ICCI for Older Patients in A&E
ICCI for Older Patients in A&E
Study Objectives

 1-To gather rich, evocative accounts of older patients aged 65 years and over -who may have
 felt disorientated in the Accident and Emergency department (A&E) of a district hospital and
 who received an Intentional Compassionate Communication Intervention (ICCI) about their
 personal experience of the A&E;
Background:

 The number of hospital emergency admissions has dramatically increased in England, by 42%,
 over the last 12 years.Qualitative research published between 1990 and 2006 on the patient
 experience within the emergency department showed that most patients arrived at the A&E with
 the perception that their injury or condition was serious or life threatening and this
 perception was often accompanied by physical pain. The situation is one in which patients
 feel vulnerable, anxious, stressed and fearful.

 In the UK, nearly a quarter of the people arriving at A&E are over 65 years, older patients
 represent a demographic group whose emergency admissions have seen a particularly sharp rise
 over the last 12 years, especially patients aged 85 years or older. This entails hospital
 staff having to deal in the emergency situation with patients presenting with much more
 complex needs associated with co-morbidities and often with less external support than
 younger people

 Older patients are more prone to feel disorientated in A&E. This can be due to a high
 percentage of them presenting with dementia, delirium, delirium superimposed on dementia or
 other CSD (Cognitive Spectrum Disorders), and they are also at higher risk of developing
 delirium while in the emergency department. Delirium is a common medical problem that is
 characterised by changes in cognitive function. When delirium occurs, people are confused.
 Its onset is quite sudden, but it usually lasts only for a few days. However, if not
 addressed delirium can become a serious complication which can lead to longer length of stay
 in hospital and higher mortality. Stress is one of the common triggers for delirium and there
 is also some evidence that longer and particularly stressful A&E experiences are associated
 with the risk of older patients developing delirium over the following hours .

 There have been a few published studies exploring the experiences of A&E from the specific
 point of view of older patients which report that most of them believe that their symptoms
 pose a serious threat to their life or to the control they exert over their lives and that
 the attitudes of nurses in A&E are often perceived as indifferent and inattentive, thus
 causing a feeling of exclusion and disappointment. Empathy and compassion are perceived by
 patients to be the most significant elements of good care in A&E .

 Compassionate Care is not a new concern for the NHS but following high profile failings
 government policies such as the Compassionate Care in the NHS have been introduced, further
 emphasising the importance of humanised care . Recent literature has explored different
 perspectives, from the poor experiences of care by older people living with frailty which,
 has been uncovered by the Francis Report, to the challenges experienced by nurses expected to
 deliver compassionate care, who often struggle to align the reality of practice to their
 ideals .

 Cornwell and Goodrich, in a study exploring patients' experiences state: "the presence or
 absence of compassion often marks the lasting and vivid memories patients and family members
 retain about the overall experience of care in hospital". This is valid also for patients who
 are temporarily confused and/or live with dementia. Projects like the "Dementia diaries"
 project, show that people can not only be aware of how they are treated and how they feel
 even in the middle of an extremely confused state, but they can also be able to recall this.
 Patient satisfaction should be considered a goal in itself; however, the literature also
 suggests that patients receiving clear and compassionate communication are more likely to
 disclose their symptoms enabling greater understanding of their situation and more accurate
 diagnoses.

 The evidence from the paragraphs above indicates that an investment in targeted compassionate
 communication for older people in A&E could make their care more effective, with the
 potential to reduce complications and make healthcare delivery more economically sustainable
 for the NHS alongside giving patients and their families a better experience.

 The awareness of the high incidence of stress in A&E, and of the importance of compassionate
 care for older people has driven the development of a specific Intentional Compassionate
 Communication Intervention (ICCI) within the A&E of a district hospital. The ICCI comprises
 proactive communication-focused support to older people. It involves a specific member of
 support staff taking responsibility for the ICCI to meet older patients' psychological needs
 and relieve their anxieties through talking to them, sharing information with them and
 reassuring them when in A&E.

 The member of the staff who delivers the ICCI has been a volunteer in the hospital for 6
 years and is now a non-clinical member of the Dementia Care Team.

 The delivery of the intervention gives priority to support older people who are in A&E alone
 and to those of them who appear to be cognitively impaired. The aim is to provide patients
 who may feel disorientated additional support in order to reduce the anxiety associated with
 being in A&E. Using effective communication skills the member of staff demonstrates
 compassion and empathy to the older patients whilst they are in a busy A&E department.
 Activities may include talking to them, gently re-orientating them if confused, by asking
 simple questions while using a friendly and reassuring tone of voice, offering a glass of
 water or a cup of tea, maybe a blanket. The member of staff can also try to reassure patients
 by enquiring with other staff about the outcome of an examination or about the next step into
 the patient's hospital stay when it happens to be too busy or staff is under too much
 pressure to be able to communicate with patients promptly and efficiently.

 She also holds many hands, because of pain or because of fear. She purposefully uses a sense
 of humor to prompt a smile or a quick laugh. If words are not helpful (because the cognitive
 impairment is too severe, for example) she might play some music using an I-pad or bringing
 some soft toys for patients to cuddle. What lays at the basis of this intervention is the
 meeting between two human beings whereas one of them is in pain (psychological and often also
 physical) and the other one somehow "feels" that pain and has a genuine wish to relieve it.
 The ICCI is totally person-centered and does not rely on any particular technique, rather it
 is exclusively based on a shared, deeply human drive.

 A 2017 systematic review of literature by Sonic et al. highlighted that most recent studies
 of patient experiences at A&E are quantitative and use methods such as surveys or interviews,
 concentrating on judgments of patients after their A&E visit. A few qualitative studies have
 been carried out. Baraff et al. in 1992 showed that patients are very concerned about losing
 autonomy and independence, and Olthuis et al. in 2014 showed that during the A&E stay
 patients not only have to deal with their disorder, its consequences, and the situation they
 are in, but they are also continuously troubled by all kinds of matters. They found that it
 is a struggle for them to admit that something is wrong with them, to trust the health care
 professionals, to endure waiting periods, to have a blood sample taken, to undress, to deal
 with their relatives and reassure them, and even to get something to drink or eat.

 Despite this, we still do not know very much about disorientated patients experiences in A&E.
 Considering the above, and that there are studies focusing on the lived experience of older
 patients in A&E but currently no published studies that focus on the experience of
 Intentional Compassionate Care Interventions (ICCI) within A&E, improved understanding of the
 lived experience of patients with regards to the provision of ICCI within A&E would be of
 great value in nursing; particularly considering that the experience of older people in A&E
 is often characterized by discomfort, fear, and pain, and can trigger disorientation and
 confusion. Moreover, people with Dementia or other cognitive impairments have a unique
 contribution to make in research. Hearing their voices can help people see the A&E experience
 from their point of view, contributing to fight the assumptions and the stigma often
 associated with such a diagnosis.

 Clinical Data:

 In the UK, nearly a quarter of the people arriving at A&E are over 65 years and older
 patients represent a demographic group whose emergency admissions have seen a particularly
 sharp rise over the last 12 years . The experience of older people in the A&E is often
 characterised by discomfort and anxiety. Stressful experiences may represent a possible
 trigger for delirium, a common and significant complication between older hospital patients
 which can affect the following course of recovery and the overall hospital length of stay.
 There is some evidence that longer and particularly stressful A&E experiences are associated
 with the risk of older patients developing delirium over the following hours.

 Compassionate care seems to reduce patient anxiety and studies conducted in A&E show that
 empathy and compassion are the most significant elements of good care for older patients in
 A&E.

 Rationale:

 The results of the research will contribute to a deeper understanding of older potentially
 disoriented patients' lived experiences of being in A&E and receiving an A&E based ICCI. This
 study could impact upon NHS consideration of possible new roles in A&E that are responsible
 for ICCI and how to make older patients' care more effective and sustainable, and give this
 patient group a better experience and outcome. Including people living with dementia or
 experiencing other cognitive disorders in the study is not only a way to improve their care,
 but also a way of valuing their contribution to society.

 Risks/Benefits:

 During the study participants will have the opportunity to reflect on their experience of
 being in A&E, on their emotional needs and if and how these were met during their period in
 A&E. Reflecting and acknowledging our need for human connection and meaningful interactions
 raises our awareness and this can translate into a benefit for these participants.

 The recruitment of patient participants for interview may include those living with dementia
 or other cognitive impairments and it is recognised that they represent a vulnerable
 population. However, only those who have been identified as being able to give informed
 consent by a registered health care professional member of the Dementia Care Team, will be
 invited to participate to the study.

 The researcher will remain sensitive to any sign of distress during the interview and suspend
 or stop their participation if indicated. Taking extra-care when interacting with vulnerable
 people is essential, however, excluding patients living with dementia from participation in
 research interviews could represent a form of discrimination, as their voice would seldom be
 heard in research and by the services they use. Lack of capacity can make people with
 dementia particularly vulnerable to discrimination and this is also valid for their
 participation to research. Under the Mental Capacity Act a person is presumed to be able to
 make their own decisions "unless all practical steps to help them to make a decision have
 been taken without success".

 Study Objectives:

 1-To gather rich, evocative accounts of older patients aged 65 years and over -who may have
 felt disorientated in the Accident and Emergency department (A&E) of a district hospital and
 who received an Intentional Compassionate Communication Intervention (ICCI) about their
 personal experience of the A&E;

 Study Endpoint:

 The end point will be the completion of the qualitative analysis of transcripts from
 patients' interviews when enough rich data to answer the research questions have been
 collected.

 Study Design:

 This is a qualitative study whose aim is to explore the lived experience of a sample of older
 patients (65 years and over) who may have felt disoriented in the A&E of a district hospital
 and who received an ICCI.

 Using Interpretative Phenomenological Analysis (IPA), in-depth interviews will be carried out
 with up to 15 patients and the data created from the transcripts will be analysed
 thematically.
Inclusion Criteria: Patients aged 65 years and over;

 -  Admitted for any reason to the hospital via A&E;

 -  Patients presenting either alone or confused or with a diagnosis of dementia;

 -  Patients who received the ICCI while in A&E;

 -  Patients referred to the Dementia Care Team (which support patients admitted into the
 hospital who have a cognitive impairment either as a result of an underlying dementia
 -diagnosed or otherwise- or who are experiencing transitory cognitive symptoms such as
 confusion as a result of a delirium);

 -  Patients who are able to give informed consent to participate in the study as
 identified by a registered health care professional

 Exclusion Criteria:

 -  Patients who cannot give informed consent;

 -  Any patient with a physical condition that is immediately life-threatening or
 unstable;

 -  Patients who are involved in other clinical trials which present a significant burden
 to them.