Mixed-methods study examining family carers' perceptions of the relationship between intrahospital transitions and patient readiness for discharge

INTRODUCTION

Intrahospital transitions (IHTs) represent movements of patients during hospitalisation. While transitions are often clinically necessary, such as a transfer from the emergency department to an intensive care unit, transitions may disrupt care coordination, such as discharge planning. Family carers often serve as liaisons between the patient and healthcare professionals. However, carers frequently experience exclusion from care planning during IHTs, potentially decreasing their awareness of patients' clinical status, postdischarge needs and carer preparation. The purpose of this study was to explore family carers' perceptions about IHTs, patient and carer ratings of patient discharge readiness and carer self-perception of preparation to engage in at home care.

METHODS

Sequential, explanatory mixed-methods study involving retrospective analysis of hospital inpatients from a parent study (1R01HS026248; PI Wallace) for whom patient and family carer Readiness for Hospital Discharge Scale (RHDS) score frequency of IHTs and patient and caregiver characteristics were available. Maximum variation sampling was used to recruit a subsample of carers with diverse backgrounds and experiences for the participation in semistructured interviews to understand their views of how IHTs influenced preparation for discharge.

RESULTS

Of discharged patients from July 2020 to April 2021, a total of 268 had completed the RHDS and 23 completed the semistructured interviews. Most patients experienced 0-2 IHTs and reported high levels of discharge readiness. During quantitative analysis, no association was found between IHTs and patients' RHDS scores. However, carers' perceptions of patient discharge readiness were negatively associated with increased IHTs. Moreover, non-spouse carers reported lower RHDS scores than spousal carers. During interviews, carers shared barriers experienced during IHTs and discussed the importance of inclusion during discharge care planning.

CONCLUSIONS

IHTs often represent disruptive events that may influence carers' understanding of patient readiness for discharge to home and, thus, their own preparation for discharge. Further consideration is needed regarding how to support carers during IHT to facilitate high-quality discharge planning.

Missed nursing care: a snapshot case study in a medical ward in Australia

BACKGROUND

Missed nursing care is a global issue in acute healthcare settings. It is a complex phenomenon that refers to nursing care that is required by patients but left undone or significantly delayed.

AIM

To investigate the nature of missed nursing care and influencing factors in a general medical ward in an acute care hospital in Brisbane, Australia.

METHOD

This is a descriptive case study. The study was carried out in a 29-bed inpatient general medical/cardiology/telemetry ward in an acute care tertiary hospital.

RESULTS

The study ward has been identified as a high complexity unit. The survey data found that the most frequent nursing care elements missed, as reported by the patients, were oral care, response to machine beep, and response to call light. The most frequent nurse-reported missed care items were ambulation, monitoring fluid intake/output and attendance at interdisciplinary conferences.

CONCLUSION

Despite mandating nurse-to-patient ratios in the study ward, inadequate staffing was still perceived as being problematic and one of the most frequent reasons leading to missed nursing care. This possible disconnect between mandated staffing ratios and the persistence of perceived missed care suggests a more complex relationship than can be managed by macro (large-scale) resourcing formulas alone.

Exploration of clinicians’ decision-making regarding transfer of patient care from the emergency department to a medical assessment unit: A qualitative study

Background

Hospitals face immense pressures in balancing patient throughput. Medical assessment units have emerged as a commonplace response to improve the flow of medical patients presenting to the emergency department requiring hospital admission and to ease overcrowding in the emergency department. The aim of this study was to understand factors influencing the decision-making behaviour of key stakeholders involved in the transfer of care of medical patients from one service to the other in a large, tertiary teaching hospital in Queensland, Australia.

Methods

We used a qualitative approach drawing on data from focus groups with key informant health and professional staff involved in the transfer of care. A theoretically-informed, semi-structured focus group guide was used to facilitate discussion and explore factors impacting on decisions made to transfer care of patients from the emergency department to the medical assessment unit. Thematic analysis was undertaken to look for patterns in the data.

Results

Two focus groups were conducted with a total of 15 participants. Four main themes were identified: (1) we have a process—we just don’t use it; (2) I can do it, but can they; (3) if only we could skype them; and (4) why can’t they just go up. Patient flow relies on efficiency in two processes—the transfer of care and the physical re-location of the patient from one service to the other. The findings suggest that factors other than clinical reasoning are at play in influencing decision-making behaviour.

Conclusions

Acknowledgement of the interaction within and between professional and health staff (human factors) with the organisational imperatives, policies, and process (system factors) may be critical to improve efficiencies in the service and minimise the introduction of workarounds that might compromise patient safety.

Exploring nurses' clinical reasons for bed transfers in acute care wards: An observational study

AIMS

To investigate the number of bed transfers (patient transfers within the same ward) and their reasons in acute care wards of mid-sized hospitals with multibed and private rooms.

BACKGROUND

Bed transfers, even when necessary, are burdensome for patients; however, the reasons for bed transfers in various types of rooms remain unclear.

METHODS

An observational study was conducted in seven wards in three hospitals in Japan. Nurses completed a questionnaire regarding each bed transfer, which elicited the reasons for the transfer. We classified transfer patterns based on the functions of the patients' rooms and the number of beds in each room and analysed scores.

RESULTS

Overall, 560 responses were analysed. The average number of bed transfers per day was 2.7. In total, 43% of bed transfers were conducted for patients aged over 70. The most frequent bed transfer pattern was 'transfer between patient rooms with the same number of beds', and the most frequent reason was 'patient did not need that bed'.

CONCLUSIONS

Unnecessary bed transfers could be reduced by ward designs that reflect nurses' clinical judgement.

IMPLICATIONS FOR NURSING MANAGEMENT

Monitoring data for the reason regarding bed transfer contributes to hospital planning and decreases unnecessary bed transfers.

Association between intrahospital transfer and hospital-acquired infection in the elderly: a retrospective case-control study in a UK hospital network

Background

Intrahospital transfers have become more common as hospital staff balance patient needs with bed availability. However, this may leave patients more vulnerable to potential pathogen transmission routes via increased exposure to contaminated surfaces and contacts with individuals.

Objective

This study aimed to quantify the association between the number of intrahospital transfers undergone during a hospital spell and the development of a hospital-acquired infection (HAI).

Methods

A retrospective case–control study was conducted using data extracted from electronic health records and microbiology cultures of non-elective, medical admissions to a large urban hospital network which consists of three hospital sites between 2015 and 2018 (n=24 240). As elderly patients comprise a large proportion of hospital users and are a high-risk population for HAIs, the analysis focused on those aged 65 years or over. Logistic regression was conducted to obtain the OR for developing an HAI as a function of intrahospital transfers until onset of HAI for cases, or hospital discharge for controls, while controlling for age, gender, time at risk, Elixhauser comorbidities, hospital site of admission, specialty of the dominant healthcare professional providing care, intensive care admission, total number of procedures and discharge destination.

Results

Of the 24 240 spells, 2877 cases were included in the analysis. 72.2% of spells contained at least one intrahospital transfer. On multivariable analysis, each additional intrahospital transfer increased the odds of acquiring an HAI by 9% (OR=1.09; 95% CI 1.05 to 1.13).

Conclusion

Intrahospital transfers are associated with increased odds of developing an HAI. Strategies for minimising intrahospital transfers should be considered, and further research is needed to identify unnecessary transfers. Their reduction may diminish spread of contagious pathogens in the hospital environment.

Time and quality of admissions: nursing workload

OBJECTIVES

to measure the average time spent by the nursing staff during patient admission and investigate their compliance with the activities described by the Nursing Interventions Classification; evaluate the degree of interference in the workload of the team.

METHODS

observational with time measurement through software. We followed 199 admissions made by the nursing staff in seven units, using two validated instruments. Total scores ≥ 70% and 50% validated the process.

RESULTS

the average time of nurses ranged from 5.5 (standard deviation = 2.3) to 13 (standard deviation = 1.1) minutes; and the auxiliary / technician, between 4.7 (standard deviation = 2.1) and 6.8 (standard deviation = 2.0) minutes (p ≤ 0.01). We qualified six admissions made by nurses and 33 by assistants/technicians. The intervention spent 16.3% to 31.5% of the working hours of the team.

CONCLUSIONS

admission impacts nursing workload and needs to be considered both in the measurement of activities and in the sizing of the nursing staff.

Longitudinal Study of the Variation in Patient Turnover and Patient-to-Nurse Ratio: Descriptive Analysis of a Swiss University Hospital

Background

Variations in patient demand increase the challenge of balancing high-quality nursing skill mixes against budgetary constraints. Developing staffing guidelines that allow high-quality care at minimal cost requires first exploring the dynamic changes in nursing workload over the course of a day.

Objective

Accordingly, this longitudinal study analyzed nursing care supply and demand in 30-minute increments over a period of 3 years. We assessed 5 care factors: patient count (care demand), nurse count (care supply), the patient-to-nurse ratio for each nurse group, extreme supply-demand mismatches, and patient turnover (ie, number of admissions, discharges, and transfers).

Methods

Our retrospective analysis of data from the Inselspital University Hospital Bern, Switzerland included all inpatients and nurses working in their units from January 1, 2015 to December 31, 2017. Two data sources were used. The nurse staffing system (tacs) provided information about nurses and all the care they provided to patients, their working time, and admission, discharge, and transfer dates and times. The medical discharge data included patient demographics, further admission and discharge details, and diagnoses. Based on several identifiers, these two data sources were linked.

Results

Our final dataset included more than 58 million data points for 128,484 patients and 4633 nurses across 70 units. Compared with patient turnover, fluctuations in the number of nurses were less pronounced. The differences mainly coincided with shifts (night, morning, evening). While the percentage of shifts with extreme staffing fluctuations ranged from fewer than 3% (mornings) to 30% (evenings and nights), the percentage within “normal” ranges ranged from fewer than 50% to more than 80%. Patient turnover occurred throughout the measurement period but was lowest at night.

Conclusions

Based on measurements of patient-to-nurse ratio and patient turnover at 30-minute intervals, our findings indicate that the patient count, which varies considerably throughout the day, is the key driver of changes in the patient-to-nurse ratio. This demand-side variability challenges the supply-side mandate to provide safe and reliable care. Detecting and describing patterns in variability such as these are key to appropriate staffing planning. This descriptive analysis was a first step towards identifying time-related variables to be considered for a predictive nurse staffing model.

Bed Moves, Ward Environment, Staff Perspectives and Falls for Older People with High Falls Risk in an Acute Hospital: A Mixed Methods Study

BACKGROUND

Falls remain an important problem for older people in hospital, particularly those with high falls risk. This mixed methods study investigated the association between multiple bed moves and falls during hospitalisation of older patients identified as a fall risk, as well as safety of ward environments, and staff person-centredness and level of inter-professional collaboration.

METHODS

Patients aged ≥70 years, admitted through the Emergency Department (ED) and identified at high fall risk, who were admitted to four target medical wards, were followed until discharge or transfer to a non-study ward. Hospital administrative data (falls, length of stay [LoS], and bed moves) were collected. Ward environmental safety audits were conducted on the four wards, and staff completed person-centredness of care, and interprofessional collaboration surveys. Staff focus groups and patient interviews provided additional qualitative data about bed moves.

RESULTS

From 486 ED tracked admissions, 397 patient records were included in comparisons between those who fell and those who did not [27 fallers/370 non-fallers (mean 84.8 years, SD 7.2; 57.4% female)]. During hospitalisation, patients experienced one to eight bed moves (mean 2.0, SD 1.2). After adjusting for LoS, the number of bed moves after the move to the initial admitting ward was significantly associated with experiencing a fall (OR 1.56, 95% CI 1.11-2.18). Ward environments had relatively few falls hazards identified, and staff surveys indicated components of person-centredness of care and interprofessional collaboration were rated as good overall, and comparable to other reported hospital data. Staff focus groups identified poor communication between discharging and admitting wards, and staff time pressures around bed moves as factors potentially increasing falls risk for involved patients. Patients reported bed moves increased their stress during an already challenging time.

CONCLUSION

Patients who are at high risk for falls admitted to hospital have an increased risk of falling associated with every additional bed move. Strategies are needed to minimise bed moves for patients who are at high risk for falls.

Patient and family description of receiving care in acuity adaptable care model

AIM

To explore patient and family perspectives of hospital care in an acuity adaptable care model implemented in an urban, public safety-net hospital.

BACKGROUND

Specialty care units result in reactionary bed management. Changes in acuity generate costly, disruptive, intra-hospital patient transfers, which negatively affect clinical outcomes while increasing nurse workload. The acuity adaptable care model is a universal bed model structured to support patients in one room while providing staff, equipment and other resources across varying levels of acuity.

METHOD

Qualitative descriptive methods were used to analyse the narratives of a purposive sample of patients and family members about receiving care in an acuity adaptable care delivery model.

RESULTS

Three content areas emerged from the narratives and were categorized as feeling safe, perceiving continuity of care and valuing family, which culminated in a sense of comfort and healing while in the hospital.

CONCLUSION

By bringing care services to the patient instead of taking the patient to the services, the acuity adaptable care model facilitated a perception of a healing environment for patients and family members.

IMPLICATIONS FOR NURSING MANAGEMENT

The acuity adaptable care model should be considered when hospital facilities are undergoing major renovation or replacement.

Intrahospital transfers and the impact on nursing workload

AIMS AND OBJECTIVES

To determine the rate of patient moves and the impact on nurses' time.

BACKGROUND

Bed shortages and strategies designed to increase patient flow have led to a global increase in patient transfers between wards. The impact of transferring patients between wards and between beds within a ward on nurses' workload has not previously been measured.

DESIGN

A two-stage sequential study. Retrospective analysis of hospital data and a prospective observational-timing study.

METHODS

Secondary analysis of an administrative data set to inform the rate of ward and bed transfers (n = 34,715) was undertaken followed by an observational-timing study of nurses' activities associated with patient transfers (n = 75).

RESULTS

Over 10,000 patients were moved 34,715 times in 1 year which equates to an average of 2.4 transfers per patient. On average, patient transfers took 42 min and bed transfers took 11 min of nurses' time. Based on the frequency of patient moves, 11.3 full-time equivalent nurses are needed to move patients within the site hospital each month.

CONCLUSION

Transferring patients is workload intensive on nurses' time and should be included in nursing workload measurement systems.

RELEVANCE TO CLINICAL PRACTICE

Nurses at the site hospital spend over 1700 hr each month on activities associated with transferring patients, meaning that less time is available for nursing care.

Effects of frequent PATient moves on patient outcomes in a large tertiary Hospital (the PATH study): a prospective cohort study

Objective The aim of the present study was to investigate the incidence of and patient outcomes associated with frequent patient moves. Methods In a prospective cohort study, any bed move and the reason for the move were documented. Patients were assessed on admission for anxiety, social support and delirium. Adverse events, length of stay and satisfaction were recorded. Patients moved three or more times were compared with those moved less than three times. Results In all, 566 patients admitted to a tertiary referral hospital were included in the study. Of these, 156 patients (27.6%) were moved once, 46 (8.1%) were moved twice and 28 (4.9%) were moved at least three times. Those moved three or more times were almost threefold more likely to have an adverse event recorded compared with those moved fewer times (relative risk (RR) 2.75; 95% confidence interval (CI) 1.18, 6.42; P=0.02) and to have a hospital stay twice as long (RR 7.10; 95% CI 2.60, 11.60; P=0.002). Levels of satisfaction and anxiety were not affected by frequent moves and there was no effect on delirium. Conclusion Frequent bed moves affect patient safety and prolong length of stay. What is known about the topic? Retrospective and qualitative studies suggest that patient safety and costs may be affected by frequent patient moves. What does this paper add? The present study is the first prospective study to assess the negative effects of frequent patient moves on specific patient outcomes, such as adverse events, length of stay and satisfaction with care. What are the implications for practitioners? Within- and between-ward moves may affect patient safety. Patients should be moved only when there is a clear and unavoidable reason for doing so.

Resources-tasks imbalance: Experiences of nurses from factors influencing workload to increase

Background:

While nursing workload is a worldwide challenge, less attention has been given to the determining factors. Understanding these factors is important and could help nursing managers to provide suitable working environment and to manage the adverse outcomes of nursing workload. The aim of this study was to discover nurses’ experiences of determinant factors of their workload.

Materials and Methods:

In this qualitative study, the participants included 15 nurses working in two hospitals in Tehran, Iran. The data were collected through 26 unstructured interviews and were analyzed using conventional content analysis. The rigor has been guaranteed with prolonged engagement, maximum variance sampling, member check, and audit trail.

Results:

Resource–task imbalance was the main theme of nurses’ experiences. It means that there was an imbalance between necessary elements to meet patients’ needs in comparison with expectation and responsibility. Resource–task imbalance included lack of resource, assignment without preparation, assigning non-care tasks, and patients’ and families’ needs/expectations.

Conclusions:

A deep and comprehensive imbalance between recourses and tasks and expectations has been perceived by the participants to be the main source of work overload. Paying more attention to resource allocation, education of quality workforce, and job description by managers is necessary.