An Exploration of the Lived Experience of Receiving and Providing an Intentional Compassionate Communication Intervention (ICCI) for Older People While in Accident and Emergency Department

1.1 Background The number of hospital emergency admissions has dramatically increased in England, by 42%, over the last 12 years (The Health Foundation 2018). 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 (Baraff et al. 1992; Olsson and Hansagi 2001; Nystrom et al. 2003) and this perception was often accompanied by physical pain (Britten and Shaw 1994). The situation is one in which patients feel vulnerable, anxious, stressed and fearful (Olsson and Hansagi 2001; Kihlgren et al. 2004).

In the UK, nearly a quarter of the people arriving at A&E are over 65 years (Geddes 2013), 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 (The Health Foundation 2018). 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 (Sorrel 2010).

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 (Reynish et al. 2017). 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 (NHS 2018). However, if not addressed delirium can become a serious complication which can lead to longer length of stay in hospital and higher mortality (Witlox et al. 2010). 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 (Bo et al. 2016).

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 (Olsson and Hansagi 2001; Kihlgrenet al. 2004) and that the attitudes of nurses in A&E are often perceived as indifferent and inattentive, thus causing a feeling of exclusion and disappointment (Olofson et al. 2012). Empathy and compassion are perceived by patients to be the most significant elements of good care in A&E (Kihlgren et al. 2005).

Compassionate Care is not a new concern for the NHS but following high profile failings (Francis 2013) government policies such as the Compassionate Care in the NHS (Department of Health 2015) have been introduced, further emphasising the importance of humanised care (Todres et al. 2009). 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 (Singh et al. 2013), to the challenges experienced by nurses expected to deliver compassionate care, who often struggle to align the reality of practice to their ideals (Curtis et al. 2012).