Environment of a hospital emergency unit for the elderly care: perception of nursing professionals

The objective of this study was to understand how nursing professionals perceive the environment of a hospital emergency for elderly care. This is an exploratory and descriptive study with a qualitative approach, performed with 15 nursing professionals from the emergency unit of a general hospital in Santa Catarina, Brazil. Data were collected in June 2013 through semi structured interview. We used the Collective Subject Discourse (CSD) for analysis. Three central ideas were identified: Inadequate physical structure for elderly care; Insufficient quantity of personnel to meet the demand; and Need for agility in care and referral of the elderly. Conclusion: The results show that the environment of the emergency service, which is the context of this study, is below that expected to provide adequate care for the elderly. Participants pointed suggestions such as shorter length of stay in the unit for the seniors and adjustments related to physical structure and quantitative of professionals.


INTRODUCTION
As a result of the progress of science and the advancement of sanitation, the world population has been undergoing its most intense aging in recent years 1 .This phenomenon is known as demographic transition, and is characterized by a change in mortality and birth rates, with a reduction of young people and increasing the proportion of elderly.In Brazil, as in other developing countries, this transition has been occurring more dramatically when compared to developed countries 2 .
Changes in the population profile, associated with the increase of risk of developing chronic degenerative diseases have generated a significant increase in demand of older people in health care, including the Emergency Department 3 .
A recent study conducted in southern Brazil revealed that 17.4% of patients assisted in an emergency public unit were older than 65 years 4 .Corroborating the findings, other Brazilian research showed a predominance of adult and elderly patients, with mean age of 59.4 years, among those readmitted in an emergency hospital service 3 .
As for the severity of health of this clientele on admission to the emergency department, a survey found that 14% of the elderly were classified as low risk, 79% with intermediate risk, 5% as high risk and 1.8% in need of immediate care 5 .Health problems that lead this population to seek emergency services are associated mostly with aggravated chronic conditions, especially those involving the cardiovascular system [3][4][5] .
Considering the above and considering that the demand of elderly to emergency services is a constant and growing fact, and that they have specific needs before their physical, psychological and social conditions, requiring thus an appropriate care environment to their needs, the following question arises: How do nursing professionals in a hospital emergency unit realize the environment of this service for elderly care?
The conception of environment in this study comprises the physical and technological aspects and interpersonal relationships that target a comfortable care focused on privacy and individuality of those involved 6 .
To answer the research question, we traced as objective: to know how nursing professionals perceive the environment of a hospital emergency for elderly care.
It is believed that the contribution of this research lies in pointing subsidies towards meeting the requirements of emergency environment, respecting the user's rights, especially the elderly's rights.

METHOD
This is an exploratory and descriptive study with a qualitative approach, developed in the adult emergency department of a general and public hospital located in the state of Santa Catarina, Brazil.
Participants of this study were nurses working in the emergency department, who met the following inclusion criteria: being a nursing professional who has been working in the emergency department for at least six months and being working during the data collection period.
This study was approved by the Research Ethics Committee on Human Research of the Federal University of Santa Catarina (Opinion Nº 318,756/2013), following the recommendations of Resolution Nº 466/12 of the National Health Council.All participants signed the Informed Consent Form.
Data collection occurred in June 2013, through semi-structured interview from the following question: how do you perceive the emergency assistance for elderly care?The interviews, previously scheduled with professionals in their workplace, were held with an average duration of 30 minutes and recorded with permission of respondents, for later transcription.
To ensure the anonymity of participants, they were identified with the letter R (Respondent), followed by the number corresponding to the sequence of the interview, for example: R1, R2, R15.
Data analysis was performed using the Collective Subject Discourse 7 .We chose this method because its representative character can act as a mirror of the thought of communities and groups, making it a useful tool for intervention in reality 7 .We used the following methodological approaches described in the method: Key Expressions (KE), Central Ideas (CI) and the Collective Subject Discourse (CSD).
The KEs are excerpts from the speech to be highlighted by the researcher, and that reveal the essence of the speech content.The CIs are names or expressions that name, as concisely and accurately as possible, the feelings present in each of the analyzed responses.The homogeneous set of KEs will lead to the CSD, which is an aggregation, or sum of the testimonies, in which each party is recognized as a constituent.It is a speech synthesis, composed by the "collage" of KEs that have the same CI 7 .
For data organization process we performed a careful reading of each interview, and highlighted in italics the key expressions (KEs) of the answers/individual speeches.We also performed the grouping of the KEs with the same meaning, with equivalent, or complementary meaning contemplated in the various speeches and corresponding to the same CI.This homogeneous set originated the CSD.

RESULTS
Study participants were 15 nurses, of which six were nurses, eight nursing technicians and one nursing assistant.Of these, 12 were women.The age ranged from 25 to 41 years, with a length of professional experience in this emergency unit ranging from one to seven years.Regarding professional training of the six nurses, five were specialists (Intensive Care; Pre-hospital Emergency; Public Health; Emergency and Pre-hospital Care; Hospital Management) and, of these, two also have a master's degree (Health Sciences and Applied Psychology).Of the nine secondary-level professionals, one has bachelor's degree in nursing and a specialization in Public Health Management.

Environment of emergency unit for the elderly care
Nascimento ERP, Silva SG, Souza BC, Souza DD, Germer Netto A From these professionals' reports, three speeches emerged with the CIs: Inadequate physical structure for elderly care; Insufficient quantity of personnel to meet the demand; and Need for agility in care and referral of the elderly.The first CI was identified in the KEs of 12 participants, the second in seven and the third in five individual speeches.Each CI has resulted in a CSD, as shown below: CI: Inadequate physical structure for elderly care CSD 1: The emergency department has not taken a posture yet according to what it really is.The elderly should not be accepted or admitted to the emergency unit, because the environment is not suitable for them.The physical structure hinders our assistance; there is lack of adequate physical space.We try to prioritize within our routine, within our needs and our structure the best for them, but seniors end up being harmed by their limitation and by the unit limitation.The care provided in the hallway is not adequate.Sometimes it is not a comfortable stretcher, there is no pyramidal mattress, there are no guardrails, and most beds are too high, with risk of falling.One cannot always give a bed bath on a stretcher, there is no way of making hygiene and comfort care, it is impossible to make change of position on a stretcher.Additionally, while the patient is in the hallway, they have no privacy and comfort.Bathrooms also are not adequate to meet the elderly because they are always clogged or wet and there is a risk of falling.All this impairs their independence, which they had at home and when they get here, they lose it.There is a need to improve the physical structure, with adapted stretchers and beds, presence of handrails on the walls, bathroom that is adapted optimally for the elderly.It is also important an area to watch television, so that the elderly can amuse and distract themselves (R1, R2, R3, R4, R6, R8, R9, R10, R11, R12, R13, R14).

CI: Insufficient quantity of personnel to meet the demand
CSD 2: There is a lack of personnel to meet the demand of elderly patients.There is an increase in the number of hospitalizations of elderly and there is a tendency of them to be weakened, bedridden and dependent.Some of them require bed bath, change of diaper, body position changes and all this demands a little more attention.The lack of personnel causes some care is not made.If the hospitalized elderly does not have a companion, the senior care becomes more fragile.There is a very large workload in this unit.(R5, R8, R9, R10, R13, R14, R15).

CI: Need for agility in care and referral of the elderly
CSD 3: Elderly should not stay longer in the emergency unit; theoretically, it should be the first care service, so it should be faster, quicker.Many elderly stay in emergency unit for too long, as if it was a nursing home.The elderly should be served here only in emergency situations.Urgent care must be done here; it should be done here, since it is the right place!After that, elderly must be removed from here.Doctors should to take into account early discharge, better evaluation of the tests, reference and counter-reference with health unit, agility in the process; it is not about removing them, but referring them and solving their cases.There should be also guidance to the family, the importance of taking their family member home, to keep caring of them at home, because it is the environment they are used to.We understand that it is difficult for the family to keep this care for the dependent family member, but emergency is not the right place for them.(R3, R6, R8, R11, R12).

DISCUSSION
The CSD 1 reveals the perception of nursing professionals about the emergency unit environment and care for the elderly.The participants consider that the infrastructure of the unit hampers nursing care and that it is inadequate for the care of elderly.
One of the problems reported by participants is regarding the safety of elderly patient, especially with regard to the risk of falls and risk of skin lesions.These perceptions have also been described in another study, which found that on elderly patients admission, 57.1% are at risk of falls and 14.2% of impaired skin integrity 8 .
It is no coincidence that these two issues are addressed as priorities in the National Program for Patient Safety (Programa Nacional para Segurança do Paciente -PNSP), which was recently set up by the Ministry of Health.The PNSP consists of six basic protocols, among them "Prevention of Falls" and "Pressure Ulcer Prevention" 9,10 .
Falls among the elderly are considered a major public health problem, since they prevent their autonomy and independence.Also, they generate anxiety, depression and fear of falling again, which ultimately increases the risk of another fall 10 .Studies point to fall as one of the major adverse events identified during hospitalization, and 50% of them occur in individuals over 60 years of age 11 .
The risk factors for falls pointed out in CSD1 refer to inadequate care equipment and physical structure of the unit.Professionals consider the stretchers used for hospitalization of patients in the emergency unit expose the elderly to greater risk, as they are generally narrower and taller than hospital beds and are not always provided with guardrails.In addition, they cite the presence of wet floor that can increase risk for the occurrence of falls in these patients.
Among the falls prevention measures described in the literature are the use of appropriate beds, presence of guardrails, good lighting and non-slip floors 8 .

Environment of emergency unit for the elderly care
Nascimento ERP, Silva SG, Souza BC, Souza DD, Germer Netto A Professionals claim that the structural problems also interfere with other nursing care such as hygiene/comfort and skin integrity.It is reported difficulty in performing basic care such as bathing and changing positions, since the accommodation on stretchers prevents the proper provision of care.
The aging process itself can be considered a risk factor for development of skin lesions.This is because with increasing age there is a considerable loss of skin thickness, decrease in collagen and reduction of Langerhans cells 8 .When this physiological vulnerability of the elderly is enhanced by extrinsic risk factors, they are more likely to develop skin breakdown and loss of integrity.
Body hygiene, besides being a measure of comfort, is an essential care to maintain the integrity of the skin and protect it against infections.A damp skin is more vulnerable and prone to the development of skin lesions and therefore should be cleaned whenever there is dirt and at regular intervals 9 .
Likewise, the redistribution of pressure exerted on the skin, especially over the bony prominences, is an essential care to prevent the occurrence of injury.Patients with limited mobility are at higher risk of developing pressure ulcers.The PNPS protocol emphasizes that every effort should be made to redistribute the pressure on the skin, either by repositioning in bed every two hours or by the use of pressure redistribution surfaces 10 .
In CSD1, professionals pointed out weaknesses in these two requisites, as reported the difficulty of performing the bath and changes in position, and the lack of pyramidal mattresses in the unit, which increases the risk of pressure ulcers in these patients.
Another problem noted in the CSD1 refers to the lack of privacy, comfort and independence of the elderly in the emergency department.In light of these reports, it is pertinent to highlight that the National Policy for Humanization (Política Nacional de Humanização -PNH) has as one of its guidelines "Environment in Health", with organization of healthy spaces that provide warm, problem-solving and human care 6 .
The concept of environment follows primarily three areas: space aimed at comfort focused on privacy and individuality of the subject; space as an enabling tool of the work process; and space for gathering between subjects 6 .Thus, it can be inferred that the environment of the studied emergency service is below expectations and does not provide adequate care for the elderly.
This reality was also identified in another study that evaluated the emergency services of eight public hospitals in four Brazilian states.The results showed that the environment was considered unsatisfactory by 91% of respondents, especially in regard to comfort, cleanliness, signalization and noise in these units 12 .
In CSD2 professionals raised the difficulties related to team work overload, which are associated with the high degree of dependence of elderly and shortfall in personnel quantitative.
The identification of the degree of dependence of the hospitalized individual is crucial for the planning of nursing care and for the staff dimensioning.For this, Patient Classification Systems (PCS) are used, which employ numerical scores to categorize patients with minimal care needs to intensive care needs 13 .
A recently conducted study evaluated the degree of dependence of elderly hospital patients using the PCS and found that 52.2% of them required intermediate care; 35.4% needed minimal care; and 12.4% demanded semi-intensive care 13 .These findings are in agreement with the perception of professionals related in CSD2, in which they state that the elderly, in most cases, are dependent on nursing to self-care, thus requiring greater availability of personnel.
To calculate the staff dimensioning, Resolution Nº 293/2004 of the Federal Nursing Council indicates assessing the number of nursing hours per bed and per user, within 24 hours, based on the degree of patient dependency, in which: 3.8 hours of nursing rendered to minimum care; 5.6 hours of nursing to intermediate care; 9.4 hours of nursing to semi-intensive care; 17.9 hours of nursing to intensive care 14 .
However, in an emergency service one has to deal with unpredictability; with the organization to meet spontaneous demand; with the references of medium and high complexity; among other characteristics, and there is still no indication on how to turn them into measurable parameters to predict the staff dimensioning 15 .
It is still mentioned in CSD2 the importance of a family member accompanying the elderly patient during their stay, claiming that when there is no companion, care becomes more fragile.The open visit and the right have a companion is part of the PNH and is also guaranteed by law to elderly patients 16 .The presence of a companion, besides strengthening in the sick person their personal identity and self-esteem, can contribute significantly to observing changes in their clinical condition and communicating them to staff 17 .
The length of stay of elderly patients in the emergency department is addressed in CSD3.Nursing professionals state that the elderly usually stay many days in the unit, and discuss the need for agility in referring these patients after stabilizing their emergency clinical condition.
The long stay of patients in emergency units and the difficulty in referring them, especially clinical, chronic and elderly patients, is a problem evidenced in different Brazilian states 12 .Study conducted in emergency departments of public hospitals, located in the states of Rio de Janeiro, Rio Grande do Sul, Pernambuco and Sergipe, points out that the length of stay of patients in these units may vary from one day to three months 12 .Corroborating the above, other research indicates that the user stay in emergency services for more than 24 hours prevents assistance to emergency cases, leading to obstacles such as overcrowding of these units 18 .

Environment of emergency unit for the elderly care
Nascimento ERP, Silva SG, Souza BC, Souza DD, Germer Netto A These obstacles are associated with the precariousness of the health care network, with deficits in the regulation of beds, lack of access to specialized outpatient care and to hospital care that, in turn, impacts the emergency care, transforming these units in depositories of unresolved problems, among other reasons.To resolve such impasses, we call for the joint action to a regulatory system with reference and counter-reference that provides following-up locations after the emergency care 12 .
Therefore, it is evident in the speeches the awareness among professionals about the difficulties observed in the emergency unit and the need for interventions to improve care for the elderly while respecting their privacy and individuality.

FINAL CONSIDERATIONS
The analysis of the perception of nursing professionals about the environment of a hospital emergency unit for the elderly care showed that they recognize several weaknesses in serving this population, given the workload reports of nursing professionals as well as inadequacies of the physical structure for the care of the elderly population, which in turn hinders nursing actions and limits the independence of the elderly within their potential.
The results also denote that nursing professionals propose suggestions to improve care for the elderly, including forming alliances with companions to strengthen care, performing adjustments on the dimensioning of nursing staff due to the high degree of dependence of elderly patients, ensuring proper maintenance and cleaning of the unit, especially of the bathrooms due to the risk of falling, providing adequate space aiming at comfort, privacy, leisure and independence of the elderly during their stay in the emergency unit.However, some actions are beyond these professionals' scope, such as the adaptation of the physical structure and the correct and agile referring of these elderly after emergency condition is stabilized.
With this study it can be inferred that the growth of the elderly population in the local community does not follow the structural conditions of this emergency hospital, especially as regards the necessary physical environment to meet the demands and needs of elderly patients.
It should be noted that this study is limited to a particular care setting, focusing on the perception of nursing professionals, which shows the importance of further research in other realities, that also unveil the perspective of other health professionals, elderly users and their companions.