Nursing the patient with developmental disability in hospital: roles of paid carers

Our aim in this narrative inquiry was to understand the roles of paid carers supporting adults with developmental disability and complex communication needs in hospital, from the perspectives of 15 paid carers, 15 adults with developmental disability, and 15 hospital nurses. Results demonstrated that paid carers have an important role in supporting the adult with disability, providing information, delivering basic care, and facilitating communication. Stories reflected paid carer volunteerism; lack of orientation of carers and hospital staff to the paid carers' roles; blurred role boundaries between paid carers, family carers, and nurses; and paid carers being uncertain about their own responsibilities for staff and patient safety. New policies and practice guidelines are needed to guide both health and disability services in clarifying paid carer roles and role boundaries, and to enable paid carers and hospital staff to work together effectively on the ward in the care of adults with developmental disability.     

The experiences of pediatric social workers providing end-of-life care

Pediatric social workers working in acute care hospital settings may care for children and their families in end-of-life circumstances. This qualitative study is part of a larger study focusing on the experiences of health care providers working with dying children. This study consisted of 9 semi-structured interviews of acute care pediatric social workers who work with dying children and their families. Themes included the role of social work with dying children, the impact of their work and coping strategies. Authors suggest a hospital-worker partnership in supporting staff and promotion of supportive resources.     

The work of hospitalized patients

Patient's participation in their own care, conceived as work, is the central theme of this paper. A second theme is the patients' work in relation to technology. A third is: the prevalence of chronic illness and how this relates to patients' work in the service of their own care. Data are from a multi-hospital field-research and interviewing study of technology and patient care, carried out in San Francisco and the Bay Area, California. Questions addressed in this paper include the following: What are the sources of patients' work? What types of work do patients do? How does that work relate to courses of illness and the phases? What is the relation of that work to staff work? Under what conditions is the work visible or invisible to staff? Under what conditions is the work appreciated or not by staff? What are some consequences of patient work for staff work, for the management of the courses of illness, and for the patients' own medical and biographical fates? How does patient work at the hospital relate to patient work done at home?     

Revenue, relationships and routines: The social organization of acute myocardial infarction patient transfers in the United States

Heart attack, or acute myocardial infarction (AMI), is a leading cause of death in the United States (US). The most effective therapy for AMI is rapid revascularization: the mechanical opening of the clogged artery in the heart. Forty-four percent of patients with AMI who are admitted to a non-revascularization hospital in the US are transferred to a hospital with that capacity. Yet, we know little about the process by which community hospitals complete these transfers, and why publicly available hospital quality data plays a small role in community hospitals' choice of transfer destinations. Therefore, we investigated how community hospital staff implement patient transfers and select destinations. We conducted a mixed methods study involving: interviews with staff at three community hospitals (n = 25) in a Midwestern state and analysis of US national Medicare records for 1996–2006. Community hospitals in the US, including our field sites, typically had longstanding relationships with one key receiving hospital. Community hospitals addressed the need for rapid AMI patient transfers by routinizing the collective, interhospital work process. Routinization reduced staff uncertainty, coordinated their efforts and conserved their cognitive resources for patient care. While destination selection was nominally a physician role, the decision was routinized, such that staff immediately contacted a “usual” transfer destination upon AMI diagnosis. Transfer destination selection was primarily driven at an institutional level by organizational concerns and bed supply, rather than physician choice or patient preference. Transfer routinization emerged as a form of social order that invoked tradeoffs between process speed and efficiency and patient-centered, quality-driven decision making. We consider the implications of routinization and institutional imperatives for health policy, quality improvement and health informatics interventions.     

A taxonomy of nursing care organization models in hospitals

ABSTRACT: BACKGROUND: Over the last decades, converging forces in hospital care, including cost-containment policies, rising healthcare demands and nursing shortages, have driven the search for new operational models of nursing care delivery that maximize the use of available nursing resources while ensuring safe, high-quality care. Little is known, however, about the distinctive features of these emergent nursing care models. This article contributes to filling this gap by presenting a theoretically and empirically grounded taxonomy of nursing care organization models in the context of acute care units in Quebec and comparing their distinctive features. METHODS: This study was based on a survey of 22 medical units in 11 acute care facilities in Quebec. Data collection methods included questionnaire, interviews, focus groups and administrative data census. The analytical procedures consisted of first generating unit profiles based on qualitative and quantitative data collected at the unit level, then applying hierarchical cluster analysis to the units' profile data. RESULTS: The study identified four models of nursing care organization: two professional models that draw mainly on registered nurses as professionals to deliver nursing services and reflect stronger support to nurses' professional practice, and two functional models that draw more significantly on licensed practical nurses (LPNs) and assistive staff (orderlies) to deliver nursing services and are characterized by registered nurses' perceptions that the practice environment is less supportive of their professional work. CONCLUSIONS: This study showed that medical units in acute care hospitals exhibit diverse staff mixes, patterns of skill use, work environment design, and support for innovation. The four models reflect not only distinct approaches to dealing with the numerous constraints in the nursing care environment, but also different degrees of approximations to an ideal|| nursing professional practice model described by some leaders in the contemporary nursing literature. While the two professional models appear closer to this ideal, the two functional models are farther removed.     

Everyone's problem but nobody's job: Staff perceptions and explanations for poor nutritional intake in older medical patients

Aim: Up to 60% of older medical patients are malnourished with further decline during hospital stay. There is limited evidence for effective nutrition intervention. Staff focus groups were conducted to improve understanding of potential contextual and cultural barriers to feeding older adults in hospital. Methods: Three focus groups involved 22 staff working on the acute medical wards of a large tertiary teaching hospital. Staff disciplines were nursing, dietetics, speech pathology, occupational therapy, physiotherapy, pharmacy. A semistructured topic guide was used by the same facilitator to prompt discussions on hospital nutrition care including barriers. Focus groups were tape‐recorded, transcribed and analysed thematically. Results: All staff recognised malnutrition to be an important problem in older patients during hospital stay and identified patient‐level barriers to nutrition care such as non‐compliance to feeding plans and hospital‐level barriers including nursing staff shortages. Differences between disciplines revealed a lack of a coordinated approach, including poor knowledge of nutrition care processes, poor interdisciplinary communication, and a lack of a sense of shared responsibility/coordinated approach to nutrition care. All staff talked about competing activities at meal times and felt disempowered to prioritise nutrition in the acute medical setting. Staff agreed education and ‘extra hands’ would address most barriers but did not consider organisational change. Conclusions: Redesigning the model of care to reprioritise meal‐time activities and redefine multidisciplinary roles and responsibilities would support coordinated nutrition care. However, effectiveness may also depend on hospital‐wide leadership and support to empower staff and increase accountability within a team‐led approach.     

Current challenges to providing personalized care in a long term care facility

Long term care facilities are finding it increasingly difficult to deliver quality, personalized care to their clients. This is related to: the integration of frail, elderly residents with cognitive impairment and/or behavioural disorders; ethical dilemmas; settings that are not conducive to providing a stimulating and supportive atmosphere which would enhance care delivery; admission of residents with increasingly complex care needs without adequate funding and/or support services, and staff training needs. This paper defines how one organization intends to facilitate the changes required to improve the delivery of quality, personalized care.     

Discharge planning strategies for acutely homeless inpatients

Medical and psychiatric inpatients who become unexpectedly homeless during the course of the hospital stay present an extremely complex and time-consuming challenge to social work staff. The sudden shift from domiciled to undomiciled status creates a crisis for both the patient and the institution. Unanticipated homelessness among inpatients is usually associated with multiple high-risk factors which contribute to the rejection of such patients by numerous community facilities and services. Social workers are under pressure to both effect a timely and safe discharge when acute care ends, and to avoid placing such persons in the shelter system where follow-up care is nonexistent or inadequate. This paper reviews characteristics of persons who become acutely homeless during a hospital admission and suggests approaches which may be used to identify and prevent this perplexing syndrome.     

The Role of the Built Environment: How Decentralized Nurse Stations Shape Communication,Patient Care Processes,and Patient Outcomes

Increasingly, health communication scholars are attending to how hospital built environments shape communication, patient care processes, and patient outcomes. This multimethod study was conducted on two floors of a newly designed urban hospital. Nine focus groups interviews were conducted with 35 health care professionals from 10 provider groups. Seven of the groups were homogeneous by profession or level: nursing (three groups), nurse managers (two groups), and one group each of nurse care technicians (“techs”) and physicians. Two mixed groups were comprised of staff from pharmacy, occupational therapy, patient care facilitators, physical therapy, social work, and pastoral care. Systematic qualitative analysis was conducted using a conceptual framework based on systems theory and prior health care design and communication research. Additionally, quantitative modeling was employed to assess walking distances in two different hospital designs. Results indicate nurses walked significantly more in the new hospital environment. Qualitative analysis revealed three insights developed in relationship to system structures, processes, and outcomes. First, decentralized nurse stations changed system interdependencies by reducing nurse-to-nurse interactions and teamwork while heightening nurse interdependencies and teamwork with other health care occupations. Second, many nursing-related processes remained centralized while nurse stations were decentralized, creating systems-based problems for nursing care. Third, nursing communities of practices were adversely affected by the new design. Implications of this study suggest that nurse station design shapes communication, patient care processes, and patient outcomes. Further, it is important to understand how the built environment, often treated as invisible in communication research, is crucial to understanding communication within complex health care systems.     

Violence towards health care staff and possible effects on the quality of patient care

Much of the research on violence in the health care sector has focused on the immediate and long-term effects of patient violence on staff victims. There is a lack of studies, however, examining whether individual reactions to violent episodes, such as anger and increased fear in one's work, have any measurable effect on staff behaviour toward their patients, and ultimately on the quality of patient care. The aim of the present study was to investigate whether an association exists between staff experiences with violence and patient-rated quality of patient care. A theoretical model was presented, suggesting that violence or threats experienced by health care staff have a negative effect on the quality of health care services offered, as measured by patients. In addition, it was theorised that there would be an association between staff work environment and staff reports of violence. Six questionnaire studies, three concerning hospital staff's views of their work environment and three dealing with patients' perceptions of the quality of care, provided the data for evaluating the model. Work environment and quality of care studies were carried out simultaneously at a single hospital in 1994, 1995, and again in 1997. Regression analysis was used to see which combination of work environment and quality of care variables would best predict a positive overall grade for quality of care from the patient perspective. Violence entered consistently as an important predictor into each of the three best regression equations for 1994, 1995, and 1997, respectively. The results of this analysis suggest that the violence experienced by health care staff is associated with lower patient ratings of the quality of care. The study indicates that violence is not merely an occupational health issue, but may have significant implications for the quality of care provided.     

Addressing the nurse shortage to improve the quality of patient care

Nurses are the largest group of health care professionals providing direct patient care in hospitals, and the quality of care for hospital patients is strongly linked to the performance of nursing staff, according to an Institute of Medicine report. This paper describes the Robert Wood Johnson Foundation's (RWJF's) work in nursing, which focuses on improving the hospital work environment to attract and retain high-quality nursing staff, with the ultimate goal of improving patient care and outcomes in hospitals. Other organizations' efforts to address the nurse shortage are also explored.     

Infection Control Measures and Prevalence of SARS-CoV-2 IgG among 4,554 University Hospital Employees,Munich, Germany

Hospital staff are at high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during the coronavirus disease (COVID-19) pandemic. This cross-sectional study aimed to determine the prevalence of SARS-CoV-2 infection in hospital staff at the University Hospital rechts der Isar in Munich, Germany, and identify modulating factors. Overall seroprevalence of SARS-CoV-2-IgG in 4,554 participants was 2.4%. Staff engaged in direct patient care, including those working in COVID-19 units, had a similar probability of being seropositive as non–patient-facing staff. Increased probability of infection was observed in staff reporting interactions with SARS-CoV-2‒infected coworkers or private contacts or exposure to COVID-19 patients without appropriate personal protective equipment. Analysis of spatiotemporal trajectories identified that distinct hotspots for SARS-CoV-2‒positive staff and patients only partially overlap. Patient-facing work in a healthcare facility during the SARS-CoV-2 pandemic might be safe as long as adequate personal protective equipment is used and infection prevention practices are followed inside and outside the hospital     

Risk management in suspected acute appendicitis

Acute appendicitis is a disease in which the essential elements for timely diagnosis are available. These elements are a careful history and thorough physical examination, the latter repeated as necessary until clinical judgment indicates that exploratory surgery should be performed or the patient safely discharged. The hospital that does not provide its staff with facilities to do so invites a potentially successful malpractice claim. In the absence of properly documented care, such a claim could include allegations of improper or inadequate evaluation of a person presenting for medical care, negligent medical care based on failure to properly use referral and consultant sources, and failure to provide adequate follow-up (including hospital admission). Such allegations would describe the foreseeable and significant consequences of the adverse event, be it premature discharge or negative exploration. Risk management includes education of hospital administration about the importance of an adequate observation period in this diagnosis, and education of the professional staff about the need for thorough documentation of the serial examinations when surgery is deferred. This article has presented fact, references, and opinion, which should help hospital risk managers to assess the documentation of appendicitis cases now being seen in their hospital, to plan educational interventions with the administration and professional staff, and to assist the hospital collections personnel if payers contest admissions that did not result in surgery.     

Accommodating health and social care needs: routine resource allocation in stroke rehabilitation

This paper explores routine resource allocation processes in health and social care. While there has been a small body of work which has drawn on Lipsky's (1980) insights into street level bureaucracy, few have taken seriously the opportunity offered by ethnography to explore in detail the work of front-line staff as a way of observing policy processes in action. Utilising ethnographic data from research into the continuing care of adults who had suffered a first acute stroke, we analyse how staff accommodated patient need and consider the implications that this had for the quality, equality and equity of service provision.     

Reconciling economic concepts and person‐centred care of the older person with cognitive impairment in the acute care setting

Person‐centred care is a relatively new orthodoxy being implemented by modern hospitals across developed nations. Research demonstrating the merits of this style of care for improving patient outcomes, staff morale and organizational efficiency is only just beginning to emerge. In contrast, a significant body of literature exists showing that attainment of person‐centred care in the acute care sector particularly, remains largely aspirational, especially for older people with cognitive impairment. In previous articles, we argued that nurses work constantly to reconcile prevailing constructions of time, space, relationships, the body and ethics, to meet expectations that the care they provide is person‐centred. In this article, we explore key concepts of neo‐liberal thought which forms an important back‐story to the articles. Economic concepts, “efficiency” and “freedom” are examined to illustrate how nurses work to reconcile both the repressive and productive effects of economic power. We conclude the article by proposing a new research agenda aimed at building a more nuanced understanding of the messy actualities of nursing practice under the influences of neo‐liberalism, that illuminates the compromises and adaptations nurses have had to make in response to economic power.     

Impact of critical care outreach services on the delivery and organization of hospital care

OBJECTIVES: To evaluate the impact of critical care outreach services on the delivery and organization of hospital care from the perspective of staff working in acute hospitals. METHODS: One hundred semi-structured interviews were undertaken with hospital staff who were either members of, or who came into contact with, the outreach service in eight hospitals in England. RESULTS: Outreach services had two main impacts on the delivery and organization of hospital care, reflecting the organizational and educational aims of the policy. First, on the organization of patient care: it was suggested that care was more timely, there were fewer referrals to the intensive care unit (ICU) and ICUs felt more able to discharge patients to hospital wards. There were also perceived to be improved links between ward nurses and medical teams and improved morale among ICU nurses. Second, on the confidence and skills of ward staff (nurses and junior doctors): increased contact on the wards resulted in more opportunities to share critical care skills. However, there remained concerns about the sustainability of improved skills and some respondents felt that junior doctors were becoming de-skilled. CONCLUSION: Critical care outreach services have had a positive impact on the delivery and organization of hospital care. In attempting to share critical care skills, however, these services can experience a tension between the aims of service delivery and education - a tension which is partly resolved by sharing skills in the clinical and organizational context of direct patient care.     

Organisation and features of hospital, intermediate care and social services in English sites with low rates of delayed discharge

In recent years, there has been significant concern, and policy activity, in relation to the problem of delayed discharges from hospital. Key elements of policy to tackle delays include new investment, the establishment of the Health and Social Care Change Agent Team, and the implementation of the Community Care (Delayed Discharge) Act 2003. Whilst the problem of delays has been widespread, some authorities have managed to tackle delays successfully. The aim of the qualitative study reported here was to investigate discharge practice and the organisation of services at sites with consistently low rates of delay, in order to identify factors supporting such good performance. Six 'high performing' English sites (each including a hospital trust, a local authority, and a primary care trust) were identified using a statistical model, and 42 interviews were undertaken with health and social services staff involved in discharge arrangements. Additionally, the authors set out to investigate the experiences of patients in the sites to examine whether there was a cost to patient care and outcomes of discharge arrangements in these sites, but unfortunately, it was not possible to secure sufficient patient participation. Whilst acknowledging the lack of patient experience and outcome data, a range of service elements was identified at the sites that contribute to the avoidance of delays, either through supporting efficiency within individual agencies or enabling more efficient joint working. Sites still struggling with delays should benefit from knowledge of this range. The government's reimbursement scheme appears to have been largely helpful in the study sites, prompting efficiency-driven changes to the organisation of services and discharge systems, but further focused research is required to provide clear evidence of its impact nationally, and in particular, how it impacts on staff, and patients and their families.     

Experiences of physical activity for adolescents in secure psychiatric care: Staff and patient perspectives

This study presents a novel contribution to understanding physical activity provision in secure psychiatric care. This is the first study to directly explore adolescent experiences, and triangulate these perspectives with two staff groups, a multidisciplinary team and physical health practitioners. This study included semi-structured with nine physical health practitioners, thirteen members of a multidisciplinary team (MDT), and five adolescent patients. Through an inductive reflexive thematic analysis, we constructed three overarching themes i) institutional barriers to PA, ii) the rehabilitative benefits of PA and iii) the need for collaborative working. Many of the barriers to PA were a function of the secure environment, which was associated with restrictions on movement, perpetuated by limited staff availability to escort to PA sessions. However, there was a widespread agreement that PA was multi-beneficial for patient's rehabilitation, incorporating mood improvement, increased engagement and increase in pro-social behaviours. For PA promotion and physical health support to become embedded within the service provision, collaboration and support is needed from a wider network of staff members. This suggests that future intervention work should target change at an institutional level, which involves targeting organisational policy. Such work could support staff to promote PA and motivate adolescent patients to engage in PA, whilst also supporting patient physical health within their job role.