Nurses' harm prevention practices during admission of an older person to the hospital: A multi-method qualitative study.
Bernice Redley, Tracy Douglas, Leonard Hoon and 2 others
PMID 35799461WHAT IT FOUND
Nurses prioritized cognition, vitals, and nutrition early in admission, but often delayed or omitted falls, skin, and continence assessments due to workload.
They relied on rapid visual cues to flag risks, sometimes missing subtle signs in older patients.
Key findings
01Nurses almost always prioritized clinical needs like cognition and vitals over functional factors such as falls prevention and skin integrity, which were often delayed or omitted.
02Nurses used rapid pattern recognition and visual cues to identify 'Red Flags' for high-risk patients, but this heuristic approach could miss subtle cues or lead to misinterpretation.
03Incomplete handover information and gaps in electronic records were major barriers, causing nurses to waste time searching for missing data and increasing the risk of missed care.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
Convenience sampling at a single health service limits transferability. The interactive nature of workshops may have influenced participant responses (response bias). Observations were limited to eight admissions, which may not capture the full range of admission scenarios. The study focused on nurses' experiences and behaviors, not patient outcomes, so it cannot prove that these practices led to harm.
Declared interests
The lead author was supported by an NHMRC fellowship and a research grant from the Nurses Board of Victoria Legacy Limited Mona Menzies Research Grant. No commercial conflicts of interest were declared.
The easy way to misread this
Do not interpret the omission of falls and skin assessments as negligence. The study shows these omissions were often a result of prioritizing immediate clinical risks and managing overwhelming workload and interruptions, rather than a lack of knowledge or intent.