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Journal of Nursing Management, 2013, 21, 94105

Assessment of the elderly: its worth covering the risks


1
BAppSci, BA (Hons) ,
3
R N , B H l t h S c i ( N u r s i n g ) , G r a d D i p B u s A d m i n and
4
MHlthMan

RACHEL LANGDON,

MAREE JOHNSON, R N , B A p p s S c i , M A p p S c i , P h D 2, VINCE CARROLL,


GERALDINE ANTONIO, R N , R M , D i p A p p S c i ( N u r s i n g ) , G r a d D i p H l t h M a n ,

Research Assistant, South Western Sydney Centre for Applied Nursing Research, Liverpool, NSW, Australia,
Professor and Director/Professor of Nursing, South Western Sydney Centre for Applied Nursing Research / School of
Nursing and Midwifery, University of Western Sydney, 3Registered Nurse, Mater Christi Residential Aged Care
Facility, Toormina, NSW, Australia and 4Operational Nurse Manager, Concord Repatriation General Hospital,
Concord, NSW, Australia

Correspondence
Rachel Langdon
SWS Centre for Applied Nursing
Research
Locked Bag 7103
Liverpool BC NSW 1871
Australia
E-mail: rachel.langdon@sswahs.
nsw.gov.au

L A N G D O N R . , J O H N S O N M . , C A R R O L L V . & A N T O N I O . G (2013) Journal of Nursing


Management 21, 94105
Assessment of the elderly: its worth covering the risks

Background Comprehensive assessments provide an invaluable opportunity to


identify those at risk of adverse health events, enabling timely access to appropriate
health care.
Aims This study aimed to evaluate the effectiveness of a comprehensive assessment
tool, the Adult Patient Assessment Tool (APAT), particularly in relation to early
identification of older people at risk of falls, pressure areas, cognitive impairment or
delirium, or patients with mental illness or substance abuse.
Methods Concurrent mixed methods including an initial retrospective medical
record audit and focus groups were used.
Results With the introduction of the APAT, assessment of falls risk and mental
illness increased. The number of nursing actions relating to pressure areas and falls
also increased, indicating a greater awareness of patients individual needs. Nonclinical information gathered through the APAT enabled a more holistic approach
to patient care.
Conclusion The use of electronic medical records would alleviate pressures on
nurses time, providing an opportunity to store and retrieve comprehensive nursing
assessment and benefit patient health care.
Implications for nursing management Early assessment results in an increased
number of nursing activities related to patient care. Further education relating to
mental health and substance abuse screening and cognitive assessment may enhance
the completion of these tools.
Keywords: comprehensive assessment, falls, mental health, medical record audit,
older patients, pressure areas, risk assessment
Accepted for publication: 13 March 2012

Introduction
Appropriate screening can identify people at risk of
adverse health outcomes and facilitate timely access to
appropriate comprehensive assessments and care. This
is relevant for all patients but is particularly important
94

for the older patient. The Adult Patient Assessment


Tool (APAT), linked to health department and health
service policies, has been developed using the PARIHS
framework of evidence, context and facilitation (RycroftMalone 2004) with clinical representation from across
21 hospitals on the mid north and north coast of NSW,
DOI: 10.1111/j.1365-2834.2012.01421.x
2012 Blackwell Publishing Ltd

Assessing risk in the elderly

Australia. This approach ensures that all adult patients


admitted to facilities within the North Coast Area Health
Service (a regional health service) receive the same
comprehensive assessment and risk identification on
admission. This will enable care planning according to
the needs of the patient and identify risks that might
impact on optimal care outcomes and will facilitate early
discharge planning. The overall aim of the project was to
evaluate the effectiveness of comprehensive assessment
using the APAT, particularly in relation to early identification and referral of: older people at risk of falls,
pressure areas, cognitive impairment, or delirium; patients with mental illness; those who suffer from substance abuse; and assess the rate of completion of the
APAT.

Literature review
Documentation by nurses of the practices and care they
undertake is vital in ensuring appropriate and continued
care of patients (Karkkainen & Eriksson 2003, Pearson
2003, Taylor 2003, Jefferies et al. 2010). Nursing
documentation has often been criticized for being
incomplete, leading to inconsistency and the duplication
of care (Taylor 2003). Although nurses believe in the
value of documentation (Tapp 1990, Bjorvell et al.
2003), they often believe they do not have enough time
to write notes, their notes are not read (Bjorvell et al.
2003) and that the actual care they provide is more
important than writing it down (Tapp 1990).
However, the importance of documenting the
assessments and activities nurses carry out has been
realized. Assessment and documentation of the risk
status of patients on admission provides an opportunity
to manage those risks at the earliest opportunity (Carroll 2007). Documenting those assessments ensures high
quality care appropriate to the needs of each individual
patient (Karkkainen & Eriksson 2003, Pearson 2003,
Cheevakasemook et al. 2006, Jefferies et al. 2010),
continuity of care, promotes better patient outcomes
and assists health care professionals to develop and
implement care plans (Cheevakasemook et al. 2006).
Further, managing risk is linked directly to positive
patient outcomes including fewer adverse events such as
falls (Uden et al. 1999), pressure areas (including reddened areas, pressure ulcers or pressure sores) (Gunningberg et al. 2000) and a reduced length of stay
(Bjorvell et al. 2000). The focus of documentation is
also shifted away from the initial assessment and care
activities to a more encompassing view of nursing care
and the recording of these activities (Karkkainen &
Eriksson 2003).
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105

Scope of risk assessment on admission of patients


to acute care
The importance of assessing patients on admission is
stressed throughout the literature. For example, the first
part of any measure to prevent falls is to identify those
patients at risk of falling (Uden et al. 1999), which is
most effectively done in the emergency department on
admission (Nordell et al. 2000). Uden et al. (1999)
found that before risk assessment on admission was
implemented, no patient record had information
regarding an assessment, nor did the nursing plan include any preventative measures. However, after the
risk assessment was developed and became health policy, almost all patients were assessed for risk of falling,
with the majority receiving some form of preventative
measure to reduce that risk (Uden et al. 1999). By also
documenting the nature of the preventative measure
undertaken (e.g. patient education, use of walking devices, walking assistance), the individual needs of the
patient are taken into account (Uden et al. 1999) thus
allowing other health care professionals to know the
level of risk (Johnson et al. 2011) and what has been
tried, ensuring continuity for the patient.
Assessing patients for risk of pressure areas has also
been demonstrated to be linked to fewer incidences of
pressure areas and better patient outcomes. As pressure
areas are likely to develop in a short amount of time,
prevention strategies need to be introduced as quickly as
possible after admission (Pieper & Weiland 1997,
Duncan 2007). It has been shown that once patients are
identified as being at risk of developing pressure areas,
nurses were more likely to carry out preventative activities and note them in a prevention plan (Gunningberg
et al. 2000), thereby reducing the incidence of pressure
areas (Hiser et al. 2006). This highlights the need for
risk assessment to be undertaken on admission and
documentation of measures undertaken to reduce risk.

Comprehensive assessment in aged care


The elderly are of particular concern when admitted to
hospital, as their presenting problem is often confounded by other conditions, including cognitive
impairment, dementia and delirium (Hayes 2000). As
these conditions often present in a similar way (Yeaw &
Burlingame 2003), a comprehensive assessment of patients allows the correct identification of these conditions (Caplan et al. 2004). This facilitates the referral of
at-risk patients to appropriate services (Basic et al.
2002, Yeaw & Burlingame 2003), improving health
outcomes and resulting in a lower rate of admission
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R. Langdon et al.

(Caplan et al. 2004) and fewer return visits to the


emergency department (Yeaw & Burlingame 2003).

Special cases of risk assessment


Alcohol and other substance use and abuse is a major
risk factor for injury (Schermer et al. 2003). Without
some form of assessment for substance abuse, only a
minority of patients who require treatment for substance
abuse are referred to services (Rockett et al. 2003).
However, when questions specifically related to substance abuse are incorporated in an assessment form,
detection of patients needing treatment increases
(Bernstein et al. 1997, Rockett et al. 2003), not only
facilitating referral to services, but also reducing repeat
visits to the emergency department (Rockett et al. 2003).
Due to the need for a standardized and comprehensive admission and risk assessment tool, the APAT was
developed and introduced across 21 hospitals within the
North Coast Area Health Service (NCAHS) initially in
May 2006 with the second version introduced in April
2008. The introduction of the APAT was supported by
a project facilitator, health executive sponsorship and
online support. The APAT (replacing 13 forms) ensures
comprehensive assessment and identification of any
risks for all adult patients on admission. This enables
care planning according to the needs of the patient and
the early identification of risks that might impact on
optimal care outcomes, also facilitating early discharge
and enhancing referral pathways. The tools used in the
APAT are shown in Table 1.
Identifying people at risk of adverse events can be
accomplished through comprehensive assessments,
thereby facilitating timely access to appropriate health
care. The purpose of this project, therefore, was to
evaluate the effectiveness of comprehensive assessment
using the APAT, particularly in relation to the early
identification and referral of older people at risk of falls,
pressure areas, cognitive impairment or delirium, or
patients with mental illness or substance abuse. The rate

of completion of the APAT was also evaluated. Finally,


the positive and negative aspects, as identified by nurses, of conducting a comprehensive patient assessment
at admission and throughout their stay were also evaluated. In terms of patient care, the overall goal of this
project was to determine whether a comprehensive approach to patient assessment resulted in increased levels
of nursing action taken when patients were identified as
being at risk.

Method
Design
This study used concurrent mixed methods, both
quantitative and qualitative methodologies. The quantitative component of this study used a retrospective
medical record audit design using an online data collection form based on the APAT. Two focus groups of
nurses who regularly use the form comprised the qualitative component, which provided complementary
findings (Lewis 2011) on how the nurses experienced
comprehensive assessment using the APAT.

Sample
A total of 286 medical records, randomly selected, from
the two participating NCAHS facilities were reviewed:
Coffs Harbour Base Hospital (2005 = 51, 2009 = 50);
Lismore Base Hospital (2005 = 92, 2009 = 93).
As the medical record audit was being conducted at
the two regional health facilities, two focus groups,
representing RNs practising at these facilities, were
conducted in November 2009. A convenience sample of
12 RNs (four from Coffs Harbour Base Hospital and
eight from Lismore Base Hospital), who responded to a
flyer distributed throughout their health facilities, participated in the focus groups. The focus groups were
digitally recorded and verbatim transcripts were produced for analysis.

Table 1
Tools included in the APAT (used in this study)
Confusion assessment method (CAM)
Mini-mental state examination
The Northern Hospital Modified STRATIFY
Malnutrition screening tool
Substance use history (as per NSW DOH Policy PD 2007_091 Nursing & Midwifery
Management of Drug & Alcohol Issues in the Delivery of Health Care)
Discharge risk screen (as per NSW DOH Policy PD 2007_092: Discharge Planning
Responsive Standards)
Assessment tools for delirium, cognitive impairment, and mental health were developed by
clinical staff based on their clinical knowledge and available evidence

96

Inouye et al. (1990)


Folstein et al. (1975)
Barker et al. (2011)
Ferguson et al. (1999)
NSW Department of Health (2007a)
NSW Department of Health (2007b)

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Journal of Nursing Management, 2013, 21, 94105

Assessing risk in the elderly

Instruments and training


An online data collection tool was developed after
extensive consultation with project team members. As
the online data collection tool followed the format of
the APAT and was thus only appropriate for the postimplementation period, additional answer options were
included to allow for the audit of the pre-implementation records. For example, for the question Is the
Community Services Used Prior to Admission section
completed? had an extra answer option of No section
available and further instructions to read through the
medical record to find the information.
Two nursing research staff (one each from Coffs
Harbour Base Hospital and Lismore Base Hospital)
were trained in the use of the online data collection tool,
and the inter-rater reliability was established. Agreement between the nursing research staff on each item of
70% or higher was deemed acceptable. Items with
agreement below 70% were examined and either reworded, had extra answer options added, or had
explanatory notes included. The inter-rater reliability
was then recalculated. The average percent agreement
between nursing research staff was 71.83%, with
66.2% of items having an agreement rate of 75% or
above. Nursing research staff also received guidelines
and training on conducting focus groups.

Data analysis
Data analysis involved both quantitative and qualitative
techniques. Quantitative data were analysed using the
Statistical Package for Social Sciences (SPSS) Version 19
for Windows (IBM SPSS Inc., Chicago, IL, USA). Chisquare statistics and t-tests were calculated to determine
differences between the two audit times.
Qualitative data from the focus groups were coded
and analysed using QSR NVivo Version 8 (QSR International Pty Ltd, Doncaster, Vic., Australia). An
inductive approach to thematic analysis was undertaken
to determine latent themes within the data (Braun &
Clarke 2006). Initial codes were generated separately for
each focus group. These initial codes were then grouped
into main themes and confirmed for both focus groups.

Results
Medical record audit
Patient demographics
There was no statistically significant difference between
the proportion of records of males and females
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105

(v2 = 1.404, P = 0.236) between the two audits. However, at an average of 10.8 days (SD = 11.4), the length
of stay for patients in 2009 was statistically significantly
longer than those in 2005 (mean = 7.8 days, SD = 7.04,
t = )2.47, P = 0.014). Similarly, the age of patients in
2009 (64.9 years) was statistically significantly higher
than those in 2005 (59.7 years) (t = )2.30, P = 0.022).
However, there was no statistically significant difference in the number of patients whose records were
audited who were older than 65 (2009 = 51%,
2005 = 50.3%, v2 = 0.014, P = 0.906) (see Table 2).
Presenting problem
The most common presenting problem in both 2005
and 2009 related to symptoms or ill-defined conditions, including abdominal pain, vomiting and shortness of breath. Conditions relating to the circulatory
system (CVA, stroke), musculoskeletal (hip and knee
replacements) and digestive system (gastroenteritis,
hernia) were also common presenting problems (see
Table 2).
Completion of major sections
There were statistically significant differences between
2005 and 2009 in a number of major sections completed. Proportionally more 2009 records had fully or
partially completed sections for the falls risk screen
(49.6% compared with 46.2%, v2 = 4.120, P = 0.042),
malnutrition screen (52.2% compared with 31.4%,
v2 = 8.070, P = 0.005), and the mental illness risk
screen (56.1% compared with 20.0%, v2 = 24.641,
P 0.001) when compared with 2005 records.
However, statistically significantly fewer records in
2009 had fully or partially completed sections of
Community Services Prior to Admission (21.2% compared with 45.2%, v2 = 17.062, P 0.001), diet
(41.4% compared with 64.2%, v2 = 11.752, P =
0.001), discharge checklist (30.8% compared with
53.5%, v2 = 15.130, P 0.001), transport arrangements (25.9% compared with 50.4%, v2 = 18.054,
P 0.001) and follow-up appointments (21.0%
compared with 43.7%, v2 = 16.770, P 0.001).
Some of these decreases in completion rates may be due
to the earlier records not having a section relating to
these checklists, thereby rendering a proportion of the
earlier records unable to be included in the analysis.
No statistically significant differences were found in
the number of records at either time period with fully or
partially completed sections for allergies, patients own
medication, complementary therapies, aids / prostheses,
orientation to the ward, discharge risk screen, referrals
made during admission, infection control, physical
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R. Langdon et al.

2005

2009

Variable

Mean (SD)

Mean (SD)

t (sig)

Age (years)
Length of stay (days)

59.7 (20.0)
7.8 (7.04)

64.9 (18.4)
10.8 (11.4)

)2.30 (0.022)
)2.47 (0.014)

n (%)

n (%)

v2 (sig)

71 (49.7)
72 (50.3)

81 (56.6)
62 (43.4)

1.404 (0.236)

71 (49.7)
72 (50.3)

70 (49.0)
73 (51.0)

0.014 (0.906)

0
16
17
3

(0.00)
(10.81)
(11.49)
(2.03)

2
20
13
3

(1.41)
(14.08)
(9.15)
(2.11)

15
15
11
1
18
4
1
6
1
32

(10.14)
(10.14)
(7.43)
(0.68)
(12.16)
(2.70)
(0.68)
(4.05)
(0.68)
(21.62)

8
14
13
3
16
4
1
8
0
27

(5.63)
(9.86)
(9.15)
(2.11)
(11.27)
(2.82)
(0.70)
(5.63)
(0.00)
(19.01)

Gender
Male
Female
Age group
Under 65
65 or older
Presenting problema
Blood disease
Circulatory system
Digestive system
Endocrine, metabolic, immune
disease
Genitourinary system
Infectious or parasitic disease
Injury or poisoning
Mental disorder
Musculoskeletal or connective tissue
Neoplasms
Nervous system or sense organs
Respiratory system
Skin or subcutaneous tissue
Symptoms, signs, ill-defined
condition
Other health influencing factors
Contact with health services

5 (3.38)
3 (2.03)

Table 2
Demographics and presenting
problem

8 (5.63)
2 (1.41)

Diagnoses coded using the Charlson comorbidity index (Charlson et al. 1987).

assessment, substance use risk screen, delirium risk


screen, cognitive risk screen, and community services
referral (see Table 3).
Pressure areas
There was a statistically significant increase in 2009 in
the number of patients whose records were audited
who were assessed for pressure areas (2009 = 5%,
2005 = 0%, v2 = 7.168, P = 0.028). While the number
of patients assessed as having a pressure area was not
high in 2009 (5%), there was a statistically significant
increase in the number of nursing actions taken to relieve the pressure area (2009 = 31.3%, 2005 = 14.3%,
v2 = 7.593, P = 0.006). The most common nursing
action taken relating to pressure areas was the completion of the pressure area risk assessment tool, followed by turning and repositioning of the patient (see
Table 4).
Falls
When compared with 2005, there was a statistically
significant increase in 2009 in the number of patients
whose records were audited who were assessed using
the falls risk screen and given a falls risk score
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(2009 = 71.6%, 2005 = 21.0%, v2 = 81.732, P <


0.001). As the majority of patients were assessed as
being low risk, it is not surprising that there was no
statistically significant difference between 2005 (5.1%)
and 2009 (9.5%) in the number of referrals made related to falls (v2 = 3.881, P = 0.275). However, there
was a statistically significant increase in 2009 in the
number of nursing actions taken relating to falls
(2009 = 43.2%, 2005 = 22.9%, v2 = 8.580, P = 0.003).
From the 2009 audit, the most common nursing actions
taken in relation to falls were the completion of the falls
assessment tool and physiotherapy or a physiotherapy review, indicating a referral to physiotherapy (see
Table 4).
Mental health
While there was a significant increase in the completion
rate of the mental illness risk screen from 2005 (20%)
to 2009 (56.1%) (v2 = 26.641, P < 0.001), very few
referrals were made to Mental Health at either time
period. In the majority of cases, it was considered not
applicable to make the referral (2009 = 76.5%,
2005 = 89.5%). However, statistically significantly
fewer referrals were made in 2009 (1.2%) compared
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105

Assessing risk in the elderly

Table 3
Completion of major sections

Allergies
Completed/Partially completed
Not completed
Patients own medication
Completed/Partially completed
Not completed
Complementary therapies
Completed/Partially completed
Not completed
Aids/Prostheses
Completed/Partially completed
Not completed
Orientation to the ward
Completed/Partially completed
Not completed
Discharge risk screen
Completed/Partially completed
Not completed
Community services prior to admission
Completed/Partially completed
Not completed
Referrals made during admission
Completed/Partially completed
Not completed
Infection control
Completed/Partially completed
Not completed
Physical assessment
Completed/Partially completed
Not completed
Falls risk screen
Completed/Partially completed
Not completed
Diet
Completed/Partially completed
Not completed
Malnutrition screen
Completed/Partially completed
Not completed
Substance use risk screen
Completed/Partially completed
Not completed
Mental illness risk screen
Completed/Partially completed
Not completed
Delirium risk screen
Completed/Partially completed
Not completed
Cognitive impairment risk screen
Completed/Partially completed
Not completed
Discharge checklist
Completed/Partially completed
Not completed
Community services referral
Completed/Partially completed
Not completed
Transport arrangements
Completed/Partially completed
Not completed
Follow-up appointments
Completed/Partially completed
Not completed

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Journal of Nursing Management, 2013, 21, 94105

2005 n (%)

2009 n (%)

v2 (sig)

101 (70.6)
42 (29.4)

97 (67.8)
46 (32.2)

0.263 (0.608)

45 (32.6)
93 (67.4)

59 (41.5)
83 (58.5)

2.396 (0.122)

21 (21.9)
75 (78.1)

17 (12.3)
121 (87.7)

3.801 (0.051)

98 (69.0)
44 (31.0)

89 (62.2)
54 (37.8)

1.450 (0.229)

75 (52.8)
67 (47.2)

86 (60.1)
57 (39.9)

1.555 (0.212)

89 (62.7)
53 (37.3)

103 (72.0)
40 (28.0)

2.835 (0.092)

56 (45.2)
68 (54.8)

29 (21.2)
108 (78.8)

17.062 (<0.001)

3 (2.1)
139 (97.9)

8 (5.6)
135 (94.4)

2.328 (0.127)

42 (59.2)
29 (40.8)

81 (58.3)
58 (41.7)

0.015 (0.902)

93 (65.5)
49 (34.5)

100 (69.9)
43 (30.1)

0.642 (0.423)

36 (46.2)
42 (53.8)

84 (60.4)
55 (39.6)

4.120 (0.042)

61 (64.2)
34 (35.8)

58 (41.4)
82 (58.6)

11.752 (0.001)

22 (31.4)
48 (68.6)

72 (52.2)
66 (47.8)

8.070 (0.005)

87 (63.0)
51 (37.0)

87 (60.8)
56 (39.2)

0.145 (0.704)

14 (20.0)
56 (80.0)

78 (56.1)
61 (43.9)

24.641 (<0.001)

0 (0.0)
3 (100)

79 (56.8)
60 (43.2)

3.843 (0.050)

0 (0.0)
3 (100)

78 (56.1)
61 (43.9)

3.735 (0.053)

76 (53.5)
66 (46.5)

44 (30.8)
99 (69.2)

15.130 (<0.001)

16 (17.2)
77 (82.8)

21 (14.8)
121 (85.2)

0.247 (0.619)

71 (50.4)
70 (49.6)

37 (25.9)
106 (74.1)

18.054 (<0.001)

62 (43.7)
80 (56.3)

30 (21.0)
113 (79.0)

16.770 (<0.001)

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R. Langdon et al.

2005 n (%)
Pressure areas present
Yes
0 (0.0)
No
22 (24.4)
Not completed/Not noted
68 (75.6)
Nursing action taken to relieve pressure areas
Yes
13 (14.3)
Risk assessment tool
4
Frequent turning/repositioning
1
Encourage movement/repositioning
3
Jordan Frame/air mattress
0
Monitoring
0
Referral made
0
No
78 (85.7)
Patients total falls risk score
02
21 (21.0)
3 or more
9 (9.0)
Not completed
5 (5.0)
No area on form/Not noted
65 (65.0)
Referrals related to falls
Referral made, documented on P1
0 (0.0)
Referral made, documented in
5 (5.1)
notes but not on P1
Referral is not made
21 (30.4)
Not applicable
69 (70.4)
Not completed
3 (3.1)
Nursing action taken related to falls
Yes
22 (22.9)
Falls assessment tool
2
Physiotherapy/Physiotherapy review
3
Assist as needed (mobilization)
7
General nursing care
1
Bed rails
1
Motor assessment scale (completed
1
by physiotherapist)
Walking aid
3
No
74 (77.1)

Table 4
Pressure areas and falls

2009 n (%)

v2 (sig)

5 (5.0)
33 (33.3)
61 (61.6)

7.168 (0.028)

30 (31.3)
23
15
7
9
2
1
66 (68.8)

7.593 (0.006)

62
20
2
3

(71.6)
(23.0)
(2.3)
(3.4)

0 (0.0)
8 (9.5)

81.732 (< 0.001)

3.881 (0.275)

19 (22.6)
57 (67.9)
0 (0.0)
38 (43.2)
37
13
5
1
1
1

8.580 (0.003)

0
50 (56.8)

Note: P1 is Page 1 of the APAT.

with 2005 (3.5%) (v2 = 6.504, P = 0.033). This may be


due to the wording of the question or the reluctance of
nurses to ask questions about mental health issues, as
discussed below.
Delirium/cognitive impairment
In the majority of cases in both 2005 and 2009, completion of the confusion assessment method was considered not applicable (2009 = 86.3%, 2005 = 89.1%)
and there were no statistically significant differences in
the number of confusion assessment methods completed
(v2 = 0.574, P = 0.750). Nor was there any statistically
significant difference in the number of referrals related
to delirium made to the Medical Team or Specialist
Health Worker (2009 = 2.4%, 2005 = 2.2%, v2 =
5.839, P = 0.120). However, while very few Folsteins
Mini Mental Status Examination were carried out for
cognitive impairment, significantly more were carried
out in 2009 (4.9%) compared with 2005 (0%)
(v2 = 8.097, P = 0.044). While a proportionally similar
100

number of referrals relating to cognitive impairment


were made to the Medical Team or Specialist Health
Worker, proportionally more referrals were not made
rather than considered not applicable in 2009 (14.6%)
compared with 2005 (5.0%) (v2 = 9.786, P = 0.020).
Other referrals
In the majority of cases, a referral to a dietician or
diabetes educator in relation to diabetes was considered
unnecessary (2009 = 81.0%, 2005 = 73.1%) and there
were no statistically significant differences in referral
rates to this service (v2 = 5.947, P = 0.203). Referrals to
a dietician for malnutrition was also considered
unnecessary in the majority of cases in both 2009
(77.0%) and 2005 (84.1%), again resulting in no
statistically significant difference in the referral rates to
this service (v2 = 1.597, P = 0.809). While again, in the
majority of cases referrals to speech pathology were
considered unnecessary, there was a statistically significant increase in the number of patients in 2009 (5.0%)
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105

Assessing risk in the elderly

who were referred to this service when compared with


2005 (2.2%) (v2 = 10.428, P = 0.015). However, this
increase in referral rate may be accounted for by the
increase in the completion of the questions relating to
referral to speech pathology (98% completion rate in
2009 compared with 86.2% in 2005).

Focus groups
Participants in the focus groups were asked a number of
questions about the form including: how important they
considered a comprehensive assessment to be; how they
found the process of completing the form; whether a
full assessment was carried out for each patient; questions they considered mandatory; questions they preferred to avoid; and how the form facilitated the care
and discharge of patients.
The verbatim transcripts of the two focus groups
were read and coded, yielding 334 comments relating to
23 individual codes. From these individual codes, five
main themes emerged relating to: items on the form;
holistic approach to care; why the form was/was not
completed; how the form was completed; and use of the
form and patient outcomes from using the form. Quotes
from the two focus groups are identified as being from
focus group 1 (FG1) or focus group 2 (FG2).
Items on form
The participants were asked what items on the form
they thought should be completed for every patient. The
participants felt the most important items on the new
form related to the discharge risk screen. Although there
was not a consensus, other items were also considered
important, namely the falls risk screen and the pressure
area assessment. Other sections mentioned were substance use, delirium, allergies, infection control and
aids/prostheses brought into hospital.
Improvements to the form were also suggested. The
addition of personal information about the patient was
considered important as participants felt it would
facilitate optimum care and build a positive relationship
with the patient.
when youve got your delirium or your
dementia you can go back to that and talk to them
That will bring them back to normality and
reality [it] makes a difference too in how they
react to you and how you can care for
them.
(FG1)
The addition of a sign-off for each section was also
proposed as the form was often completed by a number
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105

of nurses. This sign-off was felt to offer legal protection


for individual nurses.
were supposed to fill this in the first 24 hours,
which is over three shifts I do not like to sign
for other peoples assessments maybe have a
sign off on each section.
(FG2)
However, not all comments about the items on the
form were positive. Participants thought some sections
could be removed from the form as the information was
either already present and completing the sections resulted in additional work, or the sections were never
completed (e.g. referrals made during admission).
doubling up youre getting it off what the
doctors write anyway.
(FG2)
Holistic approach to care
The form was thought to be beneficial to patients in that
it encouraged health professionals to consider not only
the health problems of the patient, but also their personal circumstances, that is, to take a holistic approach
to patient care. Participants highlighted the importance
of non-clinical information in managing patients and
considering that information when planning their care.
then you put that person into an emotionally
stressful situation where you didnt need to just a
little bit of personalization to help out when she
was unhappy they could talk to her and then
bring that little bit of information which
helped.
(FG1)
Completion of form (why)
Some participants thought the form should be completed for every patient, and this was reflected in their
practice.
On our ward we do a full assessment and use this
on every patient I think it regimentally should
be filled out on admission then the next shift
that comes along if theres something thats not
completed they must fill it out.
(FG1)
In order to reflect changes in the patients circumstances or health status, participants also felt that it was
necessary to either complete a new form or review
forms completed during previous admissions each time
a patient was admitted.
A lot of these people in the medical ward are
frequent flyers (FG2) it doesnt matter whether
theyve only been in 36 hours ago, somethings
obviously happened (FG1) Just pop in details
101

R. Langdon et al.

that have changed since last time they were


in.
(FG2)
Concerns were also raised about how applicable the
form was for all patients. For example, it was thought
that the falls risk was unnecessary for young patients,
while a general reluctance to ask older people about
their mental health was also expressed. Further, completing the malnutrition screen for cancer patients was
considered inappropriate as they were losing weight due
to their disease.
As for the mental illness form screen, it embarrasses a lot of older people being asked have they
previously seen a psychiatrist of a mental health
professional.
(FG2)
These thoughts were reflected in how participants
asked questions and completed the form. Participants
noted they often used their clinical judgement of a patient in deciding whether or not to ask specific questions
or, if the questions were asked, in how they worded
their queries.
By the time you get up to the delirium and the
cognitive impairment youve usually worked it out
by that stage (FG2) you can put it in a more
subtle way or in a roundabout way to get that
answer you need.
(FG1)
Participants also found they did not complete the
whole or part of the form due to the presenting problem
or the type of admission. Participants thought it not
relevant to complete the form for an otherwise healthy
patient coming in for elective surgery.
coming in overnight for a hernia repair, I dont
think a full assessments necessary (FG1) A lot
of this stuff isnt really relevant for a one night
stay.
(FG2)
While the form was generally thought worthwhile,
participants noted that it was onerous to complete, and
that completing one section often led to extra work on
top of an already heavy workload.
they might only have one drink a night and
youve still got to fill out that whole form its
really daunting to fill that out because you know
that youre going to have to fill out another form.
That really puts you off.
(FG2)
Completion of form (how)
Reflecting on their heavy workload, and well aware of
the demanding nature of some departments, partici102

pants felt that the form should be able to be completed


by multiple health professionals across the course of
the patients admission.
ED can be busy how possible would it be to
start down there? I find often the discharge
stuff can be not filled in properly and Im just
wondering if, maybe, the doctors could put a bit
more in there?
(FG1)
Suggestions were also made regarding how the form
could be completed to make it easier. Some departments
entered the information online, while other participants
thought it would reduce their workload if they could
put stickers (FG1) on the form to indicate whether a
referral had been made or whether a risk screen had
been completed.
Use of form/patient outcomes
The form was considered to be beneficial to patients in
that it provided an opportunity to assess risk and
therefore to improve patient care and health outcomes
for the patient.
I think it has improved our falls assessment because theres a tool. I think it has improved our
pressure area care (FG2) You probably miss
less because youre looking at a lot more. (FG1)
Participants noted they became more aware of the
needs and risks of individual patients and were more
likely to carry out preventative activities due to their
assessment of the patient.
filling that in theres more strategies put
into place, even if theyre not always documented
awareness goes up with the use of the tool.
(FG2)
While most participants viewed the form in a positive
manner, some believed there was no improvement in
patient care simply as a consequence of the introduction
of the form. It was felt, rather, that specific education
supplied by clinical nurse educators was responsible for
health practitioner awareness and improved patient
care.
things like falls prevention and pressure things
the educators role has been more significant
in preventing.
(FG2)
However, the importance, in terms of care planning,
of being able to refer back to a comprehensive patient
assessment was noted. Participants felt that the form
provided an opportunity to gain a holistic picture of the
patient.
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105

Assessing risk in the elderly

We look at this document to see whats written


there. Its very important. We wouldnt know our
patients.
(FG1)
Some participants, however, felt the form was not
being used to its full advantage. That is, while the
information was gathered and available for health
professionals to use, current documentation practices
needed to be improved in order for the full potential of
the form to improve patient outcomes to be realized.
I wonder how many times people are double referred Ill hear them say we must refer them to
so-and-so and I know last week they were referred
to so-and-so It just seems to go on this form, its
just filed away, and nobody reads it again. (FG2)

Discussion
The introduction of the APAT has increased nursing
actions relating to falls and pressure areas and also resulted in increased referrals to other health professionals, for example, physiotherapists and speech
pathologists. The completion rates for some sections of
the APAT increased from 2005 to 2009, namely the
falls risk screen, the malnutrition screen and the mental
illness risk screen.
Overall, the nurses attitude towards the APAT was
positive, with important areas of the form, such as the
falls risk screen and the pressure area assessment more
likely to be completed. The completion of these
assessments has resulted in an increase in referrals and
nursing interventions, highlighting the importance of
documentation as a guide to nursing action (Jefferies
et al. 2010, Johnson et al. 2011). However, sections
facilitating discharge (discharge checklist, transport
arrangements) and long-term care to prevent readmission (follow-up appointments), while completed, were
not done so as diligently.
Although the APAT was perceived by nurses to be
lengthy, they also recognized that having a comprehensive list of screening criteria prompted them to take
action where previously they may not have. As one
participant in the focus groups noted, awareness goes
up with the use of the tool. One of the most promising
outcomes of the introduction of the APAT was the increase in the number of nursing activities undertaken,
especially in relation to the relief of pressure areas and
falls, confirming that nurses are more likely to carry out
preventative activities once patients are identified as
being at risk (Uden et al. 1999, Gunningberg et al.
2000, Jefferies et al. 2010). Similarly, assessment of
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105

cognitive impairment and subsequent referrals also increased.


A criticism often levelled at nursing documentation is
that it is incomplete, therefore leading to inconsistency
and duplication of care (Taylor 2003). Nurses noted the
importance of the form in terms of care planning in that
they were able to refer back to the comprehensive
patient assessment and gain a holistic picture of the
patient. The term comprehensive has been used to
describe the nature of the assessment, that is, assessing
risk across multiple domains for all patients. The term
holistic was used by nurses to describe the approach to
care of the patient, inclusive of broader psychosocial
issues.
Nurses, as health professionals, are concerned not
only with the medical condition of the patient, but also
the overall well-being of the patient, and the APAT
provides a valuable opportunity to gather non-health
related information and record it somewhere. Nonhealth related information facilitates health care by
allowing nurses to calm the patient when agitated
and make the patient feel more comfortable in their
surroundings.
While acknowledging the usefulness of the APAT,
nurses felt it was burdensome and onerous to complete,
especially when considering certain patient characteristics or presenting problems. Nurses felt it was
unnecessary to complete all sections on the APAT for
patients who came in to hospital for elective surgery
(e.g. hernia repair) and who were otherwise healthy.
This reluctance to complete every section on the APAT
for every patient may account for the low completion
rate of some sections (e.g. complementary therapies,
etc). Tailoring the APAT and identifying areas deemed
not applicable for the clinical caseload would therefore
be beneficial.
Mental health assessment and referral was especially
low. This may be accounted for by an overall reluctance
to ask older patients about their mental health status for
fear of embarrassing them or creating tension. However, nurses did acknowledge the importance of mental
health information when talking to patients to calm
them. Thus, to gather such information, nurses often
used their clinical judgement and rephrased questions.
While the APAT was initially designed to be a multidisciplinary assessment, the findings of this study
suggest there is little engagement by disciplines other
than nursing. Further compounding this issue, certain
items on the APAT represent initial screening criteria
for other more comprehensive sections. This seems to be
a barrier to nurses willingness to complete the initial
screening criteria when relevant to the patient.
103

R. Langdon et al.

Nurses also expressed reluctance to assess a patient for


substance use citing the absolute nature of the questions
on the APAT. That is, the need to complete the substance use history if the patient had only one drink a
night. Again, nurses tended to use their clinical judgement when asking questions relating to substance abuse.
Non-completion of the APAT, however, forms only
one aspect of nurses experiences. Nurses often raise
concerns that their documentation is not read (Bjorvell
et al. 2003), a view expressed by many of the focus
group participants that it was filled out and filed
away and nobody reads it again. It is therefore imperative that a clear process be articulated regarding the
completion of the APAT in that it represents a screening
tool with referral pathways and requires subsequent
nursing intervention. This is important not only for
treatment and referrals within a hospital admission, but
also as a way to gauge health improvement or deterioration between hospital admissions and to better manage patient care. As one nurse stated, many of the
patients they see are frequent flyers and it would be
beneficial to the treatment of the patient to be able to
add or alter details that have changed since the last time
they were in. This illustrates the importance of comprehensive assessments in allowing health care professionals to develop and implement appropriate care
plans (Cheevakasemook et al. 2006).
While in many cases referrals were considered
unnecessary, a proportion of patients were referred to
other health services/professionals. Nurses expressed
concern about the management of referrals and the
duplication of work, suggesting that any referrals made
could be better managed within the team if stickers
were placed either on the APAT or the medical record
to note that a referral had already been arranged. It is
important to note, however, that referrals are sometimes not made even when indicated, as the availability
of services varies between hospitals.
Some health facilities are introducing an electronic
medical record, enabling the storage and retrieval of
comprehensive nursing assessment forms. This would
provide a means of improvement in the health care of
patients both while in hospital and referrals upon discharge.

Limitations
Although data were collected for cognitive impairment, delirium, substance abuse and mental health,
the proportion noted as not applicable was high,
making the reporting and interpretation of the data
difficult.
104

Similarly, the sample size used in the testing of


referrals to mental health professionals was low and
further research is needed to confirm or refute the differences reported here.

Conclusion
Nurses have become more aware of the health care
needs of the patient as a result of the comprehensive
patient assessment they carry out. This has resulted in
an increase in the number of nursing actions taken,
especially in relation to falls and pressure areas. Nurses are also able to take advantage of the non-clinical
information gathered and take a more holistic approach to patient care. Electronic medical records
provide an opportunity to store and retrieve comprehensive nursing assessments that would relieve the
pressure on nurses time and benefit patient health
care.

Implications for nursing management


The APAT represents a comprehensive assessment tool
for nursing that encourages early intervention of identified risks in older people and can be used in general
medicalsurgical areas as well as specialized aged care
facilities. The APAT is a practical tool that supports
quality care planning while meeting the needs of health
policy. Information collected through the assessment
assists in developing the plan of care and increasing
referrals, particularly in relation to patient falls and
pressure areas. Regular audits of the APAT enhance the
completion rates of this comprehensive assessment tool.
Managers and educators are key figures in implementing and supporting a comprehensive assessment approach to older people, such as the APAT, within health
services.

Acknowledgements
The authors would like to acknowledge Steve Curtis (Lismore
Base Hospital) and Stuart Garland (Coffs Harbour Base
Hospital) for their hard work in data entry, insightful comments about the data entry form, and facilitating the focus
groups at their respective hospitals. The authors would also
like to acknowledge the nurses who volunteered their time to
participate in the focus groups.

Source of funding
Funding for the project was provided by the Clinical
Governance Unit of the North Coast Area Health
Service.
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105

Assessing risk in the elderly

Ethical approval
Ethical clearance was obtained from the South Western
Sydney Area Health Service Human Research Ethics
Committee (CGRH) (09/CGRH/6, CH62/6/2009009)
and the North Coast Area Health Service Research
Governance Unit.

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