Mastersarbete i omvårdnad (91-120hp) Malmö universitet Institutionen för vårdvetenskap Hälsa och samhälle
CONSTANTLY NEW CHALLENGES
FOR NURSES
- AN INTERVIEW STUDY
ABSTRACT
Introduction: The number of patients treated in inadequate hospital wards is increasing.
Elderly and fragile patients with medical conditions are particularly vulnerable for being placed in inadequate hospital wards. They also run a twice as high risk of health-related complications and increased mortality. RNs obtain specific knowledge by working on specific wards. However, RNs’ experience of caring for outliers seems relatively unexplored, as few studies explore RNs’ experiences in giving nursing care to outliers.
Aim: The aim of the study was to explore RNs’ experience of giving care to outliers with
medical conditions at a university hospital in Sweden.
Method: An interview study with 14 RNs from medical and surgical wards were conducted by
semi-structured interviews. The inclusion criteria were that they had worked as an RN for minimum two years and had experience of outliers. Data were collected between December 2016 and January 2018. The interviews were transcribed and analyzed using conventional qualitative content analysis to identify categories and themes according to the aim of the study.
Result: One overarching theme emerged: The interviewed nurses experienced that outliers’
medical and nursing care was delayed and therefore hospitalization was prolonged. The informants’ experience is substantiated by five main categories: Inadequate information from
ER to the ward leads to concern, Nursing interventions are performed later and lead to a sense of powerlessness, Unavailable drugs lead to delayed or no drug administration, Patients on inadequate wards do not receive proper information, and The RN does not know when the patient is ready for discharge planning.
Conclusion: RNs described their experience of caring for outliers as an obstacle course and
that this risks prolonged hospitalization. They are not equipped to make the most appropriate decisions, as they have other specific knowledge than the specific needs of outliers, and as a result, care is not given.
Keywords: outlier, registered nurse, experience, qualitative study, conventional content
INTRODUCTION
Elderly and fragile patients with medical conditions are particularly vulnerable for being placed as outliers in inappropriate hospital wards. Due to their complex clinical needs, sudden changes in health status may be triggered by relatively minor stress or events [1-5]. According to OECD, care facilities and the number of care places are decreasing both in most European countries and internationally [6]. At the same time, the number of patients treated in
inadequate hospital wards is increasing, and they run twice the risk of health-related complications as hospitalized patients in adequate wards. Some common complications include insufficient pain relief, nosocomial infections, medication errors, delayed treatments, and increased mortality [6-8], which has led to concerns about whether patient safety can be maintained [9]. Goulding et al. [10] and Hommel et al. [11] found that registered nurses (RNs) obtain deeper specific knowledge by working in specific wards and may at times lack the expertise required for other patient groups. For example, when RNs have clinical
experience in caring for stroke- and trauma patients, studies have shown better survival rates as well as a reduction in care injuries. In addition, experienced RNs may identify
complications earlier for certain patient groups [12-13]. A study by Hommel et al. [11] showed that outliers with hip fractures have a longer hospital stay than patients with hip fractures treated in orthopedic wards. In a study by Serafini et al. [7], fragile medical outliers have a worse outcome due to RNs working in other wards than internal medicine and have limited knowledge of critical conditions or the complications that may arise from common internal medical conditions. Jura and Walsh [14] explain that when RNs go through the nursing process, it can help them identify, understand and apply the process and ensures that nursing actions are carried out carefully, consciously, and deliberately.
Outliers are defined in this study as old and fragile hospitalized patients who are cared for in a ward other one with the specific medical responsibility and competence for the outlier’s clinical needs [8, 10]. A study by Stowell et al. [15] showed that patients who are enrolled as outliers at a university hospital received inferior care in inadequate wards, which increased their length of stay and readmission to hospital after discharge. In addition, outliers are often moved between wards, which also results in prolonged hospitalizations [16], and transfers within and between wards constitutes a patient safety risk in itself [17]. A study by Alameda and Suárez [18] found that the physicians in charge often visit outliers during afternoons, even though nursing interventions had already started in the morning without any medical care plan from the responsible physician.
Outliers can present a challenge to RNs who are notfamiliar with the complexity of the outliers’ medical or clinical needs. RNs have specific knowledge of working in certain wards and can sometimes lack the skills required to care for other patient groups. This affects the outliers’ outcome in terms of care injuries, the timely identification of complications, and survival rate, as these RNs are likely unfamiliar with the nursing process framework [14]. RNs’ experience of outliers remains relatively unexplored, and the number of studies that explore registered nurses’ experience of caring for outliers is limited.
The aim of the study was to explore registered nurses’ experience of giving care to outliers with medical conditions at a university hospital in Sweden.
METHOD
Design A qualitative study based on semi-structured interview with 14 RNs was analyzed inductively by using conventional qualitative content analysis [19].
Setting and participants A strategic sample of informants from seven surgical and medical inpatient wards at a
university hospital in Sweden was recruited by using the snowball method [20]. The inclusion criteria were that they should have worked as an RN a for minimum two years and have experience of nursing fragile outliers.
The unit managers were used as gatekeepers to facilitate contact with the informants [20]. A semi-structured interview guide with open-ended questions and probing questions was
designed. One pilot interview (not included in the study) was conducted which established the inclusion criteria of two years of professional experience. All the interviews began with the open question, ”What do you consider to be good nursing care?”. After the interviews had been conducted, they were transcribed verbatim. The 14 informants, two men and twelve women, had the median professional experience working as RNs of four (2–23) years, and they all had a bachelor’s degree in nursing. Three informants had experience giving surgical inpatient care, five informants had experience giving medical inpatient care, and six
informants had experience giving both surgical and medical inpatient care. The individual interviews lasted an average of 43 minutes (33–56) and were conducted in December 2016 and in January 2018.
Data analysis The analysis process began after the transcription had been carried out. The text was read verbatim several times to derive codes. Different subcategories were used to sort the codes relating to the aim of the study into meaningful clusters. The initial coding was done by the first author, and the second author commented on the analysis. When no data was suitable for more than one category, the process was considered saturated, as described by Hsieh and Shannon [19].
Five main categories emerged, and evolved into one overacting theme. The result is presented in Table 1. (Appendix 1 // insert table 1 here)
Ethical considerations
This study was performed in accordance with the ethical principles based on the World Medical Association (WMA) [21] and assessed by Malmö University's Ethics Council, HS 2017/69. Prior to the study, the informants received oral and written information about the study, participation, confidentiality and the option to withdraw at any time, and they signed an informed consent. All personal identifiers and quotations are without names to ensure
anonymity.
RESULTS
An overarching theme emerged: The interviewed nurses experienced that fragile outliers’ medical and nursing care was delayed, and as a result, hospitalization was prolonged. The following main categories emerged during the analysis: Inadequate information from ER to
the ward leads to concern, Nursing interventions are performed later and lead to a sense of powerlessness, Unavailable drugs lead to delayed or no drug administration, Patients on
inadequate wards do not receive proper information, and the RN does not know when the patient is ready for discharge planning.
Inadequate information from ER to the ward leads to concern
The informants described that the report from the ER department usually does not give a full picture of the patient who will be enrolled in the ward. This report is usually short and focuses on the symptoms that initially led the patient to seek medical care. When the informants read the medical record, it sometimes emerged that the oral report from ER about the patient did not match the information in the medical record. As a result, they have started to ask for each patient’s name and social security number before reading the medical record in order to get more information about the patient’s diagnosis and condition before they will take the ER report. Another issue the interviewed nurses mentioned was that when the report was given by a health professional who has not met the patient, information was missing, which
complicates the planning of nursing care on the ward where they were to be hospitalized. This means that the receiving RN did not have the possibility to ask counter questions and follow up on the outlier’s situation. They also explained that they did not have the specific
knowledge required to ask certain follow-up questions about the patients’ care plan, treatment, condition, prognosis and diagnosis related to their complex clinical needs. The informants describe how they often do not know what condition the patient is in when they arrive at the ward and that they have experienced outliers’ being admitted with
conditions such as respiratory insufficiency, circulatory failure, unidentified hip fracture and sepsis. This leads to the RNs on the wards receiving the fragile outliers expressingconcern and feelings of inadequacy: ”One outlier arrived to the ward with 70% oxygen saturation and
did not have any oxygen supply” (N1).
Nursing interventions are performed later and lead to a sense of powerlessness. The informants had experiences of different physicians coming ad hoc every day to round and
that they had to call several telephone numbers before they were able to contact the
responsible physician when outliers showed signs of deterioration or were in acute situations. They also described that the round could be performed by telephone, which implies that the responsible physician did not see or meet the patient. Those interviewed felt that the
responsible physician had full confidence in RNs to assess medical needs despite never having met in person and that the registered nurse did not have any specific knowledge of the outliers’ needs based on symptoms or diagnosis. The informants said that the amount of time spent on a round is short and communication is brief and fragmented instead of consisting of a dialogue with the responsible physician. They also mentioned that some physicians in charge talk to the patients and give the RN information about what was planned, but other physicians in charge did not see or talk to the patients but rather only read their medical journal. One example case is when one outlier did not have a physician visit them on a round for three days.
As a consequence, medical care plans for outliers were often not available, causing the informants to conclude that some medical investigations were not performed or would be done later. The same applied to blood samples, assessment of the results, and decisions about treatment. Moreover, the outliers had to wait while inpatients belonging to the ward were prioritized. This leads to outliers who are not examined in time or properly. They also
reported that some nursing interventions were not done or else performed later that day due to a focus on the administration of drugs. An example case was when a change of wound
dressing could not be performed until the responsible physician came to the ward. The interviewed nurses had experienced that outliers had not been out of bedduring the whole
period of care because they were in a ward that lacked facilities or did not receive adequate information about mobilization.
The informants explain that they worry about making mistakes or that they are not able to identify complications related to the outliers’ specific conditions. As a result, they felt that they had to take responsibility for something they did not have full knowledge about. They also explained that they want to be able to contact an RN at the unit that the patient belonged to for support and advice regarding nursing care issues. On the units that had surgical- or medical specialist nurses, the RN felt that they had a person who could further help them in the planning for the outliers. The informants felt that specialist nurses help them get an overall picture and be able to focus on the right things: ”...planned assessment will not be done and
wound dressings will not have been changed because the responsible physician did not come”
(N13).
Unavailable drugs lead to delayed- or no drug administration The informants described how drugs often were not administrated within the prescribed
timeframes, and the RNs spent a lot of time searching for and borrowing drugs from other wards. They described that when there is no prescription or a drug for the outliers, it gives them more work compared to patients who are admitted to the ward, who have access to general prescriptions and are also able to contact a responsible physician who can help them with prescription or drug issues.
The interviewed nurses clarify that they have spent more than an hour on the telephone to search for a specific drug because the prescribed drug was not available on the ward. They have to call the responsible physician for prescriptions instead of performing nursing care to the patients for whom they are responsible, and this takes time that they do not have.
Subsequently, the potential outcome of the treatment is affected. According to the informants, there were three main reasons why outliers did not receive adequate pain treatment: lack of prescription for the current drug, the dosage was too low, or the current drug was not available on the ward. One consequence was delayed drug administration, and another important issue that the informants experienced was that the outliers were not given adequate pain relief: ”Always something [drug] not given or given much later” (N8).
Patients at inappropriate wards do not receive proper information Because RNs lack knowledge of the patients’ medical conditions and their complex clinical needs, the informants explained that RNs cannot give the outliers specific information about care plans, treatments, and prognoses. They further explained that there were sometimes problems getting the physician in charge to inform the patient on the ward when the patient had questions regarding their medical care and treatment. The interviewed nurses explained that the physician in charge did not prioritize talking to the outliers because of the lack of time. They also expressed concern about when outliers received no information or inadequate information about follow-up or self-care advice and what was planned by the unit or
physician in charge during and after the hospitalization, and this results in the patient being unprepared to leave the hospital and go home. At the same time, the informants cannot ignore the fact that both they and the outliers receive fragmented information, and there may be deficiencies in the information passed on to other caregivers who will be responsible for the patient after hospitalization. As a result, outliers did not receive the information they needed. They also did not have the opportunity to ask questions, and this causes anxiety and
frustration, and in the end, can lead to prolonged hospitalization: ”I’ll see if I [the responsible
The RN does not know when the patient is ready for discharge planning The informants describe that there are variations regarding discharge planning routines to
outliers, and these depend on which unit the patient belongs to. They also tell of difficulties to get the responsible physician to come and initiate the discharge interventions to outliers. Discharge planning was often delayed, as the responsible physician did not communicate the decision to discharge the outlier to the RN in charge. The RN does not know when a patient with a specific diagnosis and thus specific needs are ready to leave the ward in order to initiate the discharge planning.
The responsible physician often left the discharge planning entirely to the RN on the ward without any information about medical care plans or treatment. The informants describe that they also are so focused on everything else that they do not start or initiate the discharge planning. At the same time, there were patients on the ward who were unable to communicate their needs to the responsible RN. This leads to patients having to remain on the ward for more days than necessary. The interviewed nurse described that some days the RN did not have time to communicate with the patient and only had a short encounters during drug delivery. This contributed to difficulties for them to identify outliers’ needs for the planning of nursing care after the hospital stay. The informants expressed that often outliers receive no information or else inadequate information about discharge planning from the responsible physician or the responsible nurse. When asked, Do you know what is planned for the fragile outliers when they leave the ward? One RN answered, ”No, I have no idea” (N8).
DISCUSSION
Method discussion The authors of this study are aware that there are limitations regarding the number of participants in the study, and that the informants came from the same university hospital in Sweden. But nevertheless, both surgical and medical units are represented in the study and the informants have experiences from one specific unit or both. By using the snowball sampling strategy to find informants for this study, the authors will reach a rich information due to good interview subjects [20]. The first author has a pre-understanding of the phenomenon of caring for outliers. During the process, this perspective has been discussed and will not affect any part of the study. But the pre-understanding has been used to ask specific probing questions during the interviews to get deeper content. All the informants were interviewed according to the same semi-structured guide with probing questions and all the questions were open-ended, as Hsieh and Shannon [19] explain will get the informants’ comments of the phenomenon. The research question was answered by the informants who have knowledge about the phenomenon to be investigated, and quotations from the informants further strengthen the results. The coding of the analysis was done by the first author, and the second author
commented on the analysis. Together, this increased the credibility of the results because the interviews and perceptions from both researchers were taken into consideration and were thoroughly processed [22].
Result discussion
The RNs’ experiences of caring for outliers was that care activities not carried out affect the outcome, and they experienced that delays occur when outliers are not prioritized. Quirke [23] explains that the reasons for suboptimal care can be categorized into patient complexity,
organization, healthcare workforce, and education factors. The RNs in this study describe
that they are not prepared to take full responsibility for the outliers because they do not have the competence or specific knowledge or skills about each outlier’s specific diagnosis or
needs. Patients who are enrolled on wards without specialist competence for their specific diagnosis may be treated by RNs who are unfamiliar with their condition and therefore not equipped to recognize subtle changes [24]. As a result of this lack of knowledge, the RN may not be comfortable or confident as they carry out their nursing interventions.
The nurses describe the lack of valid and complete reports from the ER department, and as a consequence, this affects patient safety and hampers systematic planning. They had all obtained reports that do not match the outlier’s medical record when they read it. Several of the RNs describe that the health professional who gave them the report and information about the outlier had not met the patient and were not able to answer additional questions. This lack of information affected the registered nurses’ planning and care for the patients and leads to uncertainty about the condition of the patient when she arrives at the ward. One strategy, as the RNs describe, is to take the names and social security numbers of the outliers in order to read their medical records and get more information. After reading the medical record, they call back to ER and ask for a report and can then ask follow-up questions that are adequate for the outliers. The RNs believe that if they get a good and clear report from the ER, they can start preparing what has been planned for the outliers before they arrive and not start all over again when they arrive on the ward. Apker et al. [2] and Woodhall et al. [25] confirm that if there is a lack of information, there is a high risk that the patient will not receive proper care. Incomplete information and communication deficiencies lead to negative health-related consequences, according to Leonard et al. [26]. Randmaa et al. [27] and Woodhall et al. [25] clarify that today’s care is complex, and in order to provide high quality care, information and communication must be effective and refer to the standardized SBAR communication tool that clarifies reports and reduce incidents caused by communication errors. The RNs felt that they were not up to date on the patients’ diagnoses and routines, leading to a sense of
powerless. Both medical and nursing care has become increasingly more specialized, and the nurses lacked knowledge of other units’ specific diagnoses and were not updated on nursing or medical routines that applied to outliers. Duffield et al. [28] describe that different
specialties require specific treatment methods and clarify that the nurses may not be aware of what would happen or is planned for the fragile outlier. The RNs of this study explain that they must take responsibility for something they do not have full knowledge about. Thomson [29] elucidates that nurses experienced moral stress when the structure of nursing broke down and they lacked specific knowledge, leading to worry when patient safety cannot be
maintained.
The RNs had to spend a lot of time searching for the responsible physician, and this situation could contribute to misjudgments and delayed care to outliers. For example, according to the nurses, an unnecessary administrative task is to seek and call for a physician to round with. The RNs describe that most of the rounds were fragmented, and there was no or only a short time to sit down and plan the medical and nursing care of the patient. The responsible physicians often came in the afternoon or early in the morning when the ward round already started and they had to wait or they were busy and then interruppted by the responsible physician. These interrupptions can increase the incidence of procedural failures and clinical errors [30]. The RNs felt that they had missed the opportunity to ask questions due to lack of time. At the same time, the nurses should prepare and administer drugs, evaluate the patient's nursing needs, solve problems, contact family members and make sure the outliers’ planned examinations and treatments are performed. Gugerty [31] describes that nursing care has come to a crossroads where more and more time is spent making telephone calls, filling in lists, and documenting, which affects the amount of time they have to perform nursing care, and for this reason, patient safety and nursing care will suffer. In Ball’s [32] and Kalisch and Xie’s [33] studies about care activities that are not carried out, they describe that RNs leave
one or more of 9 to13 care activities during their shift, which means four activities are left undone. In both studies, medical administration is prioritized and talking to patients is frequently left undone. The 13 nursing care activities listed by Ball [32] are undertaking treatment, skin care, preparing patient and/or family for discharge, planning care, pain management, oral hygiene, changing the patient’s position, educating the patient and/or family, updating nursing care plans, talking to patients, administrating medication on time, documenting nursing care, and conducting adequate patient surveillance. Jones et al. [34] summarize that missed or not done care is associated with several negative outcomes for the patient, and nurses, organizations and hospitals must develop strategies to reduce unfinished care. Cronenwett el al. [35] clarify that RNs need to have a separate set of competencies and identify gaps between nursing care and specific nursing care provided at their wards or units. RNs need to be able to perform care related to evidence and know what activities they can initiate, if necessary, to close gaps. Yura and Walsh [14] list certain steps in the nursing process – assessment, planning, implementation and evaluation – and as Wilkinson [36] clarifies, these will help the nurses to identify, prevent, and treat actual and potent health problems, leading to theoretical knowledge and the technical skills to provide safe nursing care, which is the essence of being a competent and respected nurse.
The outliers are not treated adequately: medical errors lead to delayed treatment and pain relief is inadequate, which can lead to a prolonged hospitalization. It takes time to obtain or administrate certain drugs or else there is no prescription or drug available to outliers, and this gives the RN more work compared to a patient who is admitted to the ward, where they have access to general prescriptions. The RNs clarify that they could not use the unit's general prescriptions regarding drugs to outliers, they must be specifically prescribed. To call and search for a responsible physician to prescribe the drug or search for a specific drug in other units or wards takes time. Blay et al. [37] describe that the increased workload that outliers bring may result in the risk of the increase in incidents such as mis-medication. Goulding [8] clarifies that, at best, there will be a delay, and at worst, it can lead to the missed
administration of the drug. In this study, it emerged that medical administration was prioritized because the prescription was usually done and other care activities were left undone or performed later, as Ball [32] and Kalisch and Xie [33] describe in their studies. The responsible physician did not prioritize talking to the outliers when they had questions regarding their medical care and treatment. This leads to the nursing care situation becoming diffuse, as nurses lacked knowledge of what to inform the patient about. The RNs were aware that they did not have the medical responsibility, but they took on a greater responsibility because the responsible physician was unavailable at the same time as the medical and nursing responsibilities needed to be dealt with. Blay et al. [37] describe that when medical and nursing responsibilities occur at the same time, there will be an increased workload for the nurses. Moreover, the RNs in this study describe a feeling of loneliness when caring for the outliers, and this is confirmed by Westbrook et al. [38], who describe that nurses spent around 37% of their time with patients. In addition, their work patterns were fragmented and interruptions with rapid changes happened between tasks. Over time, the nurses spent more time alone than talking with colleagues and patients.
In this study, the nurses’ experience was that outliers do not became discharged in time and that RNs are given the responsibility to take care of the discharge planning without any advice or information from the responsible physician. They did not know what the medical care plan would be for when the patient went home. This delayed discharge-planning experienced by the nurses can lead to a decreased quality of care and likely prolongs hospitalization. Duffield et al. [28] explain that both physicians and nurses are aware that RNs have a greater
responsibility for the patients, as they have to take overall responsibility for the outliers. Stylianou el al. [39] explain that there is evidence which confirms that a longer stay at the hospital is associated with a poorer quality of care and an increase in harmful events as well as an increase in healthcare costs and poorer utilization of care [18]. In addition, we assume that this might lead to increased expenses for the hospitals, as confirmed by Cyganska [40]. Future studies related to the subject should explore patient-related consequences for fragile outliers.
CONCLUSION
RNs described their experience of caring to outliers as an obstacle course and that care to outliers is specific and complex. They did not feel equipped to make appropriate decisions if something acute occurred that they considered may affect patient safety. They also explained that they spend a lot of time on unnecessary administration tasks, such as telephone calls, searching for the responsible physician, and finding drugs, which affects nursing care by causing it to become secondary and not carried out. It appears in the study that if RNs from the responsible units were able to support the responsible nurses regarding specific nursing care issues, this may improve the situation for the responsible nurses and the outliers. If the RN receives appropriate access from the involved stakeholders, their ability to provide appropriate care plans and nursing interventions would be improved.
REFERENCENS
1. Akner G. Frailty and Multi morbidity in Elderly People: a Shift in Management Approach. Clinical Geriatrics 2013;21(9).
2. Apker, J, Mallak, L, Gibson, S. Communicating in the ”grey zone”:perceptions about emergency physician-hospitalist hand offs and patient safety. Academic Emergency
Medicine 2007;14:884-894.
3. Clegg A, Young J, Iliffe S, Olde Rikkert M, Rockwood K. Frailty in elderly people.
Lancet 2013 March 2;381(9868):752-762.
4. Fried L, Tangen C, Walston J, Newman A, Hirsch C. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56 (3), M146-56.
5. Jha A K, Prasopa-Plaaizier N, Larizgoitia I, Bates C W. Patient safety research: an overview of the global evidence. BMJ Qual Saf Health Care 2010;19:42-47. 6. OECD/EU, (2016) ”Hospital beds”, in Health at a Glance: Europe 2016: State of
Health in the EU Cycle, OECD Publishing, Paris.
7. Serafini F, Fantin G, Brugiolo R, Lamanna O, Aprile A, Presotto F. Outlier admissions of medical patients: prognostic implications of outlying patients. The experience of the Hospital Mestre. Ital J Med 2015;9:299-302.
8. The National Board of Health and Welfare (Socialstyrelsen), (2012) Model for
knowledge management of overlocates and relocation of patients. (Modell för kunskapssyrning av överbeläggningar och utlokalisering av patienter). Stockholm,
Socialstyrelsen. [in Swedish]
9. Lepage B, Robert R, Lebeau M, Aubeneau C, Silvain C, Migeot V. Use of risk analysus method to improve care management for outlying inpatients in a University hospital. Qual Saf Health Care 2009,18(6):441-445.
10. Goulding L, Adamson, Watt I, Wright J. Patient safety in patients who occupy beds on clinically inappropriate wards: a qualitative interview study with NHS staff. BMJ Qual
Saf 2012;21:218-24.
11. Hommel A, Bjorkelund K, Thorngren K-G, Ulander K. Differences in complications and length of stay between patients with a hip fracture treated in an orthopedic
department and patients treated in other hospital departments. Journal of Orthopaedic
Nursing 2008;12:13-25.
12. Lloyd J M, Elsayed S, Majeed A, Kadambande S, Lewis D, Mothukuri R, et al. The practice of out-lying patients is dangerus: a multicentre study of nursing care provided for trauma patients. Injury 2005;36:710-13.
13. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke.
14. Stowell A, Claret P-G, Sebbane M, Bobbia X, Boyard C, Grandpierre R G, et al. Hospital out-lying though lack of beds and its impact on vare and patient outcome.
Scand J Trauma Resusc Emerg Med, 2013;21:17.
15. Yura H, Walsh M B. (1983) The nursing process, Assessing, Planning, Implementing, Evaluationg. (4th eds) Conneticut, Appleton-Century-Crofts.
16. Goulding L. The quality and safety of healthcare provided to hospital inpatients who
are placed on clinically inappropriate wards. York, University of York, Department
of Health Sciences; 2011.
17. Webster J, New K, Fenn M, Batch M, Eastgate A, Webber S, et al. Effects of freguent PATients moves in patient outcomes in a large tertiary Hospital (the PATH study): a prospective cohort study. Australian Health Review 2016;40:324-329.
18. Alameda C, Suárez C. Clinical outcomes in medical outliers admitted to hospital with heart failure. Eur J of Intern Med 2009;20:764-7.
19. Hseih H-F, Shannon SE. Three Approaches to Qualitative Content Analysis. Qual
Health Res 2005;15:1277-1288.
20. Patton M Q. Qualitative evaluation and research methods. 3 ed. Thousand Oaks, CA: Sage; 2002.
21. World Medical Association. (2013) WMA Declaration of Helsinki-Ethical principles
for medical research involving human subjects. >www.wma.net< (2018-02-11)
22. Lincoln Y S, Guba E G. Naturalistic inquiry. Newsbury Park, CA: Sage; 1985. 23. Quirke S, Coombs M, McEldowney R. Supoptimal care of the acutely unwell ward
patient: a concept analysis. Journal of Advanced Nursing (2011) 67(8),1834-1945. 24. Bakes B. Guest editorial: Acute outliers in rehabilitaion beds: Ia a bed a bed? Journal
of the Australasian Rehabilitation Nurses Association (2014) 17(3). 3-6. 25. Woodhall L, Vetacnik L, McLaughlin M. Implementation of the SBAR
Communication Technique in a tertiary center. J Emerg Nurs 2008;34:313-7. 26. Leonardo M, Graham S, Bonacum D. The human factor: the critical importance of
effektive teamwork and communication in providing safe care. BMJ Qual Saf Health
Care 2004;13:85-90
27. Randmaa M, Mårtensson G, Swenne L, Engström M. SBAR impoves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective invervention study. BMJ Open 2014;4.
28. Duffield C, Diers D, Aisbett C, Rocket M. Churn: patient turnover and casemix.
Nursing economics 2009, 27:185-191.
29. Thomson C. What should nurses do when there´s a surges in patient number? Nursing
30. Westbrook J I, Woods A, Rob M I, Dunsmuir WT, Day RO. Association of
interuptions with an increased risk and severity of medication adminitstration errors.
Arch Intern Med. 2010;170(8):683690
31. Gugerty L. Said another way. Nursing care: a lost art. Nursing Forum 2008;43: 3 160-161.
32. Ball J E, (2017) Nurse staffing levels, care left undone, & patient mortality in acute
hospitals. Stockholm: Karolinska Institutet, Department of leraning, informatic
managementand ethics.
33. Kalisch B J, Xie B. Errors of Omission: Missed Nursing Care. West J Nurs Res published online 29 April 2014 DOI: 10.1177/0193945914531859
34. Jones T L, Hamilton P, Murry N. Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. International Journal of Nursing Studies 2015;52:1121-1137.
35. Cronenwett L. Sherwood G, Barnstein J, Disch J, Johnson J, Mitchell P, et al. Quality and safety education for nurses. Nurs Outlook 2007;55:122-131
36. Willkonsson J M. (2012) Nursing process and critical thinking. (5th eds) New Yersy, Pearson.
37. Blay N, Duffield C M, Gallangher R. Patient transfers in Australian: implications for nursing workload and patient outcomes. J Nurs Manag 2012;20:302-310.
38. Westbrook J I, Duffield C, Li L, Creswick N J. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses´patterns of task time distrubution and interactions with healt professionals. BMC Health Services Research 2011, 11:319.
39. Stylianou N, Fackrell R, Vasilakis C. Are medical ourliers associated with worse patient outcomes? A retrospective study within a regional NHS hospital utsin routine data. BMJ Open 2017;7.
40. Cyganska M, The impact factors on the hospital high length of stay outliers. Procedia
APPENDIX 1
Table 1. Data analysis, themes, categories and subcategories
Theme The interviewed nurses experienced that fragile outliers’ medical and nursing care was delayed, and therefore, hospitalization was prolonged.
Main categories Inadequate information from ER to the ward leads to concern Nursing interventions are performed later and lead to a sense of powerlessness. Unavailable drugs lead to delayed or no drug adminitration Patients at inadequate wards do not recive proper information
The RN does not know when the patient is ready for discharge planning Sub categories – no valid or comprehensive information – no time for counter questions to explore the patient situation – no clear role – no appointment of responsibilities – no time for the
round or it is performed by telephone – no investigations – no treatment – no basic care – delayed prescriptions – no availability – underestimated needs – delayed or absence of pain relief – no information – no written planning –no time for information
– no follow-up information – no self-care
information
Quotes ”I can not answer that because I have not met the patient [answer from ER to counter question from a RN] ” (N14) ”Sometimes the same physician comes the whole week [to round], but sometimes we change
[physician] almost every day” (N5)
”They may need
ten drugs in the morning. If we do not have them at the ward, we can borrow them from another unit, which takes time” (N1)
”Missed
information leads to insecurity of the patient and also of family members” (N2)
”You are so
symptom-focused and forget the other [discharge
