/0493) and the staff study was approved by the University of Nottingham’s Faculty of Medicine and Health Sciences IRAS Project ID: 212966 REC Reference K14112016).Method
An interview and observational case-series study was conducted across ten Medicine for Older People wards on two acute hospital sites. This utilised structured and unstructured observations of people who call out repetitively, and records of medical and nursing documentation. Baseline and ongoing measures of calling out, cognitive ability, activities of daily living, pain, depression, and behavioural and psychological symptoms of dementia were undertaken. Interviews were conducted with patient participant’s relatives, and hospital staff members. Interview data was analysed thematically and quantitative data were analysed using descriptive statistics.Results
Thirty patient participants, 10 relative participants and 15 staff participants were recruited into the study. The patient participants scored highly for frequency and severity of calling out. They had poor mobility and functional ability, severe cognitive impairment, and were likely to have delirium. Most were in mild to moderate pain. Most displayed depression, agitation/aggression, anxiety, and apathy. Average length of stay was two and a half times more than for older patients in the United Kingdom in general. A third died within the three-month participation period. 55% of the remaining patient participants were readmitted into hospital. Patient participants were described or observed exhibiting other challenging behaviours alongside their calling out, such as physical aggression. Calling out was considered by relatives and staff members to be often due to the presence of an unmet need. Many needs were identified, relating to medical and functional biological needs, mental distress, and social relationship needs. However, uninterpretable needs, and the concept of a patient participant having “no needs” also arose, causing staff to sometimes feel that no intervention was required. Many interventions were observed or discussed by staff or relatives. These were pharmacological (analgesia and psychotropic medication, including sedation) and non-pharmacological (activity, verbal distraction, reassurance, reorientation, physical comfort, and environment). Barriers to intervention included the context of the acute hospital, staff knowledge and attitudes, and availability of individual patient information.Conclusions
These findings allow for the better understanding of the cognitive and functional abilities of people who call out repetitively within the acute hospital, and provide a detailed description of the ‘problem’ of calling out.
Hospital care for patients who call out repetitively is complex. The unmet needs model is useful for cases where needs are straightforward to understand or interpret. However, it falls short in more complex cases; such as patient feelings of existential distress, impractical communications of need, or insufficient resources available to either discover or help with the need. Staff feelings of futility are theorised to be due to generative mechanisms of a want to protect professional identity and personal morality.REC name
Yorkshire & The Humber - Bradford Leeds Research Ethics Committee
REC reference
16/YH/0493
Date of REC Opinion
19 Dec 2016
REC opinion
Favourable Opinion