title: Balancing safety and harm for older adults with dementia in rural emergency departments: healthcare professionals' perspectives.
abstract: The emergency department (ED) is a potentially harmful environment for older adults with dementia, and rural EDs face unique challenges in providing care to this population. The purpose of this study was to understand safety and harm in rural ED transitional care for community dwelling older adults with dementia from the perspective of healthcare professionals (HCPs).
  
  
  
  An interpretive, descriptive exploratory design from a social ecological perspective was used. Using purposive and snowball sampling, HCPs were recruited from two rural hospital EDs in two Canadian provinces. Data collection involved participant interviews using a semi-structured interview guide. Audio-recorded interviews were transcribed, transcripts coded, and themes identified using constant comparative analysis with thematic coding.
  
  
  
  A total of 12 HCPs, seven from one province and five from the other, participated in the study. HCPs worked directly in the ED or consulted in the ED from hospital-based social work, rehabilitation and community liaison services. Three themes were identified: physical environment (space, design and equipment), work environment (pressure to perform)and practice environment (family, knowledge and processes). A conceptual model was developed to illustrate how HCPs worked to balance safety and harm for older patients with dementia within a milieu created by the overlapping and synergistically interacting environments.
  
  
  
  HCPs in rural EDs working at the interface of hospital and community constantly attempt to balance promoting safety and avoiding harm for older adults with dementia. Participants perceived safety broadly, understanding that the consequences of the milieu were created through an interaction between physical, work and practice environments. These consequences related to the physical, cognitive and emotional wellbeing of older adults with dementia and their caregivers. Within the practice environment, participants identified a 'rural advantage' that was tied to their knowledge of community and the people with dementia and their caregivers who sought care in the participating EDs. However, familiarity can be a double-edged sword and to minimize potential harm healthcare professionals must seek input from caregivers regarding altered functional status, and policies to change triage to include gerontological knowledge and create elder-friendly rural ED environments are needed.
authors.affiliation: Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. kathleen.hunter@ualberta.ca.
authors.forename: Kathleen F
authors.initials: KF
authors.lastname: Hunter
authors.affiliation: Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. bparke@ualberta.ca.
authors.forename: Belinda
authors.initials: B
authors.lastname: Parke
authors.affiliation: Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. babb@ualberta.ca.
authors.forename: Maureen
authors.initials: M
authors.lastname: Babb
authors.affiliation: Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. dforbes@ualberta.ca.
authors.forename: Dorothy
authors.initials: D
authors.lastname: Forbes
authors.affiliation: Department of Sociology, Faculty of Arts, University of Alberta, Edmonton, Alberta, Canada. lstrain@ualberta.ca.
authors.forename: Laurel
authors.initials: L
authors.lastname: Strain
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002170:Canada; D002983:Clinical Competence; D003704:Dementia / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006282:Health Personnel / Q000458:organization & administration*; D006801:Humans; D008297:Male; D061214:Patient Safety / Q000706:statistics & numerical data*; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D036301:Qualitative Research; D012424:Rural Population
keywords: Aged Care; Allied Health; Emergency Care; Evidence-based Care; Geriatrics; Medical; North America; Nursing; Qualitative Research