Nursing and Health Sciences (2003) 5 253ndash259

Blackwell Science LtdOxford UKNHSNursing and Health Sciences1441-07452003 Blackwell Publishing Asia Pty LtdDecember 200354253259Research ArticleChallenges conducting research in older patientsK Hancock

et al

Correspondence address Esther Chang Professor and Director of Inter-national and Business University of Western Sydney School of NursingFamily and Community Health Parramatta Campus Penrith South DCNSW 1797 Australia Email echanguwseduauReceived 2 December 2002 accepted 30 April 2003

Research Article

Challenges in conducting research with acutely ill hospitalized older patients

Karen Hancock1 phd bsc(hons) Lynn Chenoweth2 phd ba ma (hons) m ad ed rn and Esther Chang1 phd bappsc (adv nurs) m ed admin rn1University of Western Sydney School of Nursing Family and Community Health Parramatta Campus Penrith South DC and 2Health and Aging Research Unit Waverley University of Technology Sydney NSW Australia

Abstract The older population is the largest consumer of health care yet little is known about their nursingneeds during acute hospitalization In undertaking a study to address this issue the researchersfaced many challenges that were related to the complexities of researching acutely ill hospitalizedolder patients The purpose of the present discussion paper is to present some of the methodolog-ical and pragmatic factors that were encountered so that health professionals and researchers canbe aware of the potential obstacles when researching this important area and plan researchaccordingly Potential barriers included the complexity of illness in the older person as a result ofcomorbidity and iatrogenesis fatigue normal age-related processes such as visualhearing impair-ment frequent ward transfer or early discharge delirium or dementia and high staff turnoverresulting in difficulties in coordinating the study This paper raises the importance of balancing theneed to maximize the rigor of research and the needs of participants Recommendations for futureresearch are made

Key words acute care hospital setting methodological difficulties older patient research vulnerability

BACKGROUND

Australians aged over 65 years of age represent 12 ofthe population yet they represent 31 of hospitaladmissions and consume 39 of total expenditure onacute hospital services (Australian Institute for Healthamp Welfare (AIHW) 1997 1999) Half of all inpatientacute-care admissions in the USA are for people overthe age of 75 years (Fulmer amp Walker 1992) Not onlyare older people over-represented in terms of hospitaladmissions they generally have longer hospital stayswith the average being 73 days compared with 45 daysfor all age groups (AIHW 1999) and 10 times longerstays than younger age groups (Duckett amp Jackson1999) The length of stay is even higher for patients 75years or older who generally have reduced physiolog-ical reserves and depressed immune system functions

and therefore slower recovery rates and a greater levelof dependence (AIHW 1997) They are also morelikely to exhibit chronic health conditions with acuteepisodes The proportion of older people in the com-munity is expected to increase (Australian Bureau ofStatistics (ABS) 1996) which is likely to lead toincreased hospital admissions length of stay and read-mission rates This increased demand and concomitanthealth budget restrictions calls for an emphasis onquality and efficiency of nursing care for older people

ACUTELY-ILL OLDER PATIENTS

There is a lack of research that has investigated thenursing needs of older patients during hospitalizationfor an acute illness which is disturbing given that theyare the major users of health care Hospitals are notalways beneficial places for older patients Not only areolder people more likely to experience a deteriorationin their health during hospitalization they oftenpresent with a multitude of chronic illnesses (Duckettamp Jackson 1999) Multiple illnesses can lead to multi-ple drug prescribing increasing the risk of drug inter-

254 K Hancock et al

actions and adverse drug reactions (National Health ampMedical Research Council (NHMRC) 1994) Duringthe early phase of hospitalization it is quite commonfor the older patient to experience episodes of confu-sion disturbed behavior incontinence and immobility(NHMRC 1994) Adding medical or surgical interven-tions to the combination of the normal aging processand illness takes a toll on older people experiencingprolonged inactivity or bed rest Inouye et al (1993)reported that one-third to half of hospitalized olderpatients lose function for reasons not related to theirprimary diagnosis

It is crucial to understand the needs of hospitalizedolder patients because if timely and purposeful healthcare does not occur during acute care hospitalizationcan trigger a negative spiral of processes that ulti-mately results in institutionalization (NHMRC 1994)

The authors conducted a research study on whichthe present discussion paper is based in response tothis area in need of research The aim was to identifynursesrsquo patientsrsquo and their carersrsquo perceptions of theimportance of and satisfaction with various aspects ofnursing care During the implementation of this studyseveral difficulties were encountered in conductingthe research which may partly explain why there is alack of research reported on older patients in thisarea While this is a priority area of research evi-denced by the Australian Governmentrsquos pledge to findnew ways of providing care to vulnerable patients(NSW Health Council 2000) it is also important thatresearchers be aware of the methodological difficul-ties encountered in investigating older patients duringacute hospitalization The aim of this paper is to dis-cuss the challenges faced in the implementation ofsuch research This information can assist researchersto plan their research to minimize these problemswhile at the same time preserving the needs of olderpatients

STUDY DESIGN

Following a pilot study of 10 patients 231 patients whowere admitted to hospital for an acute illness wererecruited for the present project The project wasdesigned to determine the importance of variousaspects of nursing care for older patients during hospi-talization as perceived by nurses the patients and theirfamily membercarer These perceptions were com-pared with perceptions of the reality of care providedand reasons for a mismatch were identified The Nurs-ing Unit Managers (NUM) on each ward assisted theresearcher to recruit subjects

This study employed a validated Likert-type ques-tionnaire that asked patients to rate the importance of

and satisfaction with various aspects of nursing carePatients were also asked open-ended questions toaddress any other aspects of nursing care they believedwere important and to discuss any other relevantissues related to their nursing care The researcherassisted the patient and family member (if needed) tocomplete the questionnaire Nursing staff and patientcarersfamily members were also asked to completethe questionnaire The process usually took approxi-mately 45 min but sometimes the process was lengthydue to various factors as discussed shortly

Ethical approval was gained from the relevant hos-pitals and universities involved The process of obtain-ing consent was a lengthy one as the researchers wereaware of the vulnerability of this population group (egHarris amp Dyson 2001) and were mindful of not lsquoover-burdeningrsquo possible participants The researchers whowere all registered nurses spent a short time chattingto patients before seeking consent in order to gaugetheir cognitive status their ability to understand thenature of the study and to communicate with theresearcher and to determine whether they were wellenough to participate Wellness was determined by thepatientrsquos self-report the researcherrsquos clinical assess-ment and by the nurse caring for the patient Prior tocompleting the questionnaire patients were assessedon their level of cognitive functioning using the Mini-Mental State Examination (MMSE) scale a reliableand valid tool developed by Cockrell and Folstein(1988) and their level of ability to perform activities ofdaily living (ADL) employing the Barthel Index(Mahoney amp Barthel 1965)

DIFFICULTIES ENCOUNTERED

Normal age-related changes affecting the research process

Other researchers have recognized that recruitingolder people to research is difficult (Uman amp Urman1990 Carter et al 1991 Harris amp Dyson 2001)Researchers need to consider special issues such asage-related sensory changes when communicatingwith older people during the course of research Aspeople age various physical changes can affect con-versation communication generally and thus theprogress of the research For example neurologicalchanges can affect comprehension and response rateas well as the speed at which information is processed(Heath 1997) Receptive ability can also be impairedby hearing deficits environmental distractions height-ened anxiety and altered level of consciousness(Heath 1997) During the current study the investiga-tors found that the time taken to administer question-

Challenges conducting research in older patients 255

naires and conduct interviews with acutely-ill olderpatients was usually longer than that for youngerpatients In order to overcome this problem it wassometimes necessary to interview in 15ndash20 min inter-vals and return a few times to complete the interviewwhich sometimes took up to 4 h of the researchersrsquotime compared to about 45 min to interview a youngerperson This occurred in approximately 12 of casesBeing mindful that the patients were required to beassessed on cognitive functioning and ADL and toread and sign a consent form and information sheetprior to completing the questionnaire and were likelyto be tired before they began completing the ques-tionnaire the researchers made a conscious decisionto allow the patient to rest for a time before engagingin the interview In such cases it was sometimes diffi-cult to complete the questionnaire with the patient onthe same day and when returning to interview thepatient may have been moved to another wardbecome ill or been discharged

For visually impaired older patients the researchersfound it necessary to either read each item on the ques-tionnaire out aloud (which considerably increased thetime to perform the interview) or use enlarged printOn occasions an enlarged Likert-scale was displayedon cardboard and the patient pointed to the corre-sponding number on the scale For patients with hear-ing loss the researchers found that it was important toreduce the pace at which the questions were deliveredensure that they were facing the patient and to speakmore loudly They also found that some patientsrsquo abil-ity to articulate their answers was hampered by respi-ratory or laryngeal disease This was often found to bethe case with patients in the respiratory or medicalwards In a few cases patients who were receiving med-ication regularly via a nebuliser wished to continuecompleting the questionnaire (however in most casesthe interviewer waited until medication had beenadministered) Use of the cardboard was useful inthese situations described

Use of questionnaires in older patients

Considering the various sensory changes and compli-cations that arise in an ill older person it is importantthat researchers consider the appropriateness of theuse of questionnaires particularly those of a lengthynature In planning this research the authors madeevery effort to use a validated tool that was not toocomplicated or lengthy In retrospect the researchersbelieve the questionnaire was too lengthy Future stud-ies should develop and validate shorter tools that reli-ably measure the construct in question for olderpatients

Patient vulnerability and consent

Another reason that the recruitment and interviewprocess was so lengthy in the present study was that theresearchers were ethically bound to ensure that theydid not abuse the vulnerability of older patients Olderpatients are often frail and in a dependent state andthey may feel compelled to consent to research thatthey either not well enough or do not wish to partici-pate in Harris and Dyson (2001) suggest that olderpeople may be suspicious of research studies becauseof feelings of vulnerability or previous experiences Aconsiderable proportion of time was devoted to con-sent ensuring that patients were fully informed of theresearch and offering assurance that they were free torefuse to participate Patients were assured that theirrefusalwithdrawal of consent would not affect theirnursing or hospital care In approximately 10 of casespatients refused to consent because the initial screen-ing process had taken so long and they were too tiredto continue Only a few cases actually refused becausethey were not interested in participating In a handfulof cases patients freely consented but their family car-ers or other family members intervened and stated thatit was in the patientrsquos best interest to rest andor spendthe time with their family rather than complete thequestionnaire

The researchers were constantly aware of the needto preserve the rights of these patients and not over-burden them with the research process Patients wereregularly asked if they were tired or feeling unwell andwhether they would like to cease the interview and theresearcher would return at a more appropriate timeOne of the possible consequences is that interviewingover several occasions could affect the reliability andvalidity of findings However as discussed this onlyoccurred in approximately 12 of cases

Harris and Dyson (2001) suggest that in order tomaximize involvement of older people in researchwhile protecting their right to refuse researchers needto be well-prepared have good communication skillsand be flexible in the way they explain the research andassess understanding of this information They contendthat researchers need to be aware of the difficultiesin recruiting older people to research and to allowample time to collect enough data Ultimately non-exploitation of this group depends on the integrity andawareness of the researcher (Harris amp Dyson 2001)

Owen (2001) also discusses the practical method-ological and ethical dilemmas of conducting researchwith vulnerable clients In Owenrsquos study focus groupswere used to ascertain perceptions of women with seri-ous and enduring mental health problems about theservices they received A major obstacle was the time

256 K Hancock et al

and effort taken to gain access to the women The nextdifficulty was ensuring that the women selected wouldbe willing and able to participate Owen also empha-sized that the researcher as facilitator requires substan-tial interpersonal skills Owen like Harris and Dyson(2001) suggests that researchers should be realisticabout the amount of time it will take to access vulner-able clients The authors also concur with this view

Patient loneliness

During the course of the interview the researchersfound that some of the patients reported that they hadfew visitors or sources of support For some patientsthe interview and questionnaire was an opportunity forsocial interaction rather than simply answering ques-tions on the researcherrsquos agenda It was important tobuild a rapport with the patient by encouraging com-munication and adopting active empathetic listeningHowever sometimes it was difficult to steer the patienttowards completing the questionnaire as they seemedto have a great need to express their thoughts andfeelings generally As a consequence the time takento complete the interviewquestionnaire was oftenlengthy or required multiple visits

Possible bias in patient satisfaction due to lack of privacy

Related to the discussion on questionnaires is the mea-sure of patient satisfaction Patient satisfaction hasbeen seen as a measure of quality with questionnairesthe most commonly used because of their ease and lowcosts (Thomas amp Bond 1996) Problems with patientsatisfaction surveys have been extensively discussed(Lin 1996 Shaw 1997) These include lack of sensitiv-ity discrimination power reliability and validity andtheir extremely positive results (Poulton 1996Salmela 1996) Thus while the goal of patient satisfac-tion questionnaires is to contribute to quality improve-ment such positive responses may assist in maintainingthe status quo and hindering positive developmentinnovation and change (Redfern amp Norman 1990Salmela 1996)

The current research requested that patients befrank in their assessment of the quality of care theyreceived and emphasized the importance of doing toensure quality of care for older patients However incases where the patients were unable to complete thequestionnaire independently and silently during theinitial stages of the research it was observed thatsometimes patients gave different responses when thenurse was present (eg tending to other patients in theroom or administering medication) That is patients

may have been afraid of criticizing particular aspectsof nursing care when nurses were within hearingrange This observation is likely to be related to thepatientrsquos sense of vulnerability in that they are depen-dent on nursing staff to have their needs met (eventhough the consent form emphasized that participa-tionnon-participation in this research would notaffect their nursing care) As all patients in this studyshared rooms with one or two other patients creatingthe likelihood that nurses would be attending to anyone of these patients during the course of the inter-view the researchers ceased interviewing until thenurse left the room so that responses were frank andconfidentiality was ensured One way of minimizingthis problem was to request that patients were inter-viewed in the lounge area or a private place Howeverthis was often not feasible as the lounge area was alsoused by other patients and their visitors with nursesproviding some aspects of treatment to patients thereSome patients were not able to leave their bed for thispurpose

Pragmatic issues

The following practical difficulty in conductingresearch in acute care wards is not isolated to olderpatients but applies to all acutely-ill patients Theresearchers found that eligible patients were often notavailable when the researcher arrived at the wardbecause the patient was sleeping being attended tohad visitors was out of the ward having proceduresperformed or had died Such incidents required theresearchers to be patient and flexible in their approachto the situation and willing to return to the ward onseveral occasions in order to complete the researchSimilar difficulties researching other acutely-illpatients have been reported elsewhere (Craig ampHancock 1994)

Due to the increased pressure to move patientstowards early discharge the researchers frequentlyfound that the patient had left the ward as a transfer orwas discharged even though previous arrangementshad been made between the researchers staff andpatients to interview the patient on specific days andtimes Occasionally this occurred within half a day ofbeing screened or even a few hours Once again flex-ibility in locating patients for recruitment was requiredIn the case of those who were discharged the patientwas eliminated from the sample and new patientsneeded to be recruited

Harris and Dyson (2001) found that the times toavoid approaching a patient for recruitment were dur-ing meal-times immediately after physiotherapy aftera painful dressing change or immediately after an unto-

Challenges conducting research in older patients 257

ward incident such as a fall The researcherrsquos experi-ence with this study concurs with these findings

Delirium (acute organic brain syndrome acute confusion) and dementia

For many older people the hospital environment is dis-orientating and threatening and can lead to the devel-opment of acute confusion (Creditor 1993) Whilemany older patients are admitted to hospital with delir-ium many more develop the condition in hospital withat least 16 of admissions being affected (Franciset al 1990) The prevalence of delirium in older post-operative patients is even greater (Levkoff et al 1990)Tolson et al (1999) found that 66 of 213 people aged65 years or older who were admitted for acute hospi-talization had cognitive impairment with 40 experi-encing severe problems One of the consequences ofthis is that it is not possible to interview the patientwhen they are experiencing an acute confusional epi-sode This may mean having to return at a later datewhen the confusion has subsided or excluding thepatient altogether if the confusion does not resolve Itwas the researcherrsquos experience that often when reso-lution occurred the patient had been moved to anotherward or discharged As a result practical issuesimpinged on the research such as having to explain thestudy to a new ward NUM and seeking assistance fromstaff In some cases the nursing staff were not awarethat the patient was becoming confused and this wasnoticed quite markedly when the researchers adminis-tered the questionnaire These patients could not par-ticipate until the period of confusion abated and thiswas up to 4 or 5 days later

Although the prevalence of dementia is less thandelirium in hospitalized patients it affects a significantproportion of older patients Dementia differs fromacute confusion in that dementia is a chronic problemcharacterized by a progressive and chronic loss ofmemory The overall prevalence of dementia is esti-mated at 63 with increases to around 30 for thoseaged 85 years and over (Ott et al 1995) Obvious dif-ficulties in conducting research that requires the use ofquestionnaires or interviews with patients who havedementia is that it is difficult to obtain valid reliabledata from such patients While the use of exclusion cri-teria can optimize internal validity or make a studymore feasible by excluding for example patients whoare unable to respond to a questionnaire because theyhave dementia exclusion criteria can have negativeimplications for the generalizability (or external valid-ity) of results to real-world practice settings (Hum-phreys amp Weisner 2000) Thus the clinical use offindings is limited

In the present study to exclude all patients with anyform of dementiacognitive impairment would meanthat the findings only apply to coherent patients in theacute care setting A panel of experts including eightclinical nurse consultants in aged and psycho-geriatricnursing three NUM of aged-specific wards a principaldirector of nursing three community aged care nursestwo geriatricians and the aged care worker of a multi-cultural health unit were consulted for this study Itwas their clinical impression that patients with low-level dementia (Alzheimers Assocation 2001) still pos-sess insight and understanding such that they wouldhave the capacity to complete the questionnaire Allpatients included in this study were assessed for cogni-tive states using the MMSE scale It was agreed by thepanel and research team that any patients who scoredless than 19 on the MMSE should be excluded Suchcriteria would increase the external validity of thepresent studyrsquos findings

The exclusion of older patients with moderate tosevere dementia in aged care research substantiallylowers the subject base for research The costs in termsof resources used (both time and financial) to assessthese patients for eligibility only to exclude them forthe reasons cited earlier needs to be considered whenconducting such research For both scientific and ethi-cal reasons in addition to studies that use exclusion cri-teria research should also be conducted with patientswho have a low level of dementia so that findings canbe better generalized to vulnerable populations Bycomparing patients who were excluded with those notexcluded one can estimate the extent to which the cri-terion produces differing outcomes However it isimportant to be mindful of the practical difficultiesinvolved in this research as reported by Tolson et al(1999)

Staff issues

The transient nature of staffing and high turnovermeant it was necessary to explain the study to nursingstaff each time the researchers visited the wards result-ing in inconsistency in staff assistance with the studyFurthermore permanent staff were often occupiedwith orienting part-time and casual staff to the issuespresenting for patients and changed care plans on adaily basis It was also the case that some staff membersspent considerable time identifying eligible patients forthe researchers only to find that the pragmatic issuesdiscussed above prevented recruitment of the patientUnderstandably staff became frustrated at what theyconsidered a waste of their time Thus it was sometimesdifficult to obtain the agreed amount of supportneeded from nursing staff to recruit patients and even

258 K Hancock et al

complete staff questionnaires This impacted signifi-cantly on time management efficiency in data collec-tion and maintenance of regular contact with wardstaff

Timing of assessment

One way of overcoming many of the problems encoun-tered in the current study is to ask patients to completethe questionnaire following discharge when they arenot as ill However such data is retrospective and thevalidity of questionnaires that rely on memory is there-fore questionable Retrospective data has validity andreliability problems in any population but older peo-ple in particular may have difficulties with short-termmemory To interview patients at home may mean thatthe researchers never discover the lsquoreal storyrsquo ofpatientsrsquo perceptions as the change in context mayhave clouded patientsrsquo responses Thus although notan ideal solution such a technique may have somevalue in attempting to determine the needs of olderpatients particularly if attempts to assess patients dur-ing hospitalization have proven to be unsuccessful Astudy by Thomas et al (1996) found no significant dif-ferences in either experience or satisfaction scoresbetween questionnaires given in hospital or at homeHowever a lower response rate occurred with retro-spective data It is difficult to generalize these findingsto older patients as the study was conducted onpatients in general

CONCLUSION AND RECOMMENDATIONS

The study of older patientsrsquo needs during an acute ill-ness in hospital is an area in great need of researchHowever various factors make it difficult to conductsuch research in a significant proportion of olderpatients It is important that researchers be prepared toallow increased time to accommodate these factorsWhile researchers should make every effort to involvestaff in the research process and ensure lines of com-munication are kept open the factors described in thepresent paper may make it more difficult to gain thenecessary assistance from staff

It is important that researchers are not deterredfrom conducting research with older patients so thateffective quality nursing care during hospitalization isensured Anticipating potential barriers such as thosediscussed in this paper can assist researchers in plan-ning their research in order to facilitate and enable theinvolvement of acutely-ill older people in researchFactors which may enhance the research processinclude allowing more time and opportunities forassessmentsinterviews to occur rather than on one

occasion because of illnessfatigue and factors such astransfer to other wards nursingmedical procedures orvisitors developing rapport with patients throughactive listening being patient and flexible and usingquestionnaires that are both simple and short in lengthAs a last resort retrospective data obtained after thepatient is discharged may be used when acute assess-ment is too difficult However this may lower thevalidity and reliability of the results given the change incontext and short-term memory loss factors discussed

The current paper identifies the issue of balancingthe need to maximize the rigor of research and theneeds of participants It is hoped that not onlyresearchers benefit from this discussion but that hos-pital-based nurses gain insight into the research pro-cess and may possibly be more able to assistresearchers in dealing with the challenges at the lsquocoalfacersquo of hospital-based research in older patients

ACKNOWLEDGMENT

The present study was funded by an AustralianResearch Council Linkage Grant and University ofWestern Sydney Partnership grant

REFERENCES

Alzheimers Assocation Welcome to the AlzheimerrsquosAssociation of WA Inc 2001 Available from httpwwwalzheimersasnau

Australian Bureau of Statistics (ABS) Projections of thePopulation of Australia States and Territories 1995ndash2001Canberra ABS 1996

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1995ndash96 Canberra AIHW 1997

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1997ndash98 Canberra AIHW 1999

Carter W Elward K Malmgren J Larson E Participation ofolder adults in health programs and research a criticalreview of the literature Gerontologist 1991 31 584ndash592

Cockrell J Folstein M Mini-Mental State Examination Psy-chopharmacol Bull 1988 24 689ndash692

Craig A Hancock K Difficulties in implementing cognitivebehaviour therapy for spinal cord injured persons a clini-cal discussion Australian Psychologist 1994 29 98ndash102

Creditor M Hazards of hospitalization of the elderly AnnIntern Med 1993 118 219ndash223

Duckett S Jackson T Do the elderly cost more Casemixfunding in acute care settings In Nay R Garratt S (eds)Nursing Older People Issues and Innovations MelbourneMaclennan amp Petty 1999 3ndash171

Francis J Martin D Kapoor W A prospective study of delir-ium in hospitalized elderly J Am Med Assoc 1990 2631097ndash1101

Fulmer T Walker M Critical Care Nursing of the ElderlyNew York Springer 1992

254 K Hancock et al

actions and adverse drug reactions (National Health ampMedical Research Council (NHMRC) 1994) Duringthe early phase of hospitalization it is quite commonfor the older patient to experience episodes of confu-sion disturbed behavior incontinence and immobility(NHMRC 1994) Adding medical or surgical interven-tions to the combination of the normal aging processand illness takes a toll on older people experiencingprolonged inactivity or bed rest Inouye et al (1993)reported that one-third to half of hospitalized olderpatients lose function for reasons not related to theirprimary diagnosis

It is crucial to understand the needs of hospitalizedolder patients because if timely and purposeful healthcare does not occur during acute care hospitalizationcan trigger a negative spiral of processes that ulti-mately results in institutionalization (NHMRC 1994)

The authors conducted a research study on whichthe present discussion paper is based in response tothis area in need of research The aim was to identifynursesrsquo patientsrsquo and their carersrsquo perceptions of theimportance of and satisfaction with various aspects ofnursing care During the implementation of this studyseveral difficulties were encountered in conductingthe research which may partly explain why there is alack of research reported on older patients in thisarea While this is a priority area of research evi-denced by the Australian Governmentrsquos pledge to findnew ways of providing care to vulnerable patients(NSW Health Council 2000) it is also important thatresearchers be aware of the methodological difficul-ties encountered in investigating older patients duringacute hospitalization The aim of this paper is to dis-cuss the challenges faced in the implementation ofsuch research This information can assist researchersto plan their research to minimize these problemswhile at the same time preserving the needs of olderpatients

STUDY DESIGN

Following a pilot study of 10 patients 231 patients whowere admitted to hospital for an acute illness wererecruited for the present project The project wasdesigned to determine the importance of variousaspects of nursing care for older patients during hospi-talization as perceived by nurses the patients and theirfamily membercarer These perceptions were com-pared with perceptions of the reality of care providedand reasons for a mismatch were identified The Nurs-ing Unit Managers (NUM) on each ward assisted theresearcher to recruit subjects

This study employed a validated Likert-type ques-tionnaire that asked patients to rate the importance of

and satisfaction with various aspects of nursing carePatients were also asked open-ended questions toaddress any other aspects of nursing care they believedwere important and to discuss any other relevantissues related to their nursing care The researcherassisted the patient and family member (if needed) tocomplete the questionnaire Nursing staff and patientcarersfamily members were also asked to completethe questionnaire The process usually took approxi-mately 45 min but sometimes the process was lengthydue to various factors as discussed shortly

Ethical approval was gained from the relevant hos-pitals and universities involved The process of obtain-ing consent was a lengthy one as the researchers wereaware of the vulnerability of this population group (egHarris amp Dyson 2001) and were mindful of not lsquoover-burdeningrsquo possible participants The researchers whowere all registered nurses spent a short time chattingto patients before seeking consent in order to gaugetheir cognitive status their ability to understand thenature of the study and to communicate with theresearcher and to determine whether they were wellenough to participate Wellness was determined by thepatientrsquos self-report the researcherrsquos clinical assess-ment and by the nurse caring for the patient Prior tocompleting the questionnaire patients were assessedon their level of cognitive functioning using the Mini-Mental State Examination (MMSE) scale a reliableand valid tool developed by Cockrell and Folstein(1988) and their level of ability to perform activities ofdaily living (ADL) employing the Barthel Index(Mahoney amp Barthel 1965)

DIFFICULTIES ENCOUNTERED

Normal age-related changes affecting the research process

Other researchers have recognized that recruitingolder people to research is difficult (Uman amp Urman1990 Carter et al 1991 Harris amp Dyson 2001)Researchers need to consider special issues such asage-related sensory changes when communicatingwith older people during the course of research Aspeople age various physical changes can affect con-versation communication generally and thus theprogress of the research For example neurologicalchanges can affect comprehension and response rateas well as the speed at which information is processed(Heath 1997) Receptive ability can also be impairedby hearing deficits environmental distractions height-ened anxiety and altered level of consciousness(Heath 1997) During the current study the investiga-tors found that the time taken to administer question-

Challenges conducting research in older patients 255

naires and conduct interviews with acutely-ill olderpatients was usually longer than that for youngerpatients In order to overcome this problem it wassometimes necessary to interview in 15ndash20 min inter-vals and return a few times to complete the interviewwhich sometimes took up to 4 h of the researchersrsquotime compared to about 45 min to interview a youngerperson This occurred in approximately 12 of casesBeing mindful that the patients were required to beassessed on cognitive functioning and ADL and toread and sign a consent form and information sheetprior to completing the questionnaire and were likelyto be tired before they began completing the ques-tionnaire the researchers made a conscious decisionto allow the patient to rest for a time before engagingin the interview In such cases it was sometimes diffi-cult to complete the questionnaire with the patient onthe same day and when returning to interview thepatient may have been moved to another wardbecome ill or been discharged

For visually impaired older patients the researchersfound it necessary to either read each item on the ques-tionnaire out aloud (which considerably increased thetime to perform the interview) or use enlarged printOn occasions an enlarged Likert-scale was displayedon cardboard and the patient pointed to the corre-sponding number on the scale For patients with hear-ing loss the researchers found that it was important toreduce the pace at which the questions were deliveredensure that they were facing the patient and to speakmore loudly They also found that some patientsrsquo abil-ity to articulate their answers was hampered by respi-ratory or laryngeal disease This was often found to bethe case with patients in the respiratory or medicalwards In a few cases patients who were receiving med-ication regularly via a nebuliser wished to continuecompleting the questionnaire (however in most casesthe interviewer waited until medication had beenadministered) Use of the cardboard was useful inthese situations described

Use of questionnaires in older patients

Considering the various sensory changes and compli-cations that arise in an ill older person it is importantthat researchers consider the appropriateness of theuse of questionnaires particularly those of a lengthynature In planning this research the authors madeevery effort to use a validated tool that was not toocomplicated or lengthy In retrospect the researchersbelieve the questionnaire was too lengthy Future stud-ies should develop and validate shorter tools that reli-ably measure the construct in question for olderpatients

Patient vulnerability and consent

Another reason that the recruitment and interviewprocess was so lengthy in the present study was that theresearchers were ethically bound to ensure that theydid not abuse the vulnerability of older patients Olderpatients are often frail and in a dependent state andthey may feel compelled to consent to research thatthey either not well enough or do not wish to partici-pate in Harris and Dyson (2001) suggest that olderpeople may be suspicious of research studies becauseof feelings of vulnerability or previous experiences Aconsiderable proportion of time was devoted to con-sent ensuring that patients were fully informed of theresearch and offering assurance that they were free torefuse to participate Patients were assured that theirrefusalwithdrawal of consent would not affect theirnursing or hospital care In approximately 10 of casespatients refused to consent because the initial screen-ing process had taken so long and they were too tiredto continue Only a few cases actually refused becausethey were not interested in participating In a handfulof cases patients freely consented but their family car-ers or other family members intervened and stated thatit was in the patientrsquos best interest to rest andor spendthe time with their family rather than complete thequestionnaire

The researchers were constantly aware of the needto preserve the rights of these patients and not over-burden them with the research process Patients wereregularly asked if they were tired or feeling unwell andwhether they would like to cease the interview and theresearcher would return at a more appropriate timeOne of the possible consequences is that interviewingover several occasions could affect the reliability andvalidity of findings However as discussed this onlyoccurred in approximately 12 of cases

Harris and Dyson (2001) suggest that in order tomaximize involvement of older people in researchwhile protecting their right to refuse researchers needto be well-prepared have good communication skillsand be flexible in the way they explain the research andassess understanding of this information They contendthat researchers need to be aware of the difficultiesin recruiting older people to research and to allowample time to collect enough data Ultimately non-exploitation of this group depends on the integrity andawareness of the researcher (Harris amp Dyson 2001)

Owen (2001) also discusses the practical method-ological and ethical dilemmas of conducting researchwith vulnerable clients In Owenrsquos study focus groupswere used to ascertain perceptions of women with seri-ous and enduring mental health problems about theservices they received A major obstacle was the time

256 K Hancock et al

and effort taken to gain access to the women The nextdifficulty was ensuring that the women selected wouldbe willing and able to participate Owen also empha-sized that the researcher as facilitator requires substan-tial interpersonal skills Owen like Harris and Dyson(2001) suggests that researchers should be realisticabout the amount of time it will take to access vulner-able clients The authors also concur with this view

Patient loneliness

During the course of the interview the researchersfound that some of the patients reported that they hadfew visitors or sources of support For some patientsthe interview and questionnaire was an opportunity forsocial interaction rather than simply answering ques-tions on the researcherrsquos agenda It was important tobuild a rapport with the patient by encouraging com-munication and adopting active empathetic listeningHowever sometimes it was difficult to steer the patienttowards completing the questionnaire as they seemedto have a great need to express their thoughts andfeelings generally As a consequence the time takento complete the interviewquestionnaire was oftenlengthy or required multiple visits

Possible bias in patient satisfaction due to lack of privacy

Related to the discussion on questionnaires is the mea-sure of patient satisfaction Patient satisfaction hasbeen seen as a measure of quality with questionnairesthe most commonly used because of their ease and lowcosts (Thomas amp Bond 1996) Problems with patientsatisfaction surveys have been extensively discussed(Lin 1996 Shaw 1997) These include lack of sensitiv-ity discrimination power reliability and validity andtheir extremely positive results (Poulton 1996Salmela 1996) Thus while the goal of patient satisfac-tion questionnaires is to contribute to quality improve-ment such positive responses may assist in maintainingthe status quo and hindering positive developmentinnovation and change (Redfern amp Norman 1990Salmela 1996)

The current research requested that patients befrank in their assessment of the quality of care theyreceived and emphasized the importance of doing toensure quality of care for older patients However incases where the patients were unable to complete thequestionnaire independently and silently during theinitial stages of the research it was observed thatsometimes patients gave different responses when thenurse was present (eg tending to other patients in theroom or administering medication) That is patients

may have been afraid of criticizing particular aspectsof nursing care when nurses were within hearingrange This observation is likely to be related to thepatientrsquos sense of vulnerability in that they are depen-dent on nursing staff to have their needs met (eventhough the consent form emphasized that participa-tionnon-participation in this research would notaffect their nursing care) As all patients in this studyshared rooms with one or two other patients creatingthe likelihood that nurses would be attending to anyone of these patients during the course of the inter-view the researchers ceased interviewing until thenurse left the room so that responses were frank andconfidentiality was ensured One way of minimizingthis problem was to request that patients were inter-viewed in the lounge area or a private place Howeverthis was often not feasible as the lounge area was alsoused by other patients and their visitors with nursesproviding some aspects of treatment to patients thereSome patients were not able to leave their bed for thispurpose

Pragmatic issues

The following practical difficulty in conductingresearch in acute care wards is not isolated to olderpatients but applies to all acutely-ill patients Theresearchers found that eligible patients were often notavailable when the researcher arrived at the wardbecause the patient was sleeping being attended tohad visitors was out of the ward having proceduresperformed or had died Such incidents required theresearchers to be patient and flexible in their approachto the situation and willing to return to the ward onseveral occasions in order to complete the researchSimilar difficulties researching other acutely-illpatients have been reported elsewhere (Craig ampHancock 1994)

Due to the increased pressure to move patientstowards early discharge the researchers frequentlyfound that the patient had left the ward as a transfer orwas discharged even though previous arrangementshad been made between the researchers staff andpatients to interview the patient on specific days andtimes Occasionally this occurred within half a day ofbeing screened or even a few hours Once again flex-ibility in locating patients for recruitment was requiredIn the case of those who were discharged the patientwas eliminated from the sample and new patientsneeded to be recruited

Harris and Dyson (2001) found that the times toavoid approaching a patient for recruitment were dur-ing meal-times immediately after physiotherapy aftera painful dressing change or immediately after an unto-

Challenges conducting research in older patients 257

ward incident such as a fall The researcherrsquos experi-ence with this study concurs with these findings

Delirium (acute organic brain syndrome acute confusion) and dementia

For many older people the hospital environment is dis-orientating and threatening and can lead to the devel-opment of acute confusion (Creditor 1993) Whilemany older patients are admitted to hospital with delir-ium many more develop the condition in hospital withat least 16 of admissions being affected (Franciset al 1990) The prevalence of delirium in older post-operative patients is even greater (Levkoff et al 1990)Tolson et al (1999) found that 66 of 213 people aged65 years or older who were admitted for acute hospi-talization had cognitive impairment with 40 experi-encing severe problems One of the consequences ofthis is that it is not possible to interview the patientwhen they are experiencing an acute confusional epi-sode This may mean having to return at a later datewhen the confusion has subsided or excluding thepatient altogether if the confusion does not resolve Itwas the researcherrsquos experience that often when reso-lution occurred the patient had been moved to anotherward or discharged As a result practical issuesimpinged on the research such as having to explain thestudy to a new ward NUM and seeking assistance fromstaff In some cases the nursing staff were not awarethat the patient was becoming confused and this wasnoticed quite markedly when the researchers adminis-tered the questionnaire These patients could not par-ticipate until the period of confusion abated and thiswas up to 4 or 5 days later

Although the prevalence of dementia is less thandelirium in hospitalized patients it affects a significantproportion of older patients Dementia differs fromacute confusion in that dementia is a chronic problemcharacterized by a progressive and chronic loss ofmemory The overall prevalence of dementia is esti-mated at 63 with increases to around 30 for thoseaged 85 years and over (Ott et al 1995) Obvious dif-ficulties in conducting research that requires the use ofquestionnaires or interviews with patients who havedementia is that it is difficult to obtain valid reliabledata from such patients While the use of exclusion cri-teria can optimize internal validity or make a studymore feasible by excluding for example patients whoare unable to respond to a questionnaire because theyhave dementia exclusion criteria can have negativeimplications for the generalizability (or external valid-ity) of results to real-world practice settings (Hum-phreys amp Weisner 2000) Thus the clinical use offindings is limited

In the present study to exclude all patients with anyform of dementiacognitive impairment would meanthat the findings only apply to coherent patients in theacute care setting A panel of experts including eightclinical nurse consultants in aged and psycho-geriatricnursing three NUM of aged-specific wards a principaldirector of nursing three community aged care nursestwo geriatricians and the aged care worker of a multi-cultural health unit were consulted for this study Itwas their clinical impression that patients with low-level dementia (Alzheimers Assocation 2001) still pos-sess insight and understanding such that they wouldhave the capacity to complete the questionnaire Allpatients included in this study were assessed for cogni-tive states using the MMSE scale It was agreed by thepanel and research team that any patients who scoredless than 19 on the MMSE should be excluded Suchcriteria would increase the external validity of thepresent studyrsquos findings

The exclusion of older patients with moderate tosevere dementia in aged care research substantiallylowers the subject base for research The costs in termsof resources used (both time and financial) to assessthese patients for eligibility only to exclude them forthe reasons cited earlier needs to be considered whenconducting such research For both scientific and ethi-cal reasons in addition to studies that use exclusion cri-teria research should also be conducted with patientswho have a low level of dementia so that findings canbe better generalized to vulnerable populations Bycomparing patients who were excluded with those notexcluded one can estimate the extent to which the cri-terion produces differing outcomes However it isimportant to be mindful of the practical difficultiesinvolved in this research as reported by Tolson et al(1999)

Staff issues

The transient nature of staffing and high turnovermeant it was necessary to explain the study to nursingstaff each time the researchers visited the wards result-ing in inconsistency in staff assistance with the studyFurthermore permanent staff were often occupiedwith orienting part-time and casual staff to the issuespresenting for patients and changed care plans on adaily basis It was also the case that some staff membersspent considerable time identifying eligible patients forthe researchers only to find that the pragmatic issuesdiscussed above prevented recruitment of the patientUnderstandably staff became frustrated at what theyconsidered a waste of their time Thus it was sometimesdifficult to obtain the agreed amount of supportneeded from nursing staff to recruit patients and even

258 K Hancock et al

complete staff questionnaires This impacted signifi-cantly on time management efficiency in data collec-tion and maintenance of regular contact with wardstaff

Timing of assessment

One way of overcoming many of the problems encoun-tered in the current study is to ask patients to completethe questionnaire following discharge when they arenot as ill However such data is retrospective and thevalidity of questionnaires that rely on memory is there-fore questionable Retrospective data has validity andreliability problems in any population but older peo-ple in particular may have difficulties with short-termmemory To interview patients at home may mean thatthe researchers never discover the lsquoreal storyrsquo ofpatientsrsquo perceptions as the change in context mayhave clouded patientsrsquo responses Thus although notan ideal solution such a technique may have somevalue in attempting to determine the needs of olderpatients particularly if attempts to assess patients dur-ing hospitalization have proven to be unsuccessful Astudy by Thomas et al (1996) found no significant dif-ferences in either experience or satisfaction scoresbetween questionnaires given in hospital or at homeHowever a lower response rate occurred with retro-spective data It is difficult to generalize these findingsto older patients as the study was conducted onpatients in general

CONCLUSION AND RECOMMENDATIONS

The study of older patientsrsquo needs during an acute ill-ness in hospital is an area in great need of researchHowever various factors make it difficult to conductsuch research in a significant proportion of olderpatients It is important that researchers be prepared toallow increased time to accommodate these factorsWhile researchers should make every effort to involvestaff in the research process and ensure lines of com-munication are kept open the factors described in thepresent paper may make it more difficult to gain thenecessary assistance from staff

It is important that researchers are not deterredfrom conducting research with older patients so thateffective quality nursing care during hospitalization isensured Anticipating potential barriers such as thosediscussed in this paper can assist researchers in plan-ning their research in order to facilitate and enable theinvolvement of acutely-ill older people in researchFactors which may enhance the research processinclude allowing more time and opportunities forassessmentsinterviews to occur rather than on one

occasion because of illnessfatigue and factors such astransfer to other wards nursingmedical procedures orvisitors developing rapport with patients throughactive listening being patient and flexible and usingquestionnaires that are both simple and short in lengthAs a last resort retrospective data obtained after thepatient is discharged may be used when acute assess-ment is too difficult However this may lower thevalidity and reliability of the results given the change incontext and short-term memory loss factors discussed

The current paper identifies the issue of balancingthe need to maximize the rigor of research and theneeds of participants It is hoped that not onlyresearchers benefit from this discussion but that hos-pital-based nurses gain insight into the research pro-cess and may possibly be more able to assistresearchers in dealing with the challenges at the lsquocoalfacersquo of hospital-based research in older patients

ACKNOWLEDGMENT

The present study was funded by an AustralianResearch Council Linkage Grant and University ofWestern Sydney Partnership grant

REFERENCES

Alzheimers Assocation Welcome to the AlzheimerrsquosAssociation of WA Inc 2001 Available from httpwwwalzheimersasnau

Australian Bureau of Statistics (ABS) Projections of thePopulation of Australia States and Territories 1995ndash2001Canberra ABS 1996

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1995ndash96 Canberra AIHW 1997

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1997ndash98 Canberra AIHW 1999

Carter W Elward K Malmgren J Larson E Participation ofolder adults in health programs and research a criticalreview of the literature Gerontologist 1991 31 584ndash592

Cockrell J Folstein M Mini-Mental State Examination Psy-chopharmacol Bull 1988 24 689ndash692

Craig A Hancock K Difficulties in implementing cognitivebehaviour therapy for spinal cord injured persons a clini-cal discussion Australian Psychologist 1994 29 98ndash102

Creditor M Hazards of hospitalization of the elderly AnnIntern Med 1993 118 219ndash223

Duckett S Jackson T Do the elderly cost more Casemixfunding in acute care settings In Nay R Garratt S (eds)Nursing Older People Issues and Innovations MelbourneMaclennan amp Petty 1999 3ndash171

Francis J Martin D Kapoor W A prospective study of delir-ium in hospitalized elderly J Am Med Assoc 1990 2631097ndash1101

Fulmer T Walker M Critical Care Nursing of the ElderlyNew York Springer 1992

Challenges conducting research in older patients 255

naires and conduct interviews with acutely-ill olderpatients was usually longer than that for youngerpatients In order to overcome this problem it wassometimes necessary to interview in 15ndash20 min inter-vals and return a few times to complete the interviewwhich sometimes took up to 4 h of the researchersrsquotime compared to about 45 min to interview a youngerperson This occurred in approximately 12 of casesBeing mindful that the patients were required to beassessed on cognitive functioning and ADL and toread and sign a consent form and information sheetprior to completing the questionnaire and were likelyto be tired before they began completing the ques-tionnaire the researchers made a conscious decisionto allow the patient to rest for a time before engagingin the interview In such cases it was sometimes diffi-cult to complete the questionnaire with the patient onthe same day and when returning to interview thepatient may have been moved to another wardbecome ill or been discharged

For visually impaired older patients the researchersfound it necessary to either read each item on the ques-tionnaire out aloud (which considerably increased thetime to perform the interview) or use enlarged printOn occasions an enlarged Likert-scale was displayedon cardboard and the patient pointed to the corre-sponding number on the scale For patients with hear-ing loss the researchers found that it was important toreduce the pace at which the questions were deliveredensure that they were facing the patient and to speakmore loudly They also found that some patientsrsquo abil-ity to articulate their answers was hampered by respi-ratory or laryngeal disease This was often found to bethe case with patients in the respiratory or medicalwards In a few cases patients who were receiving med-ication regularly via a nebuliser wished to continuecompleting the questionnaire (however in most casesthe interviewer waited until medication had beenadministered) Use of the cardboard was useful inthese situations described

Use of questionnaires in older patients

Considering the various sensory changes and compli-cations that arise in an ill older person it is importantthat researchers consider the appropriateness of theuse of questionnaires particularly those of a lengthynature In planning this research the authors madeevery effort to use a validated tool that was not toocomplicated or lengthy In retrospect the researchersbelieve the questionnaire was too lengthy Future stud-ies should develop and validate shorter tools that reli-ably measure the construct in question for olderpatients

Patient vulnerability and consent

Another reason that the recruitment and interviewprocess was so lengthy in the present study was that theresearchers were ethically bound to ensure that theydid not abuse the vulnerability of older patients Olderpatients are often frail and in a dependent state andthey may feel compelled to consent to research thatthey either not well enough or do not wish to partici-pate in Harris and Dyson (2001) suggest that olderpeople may be suspicious of research studies becauseof feelings of vulnerability or previous experiences Aconsiderable proportion of time was devoted to con-sent ensuring that patients were fully informed of theresearch and offering assurance that they were free torefuse to participate Patients were assured that theirrefusalwithdrawal of consent would not affect theirnursing or hospital care In approximately 10 of casespatients refused to consent because the initial screen-ing process had taken so long and they were too tiredto continue Only a few cases actually refused becausethey were not interested in participating In a handfulof cases patients freely consented but their family car-ers or other family members intervened and stated thatit was in the patientrsquos best interest to rest andor spendthe time with their family rather than complete thequestionnaire

The researchers were constantly aware of the needto preserve the rights of these patients and not over-burden them with the research process Patients wereregularly asked if they were tired or feeling unwell andwhether they would like to cease the interview and theresearcher would return at a more appropriate timeOne of the possible consequences is that interviewingover several occasions could affect the reliability andvalidity of findings However as discussed this onlyoccurred in approximately 12 of cases

Harris and Dyson (2001) suggest that in order tomaximize involvement of older people in researchwhile protecting their right to refuse researchers needto be well-prepared have good communication skillsand be flexible in the way they explain the research andassess understanding of this information They contendthat researchers need to be aware of the difficultiesin recruiting older people to research and to allowample time to collect enough data Ultimately non-exploitation of this group depends on the integrity andawareness of the researcher (Harris amp Dyson 2001)

Owen (2001) also discusses the practical method-ological and ethical dilemmas of conducting researchwith vulnerable clients In Owenrsquos study focus groupswere used to ascertain perceptions of women with seri-ous and enduring mental health problems about theservices they received A major obstacle was the time

256 K Hancock et al

and effort taken to gain access to the women The nextdifficulty was ensuring that the women selected wouldbe willing and able to participate Owen also empha-sized that the researcher as facilitator requires substan-tial interpersonal skills Owen like Harris and Dyson(2001) suggests that researchers should be realisticabout the amount of time it will take to access vulner-able clients The authors also concur with this view

Patient loneliness

During the course of the interview the researchersfound that some of the patients reported that they hadfew visitors or sources of support For some patientsthe interview and questionnaire was an opportunity forsocial interaction rather than simply answering ques-tions on the researcherrsquos agenda It was important tobuild a rapport with the patient by encouraging com-munication and adopting active empathetic listeningHowever sometimes it was difficult to steer the patienttowards completing the questionnaire as they seemedto have a great need to express their thoughts andfeelings generally As a consequence the time takento complete the interviewquestionnaire was oftenlengthy or required multiple visits

Possible bias in patient satisfaction due to lack of privacy

Related to the discussion on questionnaires is the mea-sure of patient satisfaction Patient satisfaction hasbeen seen as a measure of quality with questionnairesthe most commonly used because of their ease and lowcosts (Thomas amp Bond 1996) Problems with patientsatisfaction surveys have been extensively discussed(Lin 1996 Shaw 1997) These include lack of sensitiv-ity discrimination power reliability and validity andtheir extremely positive results (Poulton 1996Salmela 1996) Thus while the goal of patient satisfac-tion questionnaires is to contribute to quality improve-ment such positive responses may assist in maintainingthe status quo and hindering positive developmentinnovation and change (Redfern amp Norman 1990Salmela 1996)

The current research requested that patients befrank in their assessment of the quality of care theyreceived and emphasized the importance of doing toensure quality of care for older patients However incases where the patients were unable to complete thequestionnaire independently and silently during theinitial stages of the research it was observed thatsometimes patients gave different responses when thenurse was present (eg tending to other patients in theroom or administering medication) That is patients

may have been afraid of criticizing particular aspectsof nursing care when nurses were within hearingrange This observation is likely to be related to thepatientrsquos sense of vulnerability in that they are depen-dent on nursing staff to have their needs met (eventhough the consent form emphasized that participa-tionnon-participation in this research would notaffect their nursing care) As all patients in this studyshared rooms with one or two other patients creatingthe likelihood that nurses would be attending to anyone of these patients during the course of the inter-view the researchers ceased interviewing until thenurse left the room so that responses were frank andconfidentiality was ensured One way of minimizingthis problem was to request that patients were inter-viewed in the lounge area or a private place Howeverthis was often not feasible as the lounge area was alsoused by other patients and their visitors with nursesproviding some aspects of treatment to patients thereSome patients were not able to leave their bed for thispurpose

Pragmatic issues

The following practical difficulty in conductingresearch in acute care wards is not isolated to olderpatients but applies to all acutely-ill patients Theresearchers found that eligible patients were often notavailable when the researcher arrived at the wardbecause the patient was sleeping being attended tohad visitors was out of the ward having proceduresperformed or had died Such incidents required theresearchers to be patient and flexible in their approachto the situation and willing to return to the ward onseveral occasions in order to complete the researchSimilar difficulties researching other acutely-illpatients have been reported elsewhere (Craig ampHancock 1994)

Due to the increased pressure to move patientstowards early discharge the researchers frequentlyfound that the patient had left the ward as a transfer orwas discharged even though previous arrangementshad been made between the researchers staff andpatients to interview the patient on specific days andtimes Occasionally this occurred within half a day ofbeing screened or even a few hours Once again flex-ibility in locating patients for recruitment was requiredIn the case of those who were discharged the patientwas eliminated from the sample and new patientsneeded to be recruited

Harris and Dyson (2001) found that the times toavoid approaching a patient for recruitment were dur-ing meal-times immediately after physiotherapy aftera painful dressing change or immediately after an unto-

Challenges conducting research in older patients 257

ward incident such as a fall The researcherrsquos experi-ence with this study concurs with these findings

Delirium (acute organic brain syndrome acute confusion) and dementia

For many older people the hospital environment is dis-orientating and threatening and can lead to the devel-opment of acute confusion (Creditor 1993) Whilemany older patients are admitted to hospital with delir-ium many more develop the condition in hospital withat least 16 of admissions being affected (Franciset al 1990) The prevalence of delirium in older post-operative patients is even greater (Levkoff et al 1990)Tolson et al (1999) found that 66 of 213 people aged65 years or older who were admitted for acute hospi-talization had cognitive impairment with 40 experi-encing severe problems One of the consequences ofthis is that it is not possible to interview the patientwhen they are experiencing an acute confusional epi-sode This may mean having to return at a later datewhen the confusion has subsided or excluding thepatient altogether if the confusion does not resolve Itwas the researcherrsquos experience that often when reso-lution occurred the patient had been moved to anotherward or discharged As a result practical issuesimpinged on the research such as having to explain thestudy to a new ward NUM and seeking assistance fromstaff In some cases the nursing staff were not awarethat the patient was becoming confused and this wasnoticed quite markedly when the researchers adminis-tered the questionnaire These patients could not par-ticipate until the period of confusion abated and thiswas up to 4 or 5 days later

Although the prevalence of dementia is less thandelirium in hospitalized patients it affects a significantproportion of older patients Dementia differs fromacute confusion in that dementia is a chronic problemcharacterized by a progressive and chronic loss ofmemory The overall prevalence of dementia is esti-mated at 63 with increases to around 30 for thoseaged 85 years and over (Ott et al 1995) Obvious dif-ficulties in conducting research that requires the use ofquestionnaires or interviews with patients who havedementia is that it is difficult to obtain valid reliabledata from such patients While the use of exclusion cri-teria can optimize internal validity or make a studymore feasible by excluding for example patients whoare unable to respond to a questionnaire because theyhave dementia exclusion criteria can have negativeimplications for the generalizability (or external valid-ity) of results to real-world practice settings (Hum-phreys amp Weisner 2000) Thus the clinical use offindings is limited

In the present study to exclude all patients with anyform of dementiacognitive impairment would meanthat the findings only apply to coherent patients in theacute care setting A panel of experts including eightclinical nurse consultants in aged and psycho-geriatricnursing three NUM of aged-specific wards a principaldirector of nursing three community aged care nursestwo geriatricians and the aged care worker of a multi-cultural health unit were consulted for this study Itwas their clinical impression that patients with low-level dementia (Alzheimers Assocation 2001) still pos-sess insight and understanding such that they wouldhave the capacity to complete the questionnaire Allpatients included in this study were assessed for cogni-tive states using the MMSE scale It was agreed by thepanel and research team that any patients who scoredless than 19 on the MMSE should be excluded Suchcriteria would increase the external validity of thepresent studyrsquos findings

The exclusion of older patients with moderate tosevere dementia in aged care research substantiallylowers the subject base for research The costs in termsof resources used (both time and financial) to assessthese patients for eligibility only to exclude them forthe reasons cited earlier needs to be considered whenconducting such research For both scientific and ethi-cal reasons in addition to studies that use exclusion cri-teria research should also be conducted with patientswho have a low level of dementia so that findings canbe better generalized to vulnerable populations Bycomparing patients who were excluded with those notexcluded one can estimate the extent to which the cri-terion produces differing outcomes However it isimportant to be mindful of the practical difficultiesinvolved in this research as reported by Tolson et al(1999)

Staff issues

The transient nature of staffing and high turnovermeant it was necessary to explain the study to nursingstaff each time the researchers visited the wards result-ing in inconsistency in staff assistance with the studyFurthermore permanent staff were often occupiedwith orienting part-time and casual staff to the issuespresenting for patients and changed care plans on adaily basis It was also the case that some staff membersspent considerable time identifying eligible patients forthe researchers only to find that the pragmatic issuesdiscussed above prevented recruitment of the patientUnderstandably staff became frustrated at what theyconsidered a waste of their time Thus it was sometimesdifficult to obtain the agreed amount of supportneeded from nursing staff to recruit patients and even

258 K Hancock et al

complete staff questionnaires This impacted signifi-cantly on time management efficiency in data collec-tion and maintenance of regular contact with wardstaff

Timing of assessment

One way of overcoming many of the problems encoun-tered in the current study is to ask patients to completethe questionnaire following discharge when they arenot as ill However such data is retrospective and thevalidity of questionnaires that rely on memory is there-fore questionable Retrospective data has validity andreliability problems in any population but older peo-ple in particular may have difficulties with short-termmemory To interview patients at home may mean thatthe researchers never discover the lsquoreal storyrsquo ofpatientsrsquo perceptions as the change in context mayhave clouded patientsrsquo responses Thus although notan ideal solution such a technique may have somevalue in attempting to determine the needs of olderpatients particularly if attempts to assess patients dur-ing hospitalization have proven to be unsuccessful Astudy by Thomas et al (1996) found no significant dif-ferences in either experience or satisfaction scoresbetween questionnaires given in hospital or at homeHowever a lower response rate occurred with retro-spective data It is difficult to generalize these findingsto older patients as the study was conducted onpatients in general

CONCLUSION AND RECOMMENDATIONS

The study of older patientsrsquo needs during an acute ill-ness in hospital is an area in great need of researchHowever various factors make it difficult to conductsuch research in a significant proportion of olderpatients It is important that researchers be prepared toallow increased time to accommodate these factorsWhile researchers should make every effort to involvestaff in the research process and ensure lines of com-munication are kept open the factors described in thepresent paper may make it more difficult to gain thenecessary assistance from staff

It is important that researchers are not deterredfrom conducting research with older patients so thateffective quality nursing care during hospitalization isensured Anticipating potential barriers such as thosediscussed in this paper can assist researchers in plan-ning their research in order to facilitate and enable theinvolvement of acutely-ill older people in researchFactors which may enhance the research processinclude allowing more time and opportunities forassessmentsinterviews to occur rather than on one

occasion because of illnessfatigue and factors such astransfer to other wards nursingmedical procedures orvisitors developing rapport with patients throughactive listening being patient and flexible and usingquestionnaires that are both simple and short in lengthAs a last resort retrospective data obtained after thepatient is discharged may be used when acute assess-ment is too difficult However this may lower thevalidity and reliability of the results given the change incontext and short-term memory loss factors discussed

The current paper identifies the issue of balancingthe need to maximize the rigor of research and theneeds of participants It is hoped that not onlyresearchers benefit from this discussion but that hos-pital-based nurses gain insight into the research pro-cess and may possibly be more able to assistresearchers in dealing with the challenges at the lsquocoalfacersquo of hospital-based research in older patients

ACKNOWLEDGMENT

The present study was funded by an AustralianResearch Council Linkage Grant and University ofWestern Sydney Partnership grant

REFERENCES

Alzheimers Assocation Welcome to the AlzheimerrsquosAssociation of WA Inc 2001 Available from httpwwwalzheimersasnau

Australian Bureau of Statistics (ABS) Projections of thePopulation of Australia States and Territories 1995ndash2001Canberra ABS 1996

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1995ndash96 Canberra AIHW 1997

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1997ndash98 Canberra AIHW 1999

Carter W Elward K Malmgren J Larson E Participation ofolder adults in health programs and research a criticalreview of the literature Gerontologist 1991 31 584ndash592

Cockrell J Folstein M Mini-Mental State Examination Psy-chopharmacol Bull 1988 24 689ndash692

Craig A Hancock K Difficulties in implementing cognitivebehaviour therapy for spinal cord injured persons a clini-cal discussion Australian Psychologist 1994 29 98ndash102

Creditor M Hazards of hospitalization of the elderly AnnIntern Med 1993 118 219ndash223

Duckett S Jackson T Do the elderly cost more Casemixfunding in acute care settings In Nay R Garratt S (eds)Nursing Older People Issues and Innovations MelbourneMaclennan amp Petty 1999 3ndash171

Francis J Martin D Kapoor W A prospective study of delir-ium in hospitalized elderly J Am Med Assoc 1990 2631097ndash1101

Fulmer T Walker M Critical Care Nursing of the ElderlyNew York Springer 1992

256 K Hancock et al

and effort taken to gain access to the women The nextdifficulty was ensuring that the women selected wouldbe willing and able to participate Owen also empha-sized that the researcher as facilitator requires substan-tial interpersonal skills Owen like Harris and Dyson(2001) suggests that researchers should be realisticabout the amount of time it will take to access vulner-able clients The authors also concur with this view

Patient loneliness

During the course of the interview the researchersfound that some of the patients reported that they hadfew visitors or sources of support For some patientsthe interview and questionnaire was an opportunity forsocial interaction rather than simply answering ques-tions on the researcherrsquos agenda It was important tobuild a rapport with the patient by encouraging com-munication and adopting active empathetic listeningHowever sometimes it was difficult to steer the patienttowards completing the questionnaire as they seemedto have a great need to express their thoughts andfeelings generally As a consequence the time takento complete the interviewquestionnaire was oftenlengthy or required multiple visits

Possible bias in patient satisfaction due to lack of privacy

Related to the discussion on questionnaires is the mea-sure of patient satisfaction Patient satisfaction hasbeen seen as a measure of quality with questionnairesthe most commonly used because of their ease and lowcosts (Thomas amp Bond 1996) Problems with patientsatisfaction surveys have been extensively discussed(Lin 1996 Shaw 1997) These include lack of sensitiv-ity discrimination power reliability and validity andtheir extremely positive results (Poulton 1996Salmela 1996) Thus while the goal of patient satisfac-tion questionnaires is to contribute to quality improve-ment such positive responses may assist in maintainingthe status quo and hindering positive developmentinnovation and change (Redfern amp Norman 1990Salmela 1996)

The current research requested that patients befrank in their assessment of the quality of care theyreceived and emphasized the importance of doing toensure quality of care for older patients However incases where the patients were unable to complete thequestionnaire independently and silently during theinitial stages of the research it was observed thatsometimes patients gave different responses when thenurse was present (eg tending to other patients in theroom or administering medication) That is patients

may have been afraid of criticizing particular aspectsof nursing care when nurses were within hearingrange This observation is likely to be related to thepatientrsquos sense of vulnerability in that they are depen-dent on nursing staff to have their needs met (eventhough the consent form emphasized that participa-tionnon-participation in this research would notaffect their nursing care) As all patients in this studyshared rooms with one or two other patients creatingthe likelihood that nurses would be attending to anyone of these patients during the course of the inter-view the researchers ceased interviewing until thenurse left the room so that responses were frank andconfidentiality was ensured One way of minimizingthis problem was to request that patients were inter-viewed in the lounge area or a private place Howeverthis was often not feasible as the lounge area was alsoused by other patients and their visitors with nursesproviding some aspects of treatment to patients thereSome patients were not able to leave their bed for thispurpose

Pragmatic issues

The following practical difficulty in conductingresearch in acute care wards is not isolated to olderpatients but applies to all acutely-ill patients Theresearchers found that eligible patients were often notavailable when the researcher arrived at the wardbecause the patient was sleeping being attended tohad visitors was out of the ward having proceduresperformed or had died Such incidents required theresearchers to be patient and flexible in their approachto the situation and willing to return to the ward onseveral occasions in order to complete the researchSimilar difficulties researching other acutely-illpatients have been reported elsewhere (Craig ampHancock 1994)

Due to the increased pressure to move patientstowards early discharge the researchers frequentlyfound that the patient had left the ward as a transfer orwas discharged even though previous arrangementshad been made between the researchers staff andpatients to interview the patient on specific days andtimes Occasionally this occurred within half a day ofbeing screened or even a few hours Once again flex-ibility in locating patients for recruitment was requiredIn the case of those who were discharged the patientwas eliminated from the sample and new patientsneeded to be recruited

Harris and Dyson (2001) found that the times toavoid approaching a patient for recruitment were dur-ing meal-times immediately after physiotherapy aftera painful dressing change or immediately after an unto-

Challenges conducting research in older patients 257

ward incident such as a fall The researcherrsquos experi-ence with this study concurs with these findings

Delirium (acute organic brain syndrome acute confusion) and dementia

For many older people the hospital environment is dis-orientating and threatening and can lead to the devel-opment of acute confusion (Creditor 1993) Whilemany older patients are admitted to hospital with delir-ium many more develop the condition in hospital withat least 16 of admissions being affected (Franciset al 1990) The prevalence of delirium in older post-operative patients is even greater (Levkoff et al 1990)Tolson et al (1999) found that 66 of 213 people aged65 years or older who were admitted for acute hospi-talization had cognitive impairment with 40 experi-encing severe problems One of the consequences ofthis is that it is not possible to interview the patientwhen they are experiencing an acute confusional epi-sode This may mean having to return at a later datewhen the confusion has subsided or excluding thepatient altogether if the confusion does not resolve Itwas the researcherrsquos experience that often when reso-lution occurred the patient had been moved to anotherward or discharged As a result practical issuesimpinged on the research such as having to explain thestudy to a new ward NUM and seeking assistance fromstaff In some cases the nursing staff were not awarethat the patient was becoming confused and this wasnoticed quite markedly when the researchers adminis-tered the questionnaire These patients could not par-ticipate until the period of confusion abated and thiswas up to 4 or 5 days later

Although the prevalence of dementia is less thandelirium in hospitalized patients it affects a significantproportion of older patients Dementia differs fromacute confusion in that dementia is a chronic problemcharacterized by a progressive and chronic loss ofmemory The overall prevalence of dementia is esti-mated at 63 with increases to around 30 for thoseaged 85 years and over (Ott et al 1995) Obvious dif-ficulties in conducting research that requires the use ofquestionnaires or interviews with patients who havedementia is that it is difficult to obtain valid reliabledata from such patients While the use of exclusion cri-teria can optimize internal validity or make a studymore feasible by excluding for example patients whoare unable to respond to a questionnaire because theyhave dementia exclusion criteria can have negativeimplications for the generalizability (or external valid-ity) of results to real-world practice settings (Hum-phreys amp Weisner 2000) Thus the clinical use offindings is limited

In the present study to exclude all patients with anyform of dementiacognitive impairment would meanthat the findings only apply to coherent patients in theacute care setting A panel of experts including eightclinical nurse consultants in aged and psycho-geriatricnursing three NUM of aged-specific wards a principaldirector of nursing three community aged care nursestwo geriatricians and the aged care worker of a multi-cultural health unit were consulted for this study Itwas their clinical impression that patients with low-level dementia (Alzheimers Assocation 2001) still pos-sess insight and understanding such that they wouldhave the capacity to complete the questionnaire Allpatients included in this study were assessed for cogni-tive states using the MMSE scale It was agreed by thepanel and research team that any patients who scoredless than 19 on the MMSE should be excluded Suchcriteria would increase the external validity of thepresent studyrsquos findings

The exclusion of older patients with moderate tosevere dementia in aged care research substantiallylowers the subject base for research The costs in termsof resources used (both time and financial) to assessthese patients for eligibility only to exclude them forthe reasons cited earlier needs to be considered whenconducting such research For both scientific and ethi-cal reasons in addition to studies that use exclusion cri-teria research should also be conducted with patientswho have a low level of dementia so that findings canbe better generalized to vulnerable populations Bycomparing patients who were excluded with those notexcluded one can estimate the extent to which the cri-terion produces differing outcomes However it isimportant to be mindful of the practical difficultiesinvolved in this research as reported by Tolson et al(1999)

Staff issues

The transient nature of staffing and high turnovermeant it was necessary to explain the study to nursingstaff each time the researchers visited the wards result-ing in inconsistency in staff assistance with the studyFurthermore permanent staff were often occupiedwith orienting part-time and casual staff to the issuespresenting for patients and changed care plans on adaily basis It was also the case that some staff membersspent considerable time identifying eligible patients forthe researchers only to find that the pragmatic issuesdiscussed above prevented recruitment of the patientUnderstandably staff became frustrated at what theyconsidered a waste of their time Thus it was sometimesdifficult to obtain the agreed amount of supportneeded from nursing staff to recruit patients and even

258 K Hancock et al

complete staff questionnaires This impacted signifi-cantly on time management efficiency in data collec-tion and maintenance of regular contact with wardstaff

Timing of assessment

One way of overcoming many of the problems encoun-tered in the current study is to ask patients to completethe questionnaire following discharge when they arenot as ill However such data is retrospective and thevalidity of questionnaires that rely on memory is there-fore questionable Retrospective data has validity andreliability problems in any population but older peo-ple in particular may have difficulties with short-termmemory To interview patients at home may mean thatthe researchers never discover the lsquoreal storyrsquo ofpatientsrsquo perceptions as the change in context mayhave clouded patientsrsquo responses Thus although notan ideal solution such a technique may have somevalue in attempting to determine the needs of olderpatients particularly if attempts to assess patients dur-ing hospitalization have proven to be unsuccessful Astudy by Thomas et al (1996) found no significant dif-ferences in either experience or satisfaction scoresbetween questionnaires given in hospital or at homeHowever a lower response rate occurred with retro-spective data It is difficult to generalize these findingsto older patients as the study was conducted onpatients in general

CONCLUSION AND RECOMMENDATIONS

The study of older patientsrsquo needs during an acute ill-ness in hospital is an area in great need of researchHowever various factors make it difficult to conductsuch research in a significant proportion of olderpatients It is important that researchers be prepared toallow increased time to accommodate these factorsWhile researchers should make every effort to involvestaff in the research process and ensure lines of com-munication are kept open the factors described in thepresent paper may make it more difficult to gain thenecessary assistance from staff

It is important that researchers are not deterredfrom conducting research with older patients so thateffective quality nursing care during hospitalization isensured Anticipating potential barriers such as thosediscussed in this paper can assist researchers in plan-ning their research in order to facilitate and enable theinvolvement of acutely-ill older people in researchFactors which may enhance the research processinclude allowing more time and opportunities forassessmentsinterviews to occur rather than on one

occasion because of illnessfatigue and factors such astransfer to other wards nursingmedical procedures orvisitors developing rapport with patients throughactive listening being patient and flexible and usingquestionnaires that are both simple and short in lengthAs a last resort retrospective data obtained after thepatient is discharged may be used when acute assess-ment is too difficult However this may lower thevalidity and reliability of the results given the change incontext and short-term memory loss factors discussed

The current paper identifies the issue of balancingthe need to maximize the rigor of research and theneeds of participants It is hoped that not onlyresearchers benefit from this discussion but that hos-pital-based nurses gain insight into the research pro-cess and may possibly be more able to assistresearchers in dealing with the challenges at the lsquocoalfacersquo of hospital-based research in older patients

ACKNOWLEDGMENT

The present study was funded by an AustralianResearch Council Linkage Grant and University ofWestern Sydney Partnership grant

REFERENCES

Alzheimers Assocation Welcome to the AlzheimerrsquosAssociation of WA Inc 2001 Available from httpwwwalzheimersasnau

Australian Bureau of Statistics (ABS) Projections of thePopulation of Australia States and Territories 1995ndash2001Canberra ABS 1996

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1995ndash96 Canberra AIHW 1997

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1997ndash98 Canberra AIHW 1999

Carter W Elward K Malmgren J Larson E Participation ofolder adults in health programs and research a criticalreview of the literature Gerontologist 1991 31 584ndash592

Cockrell J Folstein M Mini-Mental State Examination Psy-chopharmacol Bull 1988 24 689ndash692

Craig A Hancock K Difficulties in implementing cognitivebehaviour therapy for spinal cord injured persons a clini-cal discussion Australian Psychologist 1994 29 98ndash102

Creditor M Hazards of hospitalization of the elderly AnnIntern Med 1993 118 219ndash223

Duckett S Jackson T Do the elderly cost more Casemixfunding in acute care settings In Nay R Garratt S (eds)Nursing Older People Issues and Innovations MelbourneMaclennan amp Petty 1999 3ndash171

Francis J Martin D Kapoor W A prospective study of delir-ium in hospitalized elderly J Am Med Assoc 1990 2631097ndash1101

Fulmer T Walker M Critical Care Nursing of the ElderlyNew York Springer 1992

Challenges conducting research in older patients 257

ward incident such as a fall The researcherrsquos experi-ence with this study concurs with these findings

Delirium (acute organic brain syndrome acute confusion) and dementia

For many older people the hospital environment is dis-orientating and threatening and can lead to the devel-opment of acute confusion (Creditor 1993) Whilemany older patients are admitted to hospital with delir-ium many more develop the condition in hospital withat least 16 of admissions being affected (Franciset al 1990) The prevalence of delirium in older post-operative patients is even greater (Levkoff et al 1990)Tolson et al (1999) found that 66 of 213 people aged65 years or older who were admitted for acute hospi-talization had cognitive impairment with 40 experi-encing severe problems One of the consequences ofthis is that it is not possible to interview the patientwhen they are experiencing an acute confusional epi-sode This may mean having to return at a later datewhen the confusion has subsided or excluding thepatient altogether if the confusion does not resolve Itwas the researcherrsquos experience that often when reso-lution occurred the patient had been moved to anotherward or discharged As a result practical issuesimpinged on the research such as having to explain thestudy to a new ward NUM and seeking assistance fromstaff In some cases the nursing staff were not awarethat the patient was becoming confused and this wasnoticed quite markedly when the researchers adminis-tered the questionnaire These patients could not par-ticipate until the period of confusion abated and thiswas up to 4 or 5 days later

Although the prevalence of dementia is less thandelirium in hospitalized patients it affects a significantproportion of older patients Dementia differs fromacute confusion in that dementia is a chronic problemcharacterized by a progressive and chronic loss ofmemory The overall prevalence of dementia is esti-mated at 63 with increases to around 30 for thoseaged 85 years and over (Ott et al 1995) Obvious dif-ficulties in conducting research that requires the use ofquestionnaires or interviews with patients who havedementia is that it is difficult to obtain valid reliabledata from such patients While the use of exclusion cri-teria can optimize internal validity or make a studymore feasible by excluding for example patients whoare unable to respond to a questionnaire because theyhave dementia exclusion criteria can have negativeimplications for the generalizability (or external valid-ity) of results to real-world practice settings (Hum-phreys amp Weisner 2000) Thus the clinical use offindings is limited

In the present study to exclude all patients with anyform of dementiacognitive impairment would meanthat the findings only apply to coherent patients in theacute care setting A panel of experts including eightclinical nurse consultants in aged and psycho-geriatricnursing three NUM of aged-specific wards a principaldirector of nursing three community aged care nursestwo geriatricians and the aged care worker of a multi-cultural health unit were consulted for this study Itwas their clinical impression that patients with low-level dementia (Alzheimers Assocation 2001) still pos-sess insight and understanding such that they wouldhave the capacity to complete the questionnaire Allpatients included in this study were assessed for cogni-tive states using the MMSE scale It was agreed by thepanel and research team that any patients who scoredless than 19 on the MMSE should be excluded Suchcriteria would increase the external validity of thepresent studyrsquos findings

The exclusion of older patients with moderate tosevere dementia in aged care research substantiallylowers the subject base for research The costs in termsof resources used (both time and financial) to assessthese patients for eligibility only to exclude them forthe reasons cited earlier needs to be considered whenconducting such research For both scientific and ethi-cal reasons in addition to studies that use exclusion cri-teria research should also be conducted with patientswho have a low level of dementia so that findings canbe better generalized to vulnerable populations Bycomparing patients who were excluded with those notexcluded one can estimate the extent to which the cri-terion produces differing outcomes However it isimportant to be mindful of the practical difficultiesinvolved in this research as reported by Tolson et al(1999)

Staff issues

The transient nature of staffing and high turnovermeant it was necessary to explain the study to nursingstaff each time the researchers visited the wards result-ing in inconsistency in staff assistance with the studyFurthermore permanent staff were often occupiedwith orienting part-time and casual staff to the issuespresenting for patients and changed care plans on adaily basis It was also the case that some staff membersspent considerable time identifying eligible patients forthe researchers only to find that the pragmatic issuesdiscussed above prevented recruitment of the patientUnderstandably staff became frustrated at what theyconsidered a waste of their time Thus it was sometimesdifficult to obtain the agreed amount of supportneeded from nursing staff to recruit patients and even

258 K Hancock et al

complete staff questionnaires This impacted signifi-cantly on time management efficiency in data collec-tion and maintenance of regular contact with wardstaff

Timing of assessment

One way of overcoming many of the problems encoun-tered in the current study is to ask patients to completethe questionnaire following discharge when they arenot as ill However such data is retrospective and thevalidity of questionnaires that rely on memory is there-fore questionable Retrospective data has validity andreliability problems in any population but older peo-ple in particular may have difficulties with short-termmemory To interview patients at home may mean thatthe researchers never discover the lsquoreal storyrsquo ofpatientsrsquo perceptions as the change in context mayhave clouded patientsrsquo responses Thus although notan ideal solution such a technique may have somevalue in attempting to determine the needs of olderpatients particularly if attempts to assess patients dur-ing hospitalization have proven to be unsuccessful Astudy by Thomas et al (1996) found no significant dif-ferences in either experience or satisfaction scoresbetween questionnaires given in hospital or at homeHowever a lower response rate occurred with retro-spective data It is difficult to generalize these findingsto older patients as the study was conducted onpatients in general

CONCLUSION AND RECOMMENDATIONS

The study of older patientsrsquo needs during an acute ill-ness in hospital is an area in great need of researchHowever various factors make it difficult to conductsuch research in a significant proportion of olderpatients It is important that researchers be prepared toallow increased time to accommodate these factorsWhile researchers should make every effort to involvestaff in the research process and ensure lines of com-munication are kept open the factors described in thepresent paper may make it more difficult to gain thenecessary assistance from staff

It is important that researchers are not deterredfrom conducting research with older patients so thateffective quality nursing care during hospitalization isensured Anticipating potential barriers such as thosediscussed in this paper can assist researchers in plan-ning their research in order to facilitate and enable theinvolvement of acutely-ill older people in researchFactors which may enhance the research processinclude allowing more time and opportunities forassessmentsinterviews to occur rather than on one

occasion because of illnessfatigue and factors such astransfer to other wards nursingmedical procedures orvisitors developing rapport with patients throughactive listening being patient and flexible and usingquestionnaires that are both simple and short in lengthAs a last resort retrospective data obtained after thepatient is discharged may be used when acute assess-ment is too difficult However this may lower thevalidity and reliability of the results given the change incontext and short-term memory loss factors discussed

The current paper identifies the issue of balancingthe need to maximize the rigor of research and theneeds of participants It is hoped that not onlyresearchers benefit from this discussion but that hos-pital-based nurses gain insight into the research pro-cess and may possibly be more able to assistresearchers in dealing with the challenges at the lsquocoalfacersquo of hospital-based research in older patients

ACKNOWLEDGMENT

The present study was funded by an AustralianResearch Council Linkage Grant and University ofWestern Sydney Partnership grant

REFERENCES

Alzheimers Assocation Welcome to the AlzheimerrsquosAssociation of WA Inc 2001 Available from httpwwwalzheimersasnau

Australian Bureau of Statistics (ABS) Projections of thePopulation of Australia States and Territories 1995ndash2001Canberra ABS 1996

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1995ndash96 Canberra AIHW 1997

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1997ndash98 Canberra AIHW 1999

Carter W Elward K Malmgren J Larson E Participation ofolder adults in health programs and research a criticalreview of the literature Gerontologist 1991 31 584ndash592

Cockrell J Folstein M Mini-Mental State Examination Psy-chopharmacol Bull 1988 24 689ndash692

Craig A Hancock K Difficulties in implementing cognitivebehaviour therapy for spinal cord injured persons a clini-cal discussion Australian Psychologist 1994 29 98ndash102

Creditor M Hazards of hospitalization of the elderly AnnIntern Med 1993 118 219ndash223

Duckett S Jackson T Do the elderly cost more Casemixfunding in acute care settings In Nay R Garratt S (eds)Nursing Older People Issues and Innovations MelbourneMaclennan amp Petty 1999 3ndash171

Francis J Martin D Kapoor W A prospective study of delir-ium in hospitalized elderly J Am Med Assoc 1990 2631097ndash1101

Fulmer T Walker M Critical Care Nursing of the ElderlyNew York Springer 1992

258 K Hancock et al

complete staff questionnaires This impacted signifi-cantly on time management efficiency in data collec-tion and maintenance of regular contact with wardstaff

Timing of assessment

One way of overcoming many of the problems encoun-tered in the current study is to ask patients to completethe questionnaire following discharge when they arenot as ill However such data is retrospective and thevalidity of questionnaires that rely on memory is there-fore questionable Retrospective data has validity andreliability problems in any population but older peo-ple in particular may have difficulties with short-termmemory To interview patients at home may mean thatthe researchers never discover the lsquoreal storyrsquo ofpatientsrsquo perceptions as the change in context mayhave clouded patientsrsquo responses Thus although notan ideal solution such a technique may have somevalue in attempting to determine the needs of olderpatients particularly if attempts to assess patients dur-ing hospitalization have proven to be unsuccessful Astudy by Thomas et al (1996) found no significant dif-ferences in either experience or satisfaction scoresbetween questionnaires given in hospital or at homeHowever a lower response rate occurred with retro-spective data It is difficult to generalize these findingsto older patients as the study was conducted onpatients in general

CONCLUSION AND RECOMMENDATIONS

The study of older patientsrsquo needs during an acute ill-ness in hospital is an area in great need of researchHowever various factors make it difficult to conductsuch research in a significant proportion of olderpatients It is important that researchers be prepared toallow increased time to accommodate these factorsWhile researchers should make every effort to involvestaff in the research process and ensure lines of com-munication are kept open the factors described in thepresent paper may make it more difficult to gain thenecessary assistance from staff

It is important that researchers are not deterredfrom conducting research with older patients so thateffective quality nursing care during hospitalization isensured Anticipating potential barriers such as thosediscussed in this paper can assist researchers in plan-ning their research in order to facilitate and enable theinvolvement of acutely-ill older people in researchFactors which may enhance the research processinclude allowing more time and opportunities forassessmentsinterviews to occur rather than on one

occasion because of illnessfatigue and factors such astransfer to other wards nursingmedical procedures orvisitors developing rapport with patients throughactive listening being patient and flexible and usingquestionnaires that are both simple and short in lengthAs a last resort retrospective data obtained after thepatient is discharged may be used when acute assess-ment is too difficult However this may lower thevalidity and reliability of the results given the change incontext and short-term memory loss factors discussed

The current paper identifies the issue of balancingthe need to maximize the rigor of research and theneeds of participants It is hoped that not onlyresearchers benefit from this discussion but that hos-pital-based nurses gain insight into the research pro-cess and may possibly be more able to assistresearchers in dealing with the challenges at the lsquocoalfacersquo of hospital-based research in older patients

ACKNOWLEDGMENT

The present study was funded by an AustralianResearch Council Linkage Grant and University ofWestern Sydney Partnership grant

REFERENCES

Alzheimers Assocation Welcome to the AlzheimerrsquosAssociation of WA Inc 2001 Available from httpwwwalzheimersasnau

Australian Bureau of Statistics (ABS) Projections of thePopulation of Australia States and Territories 1995ndash2001Canberra ABS 1996

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1995ndash96 Canberra AIHW 1997

Australian Institute of Health and Welfare (AIHW) Austra-lian Hospital Statistics 1997ndash98 Canberra AIHW 1999

Carter W Elward K Malmgren J Larson E Participation ofolder adults in health programs and research a criticalreview of the literature Gerontologist 1991 31 584ndash592

Cockrell J Folstein M Mini-Mental State Examination Psy-chopharmacol Bull 1988 24 689ndash692

Craig A Hancock K Difficulties in implementing cognitivebehaviour therapy for spinal cord injured persons a clini-cal discussion Australian Psychologist 1994 29 98ndash102

Creditor M Hazards of hospitalization of the elderly AnnIntern Med 1993 118 219ndash223

Duckett S Jackson T Do the elderly cost more Casemixfunding in acute care settings In Nay R Garratt S (eds)Nursing Older People Issues and Innovations MelbourneMaclennan amp Petty 1999 3ndash171

Francis J Martin D Kapoor W A prospective study of delir-ium in hospitalized elderly J Am Med Assoc 1990 2631097ndash1101

Fulmer T Walker M Critical Care Nursing of the ElderlyNew York Springer 1992

Challenges conducting research in older patients 259

Harris R Dyson E Recruitment of frail older people toresearch lessons learnt through experience J Adv Nurs2001 36 643ndash651

Heath H Communicating with older people Nurs Stand1997 11 48ndash56

Humphreys K Weisner C Use of exclusion criteria in select-ing research subjects and its effect on the generalizabilityof alcohol treatment studies Am J Psychiatry 2000 157588ndash594

Inouye S Wagner D Acampora D et al A controlledtrial of a nursing-centred intervention in hospitalizedelderly medical patients The Yale geriatric care programJ Am Geriatrics Soc 1993 41 1353ndash1360

Levkoff S Cleary P Liptzin B Evans D Epidemiologyof delirium an overview of research issues and findingsInt Pyschogeriatrics 1990 3 149ndash167

Lin C Patient satisfaction with nursing care as an outcomevariable dilemmas for nursing evaluation research J ProfNurs 1996 12 207ndash216

Mahoney F Barthel D Functional evaluation the BarthelIndex Maryland State Med J 1965 14 56ndash61

National Health and Medical Research Council Minimisingadverse consequences of hospitalization in the older personSeries on clinical management problems in the elderly no 3Canberra National Health and Medical Research Council1994 Report of the Health Care Committee Expert Panelfor health care of the elderly

NSW Health Council Report of the NSW Health Council2000mdashA Better Health System for NSW North SydneyNSW Health Council 2000

Ott A van Breteler M Harskamp F et al Prevalence ofAlzheimerrsquos disease and vascular dementia association

with education The Rotterdam study BMJ 1995 15 970ndash973

Owen S The practical methodological and ethical dilemmasof conducting focus groups with vulnerable clients J AdvNurs 2001 36 652ndash658

Poulton B Use of the consultation satisfaction questionnaireto examine patientsrsquo satisfaction with general practitionersand community nursesrsquo reliability replicability and dis-criminant validity Br J Gen Prac 1996 4 26ndash31

Redfern S Norman I Measuring the quality of nursing carea consideration of different approaches J Adv Nurs1990 15 1260ndash1271

Salmela T Problems of the concept of satisfaction in publicsector satisfaction surveys Admin Res 1996 1 32ndash41

Shaw I Assessing quality in health care services lessonsfrom mental health nursing J Adv Nurs 1997 26 758ndash764

Thomas L Bond S Measuring patientsrsquo satisfaction withnursing 1990ndash94 J Adv Nurs 1996 23 747ndash756

Thomas L McColl E Priest J Bond S Boys R Newcastlesatisfaction with nursing scales an instrument for qualityassessments of nursing care Qual Health Care 1996 5 67ndash72

Tolson D Smith M Knight P An investigation of thecomponents of best nursing practice in the care ofacutely ill hospitalized older patients with coincidentaldementia a multi-method design J Adv Nurs 1999 301127ndash1136

Uman G Urman H Elder care the challenge of conductingclinical nursing research with elderly populations Associ-ation of Perioperative Registered Nurses Journal 1990 52400ndash406

echanguwseduau