Managing the deteriorating nursing home resident after the introduction of a hospital avoidance programme: a nursing perspective.

Background: Hospital avoidance programmes aim to reduce the number of emergency transfers from nursing homes to hospitals and facilitate early discharge for hospitalised residents. Nursing staff are at the forefront of these efforts, yet little is known about how the programmes affect them and their management of the deteriorating resident. This information is needed to inform hospital avoidance programmes and better understand their work. Aim: To examine nursing home nursing staff perceptions regarding their management of the deteriorating resident after the introduction of a hospital avoidance programme. Methods: A thematic analysis was conducted of focus group data collected from nursing staff 14 to 15 months after the introduction of a pilot hospital avoidance programme at an Australian nursing home. Findings: The programme was well received and filled a gap in nursing staff management of residents with deteriorating health by providing structure and support. Staff were more confident and focused on this area of their work. Nursing assistants felt more integrated into the system and were supported and learning from nurses. Workload remained heavy and there was a shift in how time was allocated, but nursing staff preferred to keep residents at the facility. Conclusion: Nursing staff welcomed the programme and benefitted from its implementation. However, strategies must be explored to accommodate the staffing needs associated with providing emergency and subacute care in the nursing home setting.

focus groups; qualitative approaches; nursing homes; hospital avoidance; nurses; nursing assistants; hospital transfers; subacute care; attitude of health personnel; quality improvement programs; nurse practitioners

Nursing staff, due to their close proximity to patients, are likely to be the first to detect early signs of deteriorating health and to respond accordingly to minimise the level of intervention required. In the hospital setting, early warning systems help to recognise physiological changes, signalling a problem, and a response team can be activated. For nurses working in nursing homes, the challenges of identifying and managing a deteriorating resident are similar, but the system for recognition and response may be absent or not clearly defined. Detection in this setting is further tested by the fact nursing home residents are typically frail and have complex health needs associated with at least one chronic condition [1] . Signs and symptoms of an acute exacerbation can be subtle or difficult to detect and interpret in this population [2] . Delays in recognition can lead to hospitalisation for a problem that could have been managed in the nursing home if detected early [3] , [4] . But the capacity for nursing homes to manage and treat certain conditions varies, as nursing homes are not ‘miniature hospitals’ [5] . Hospital avoidance programmes in the nursing home setting have the potential to address this gap by facilitating a more coordinated approach to the recognition, response and management of the deteriorating resident.

Hospital avoidance programmes, which are also referred to in the literature as admission avoidance programmes [6] and quality improvement programmes [7] , vary in scope but are designed to support early recognition and response to deteriorating health to avoid hospitalisation. In the nursing home setting, reducing hospitalisations decreases healthcare expenditures [8] , [9] , [10] , unburdens emergency and in‐patient hospital services [11] , and prevents the stress and possible iatrogenic complications nursing home residents experience when hospitalised [12] . These programmes typically include a combination of nursing staff training, advance care planning (ACP), early warning and decision‐support tools, diagnostic equipment, access to advanced healthcare individuals or teams, and options for providing some level of subacute care [11] , [13] , [14] , [15] , [16] . These programmes address national and international priorities that aim to avoid unnecessary hospitalisation of older persons [17] , [18] , [19] but are not meant to preclude the transfer of a nursing home resident to hospital when warranted [20] . The literature recognises that the decision to transfer a resident to hospital is complex and can take into account a number of factors, including resident acuity, family pressures, legal concerns, access to diagnostic equipment and staffing [21] , [22] , [23] , [24] ; yet hospitalisation for certain clinical and chronic conditions can be avoided when there is proactive management in the nursing home setting [25] , [26] . As infections are a common cause of emergency transfers, on‐site evaluation and administration of intravenous antibiotics is one possible solution [26] , especially when outcomes for nursing home residents transferred to hospital with infections have been found to have worse outcomes than those who stayed in the nursing home [27] . Adherence to current medical plans and advance directives further supports hospital avoidance efforts [28] , [29] . Nursing homes that are forthright in their policy and approach to ACP are less inclined to make unnecessary hospital transfers [24] , [28] , [29] , [30] , [31] .

A frequently referenced programme in this area is Interventions to Reduce Acute Care Transfers (INTERACT) II that originated in the United States and has been operationalised in Canada, the United Kingdom and Singapore [7] . The expansion may be attributed to a growing need and evidence the programme contributes to fewer hospitalisations. Outcomes of hospital avoidance programmes are mainly measured by reduction in the number of transfers to hospital or shorter lengths of hospital stays for admitted residents. Up to a 24 per cent decrease in hospitalisations over a 6‐month period compared to the same time frame a year earlier were reported in 25 nursing homes using INTERACT II, with estimated savings to the government health fund provider of around $125 000 (US) per year per 100‐bed nursing home [14] . Similarly, nursing home residents enrolled in a Hospital in the Nursing Home (HINH) initiative in Australia experienced a shorter length of stay in hospital than residents not enrolled in the programme [6] . HINH facilitates acute care services for nursing homes, as well as staff training and support. A review of secondary literature by Grimmer‐Somers and Kumar [32] around the effectiveness of hospital avoidance programmes in general, not focusing solely on nursing homes, determined there was evidence of positive patient‐centred outcomes from these programmes.

Often missing from discussion of the outcomes of hospital avoidance programmes is nursing staff response. Nurses are the rescuers when someone's health deteriorates [33] . They are often the first to detect, assess and manage the plan of care for deterioration and are therefore instrumental in following the guidelines outlined by a hospital avoidance programme. Yet insufficient attention has been given to their views in this area [5] , [22] , [34] , [35] .

Qualitative data on the factors that permit nursing staff to ‘confidently’ offer care and avoid hospitalisation are lacking [21] . The few studies found examining nursing staff perceptions around hospital avoidance projects indicate they prefer to keep residents from being hospitalised and support hospital avoidance efforts [35] , [36] , [37] . However, further monitoring and sharing the effect of hospital avoidance initiatives is needed for their continued enhancement and effectiveness [19] . Discussions with staff regarding their fears and concerns about a hospital avoidance programmes are imperative for success of hospital avoidance efforts [38] . Therefore, the aim of this study was to examine nursing staff perceptions regarding their management of the deteriorating resident after the introduction of a hospital avoidance programme.

The research was located at a 94‐bed nursing home in Queensland, Australia, where a pilot hospital avoidance programme had been introduced, referred to in this study as the ‘subacute programme.’ The aim of the subacute programme was to implement a model of care for providing sustainable subacute care for residents to prevent unnecessary transfers and to promote early discharge from hospital if a resident was transferred. The subacute programme was based on a traffic light system, whereby colour‐coded parameters were established on assessment documentation to determine a change in health status, which then triggered further assessment and treatment. The components of the programme are outlined in Table [NaN] .

Components of the subacute programme

1 Reprinted with permission from The Presbyterian Church of QLD trading as PresCare

Ethics approval to conduct this research was secured from the University Human Research Ethics Committee. Informed written consent was obtained from all participants.

A qualitative approach was undertaken because this method permits the researcher to access the ‘inner experience of participants’ [39] . Focus groups were chosen as the most appropriate data collection method. The sharing and comparing process that occurs in focus group sessions allows individuals to formulate and refine their own views [40] , thus contributing insight into this underexplored area of nursing work.

A purposive sample of all clinical staff directly involved in the delivery of nursing care for residents at the nursing home were notified by the facility's administrative assistant of the focus group sessions and invited to participate. This group of 15 Registered Nurses (RNs), 10 Enrolled Nurses (ENs) and 50 Personal Carers (PCs) were purposely chosen because the training, tools and resources in the subacute programme were designed for their usage. RNs and ENs are licensed and regulated nurses in Australia [41] and will be referred to as nurses, when applicable. PCs are unlicensed and unregulated and work under the guidance of the RN; PCs are the international equivalent of nursing assistants and will therefore be referred to in this study as nursing assistants. The high proportion of nursing assistants is indicative of their predominance in aged care staff [42] . Participation was voluntary and out of a population of 75 nursing staff members, 21 participated, including 13 nursing assistants and eight nurses. The sessions were held on the study site during day shift hours.

The subacute programme was introduced in stages in early 2014 and three focus groups were conducted 14–15 months postimplementation. The number of participants in each session ranged from 5 to 10. Each session lasted 30–45 minutes, included a mix of all levels of nursing personnel with the exception of the last session, which by chance included nursing assistants only. Each session was recorded and transcribed verbatim. The first author (B.J.O.) served as group moderator for all sessions. Questions presented were specifically developed to elicit participant attitudes and perceptions of the facilitators and barriers to changing behaviour and adopting and using the subacute programme (Table [NaN] ) [43] , [44] . The moderator also used probing questions to seek clarification and explore emergent themes. Focus groups continued to the point where all participants had sufficient opportunity to contribute, group interaction and discussion ebbed, and no new themes emerged.

Questions asked in the focus group sessions

The data were entered into NVivo 10 and analysed by the first author (B.J.O.) using the thematic analysis guidelines outlined by Braun and Clarke [45] , [46] . This method captures themes from across the entire data set, thus permitting the researcher to identify and interpret commonalities [45] . An inductive approach was adopted whereby the themes were data‐driven. The analysis steps included familiarisation with the data: generating codes, searching for themes, defining and refining the themes, and producing a report [46] . Thus, the audiotapes were listened to repeatedly and reviewed with the transcripts; 30 codes were initially identified and then grouped under six main headings and then further refined into five themes (Table [NaN] ). To further explore and understand the data, thematic maps and a reflective journal were produced [46] . The themes work together to tell the nursing staff story about how they recognised and responded to the deteriorating resident after the introduction of the programme. To support the credibility of the findings, the transcripts, coding and thematic maps were reviewed and discussed within the research team. Credibility is also determined by sharing the finding with the participants [47] ; therefore, the findings were also described and discussed in a 40‐minute focus group session with five members of the study site nursing staff to ensure the findings represented the views of the participants.

Coding decision process

2 RAC, residential aged care

The implementation of the subacute programme around the deteriorating resident was well received by the nursing staff and affirmed an important but underexplored area of their work. Five themes were identified that reflected their perceptions: valuing structure and support, responding with confidence, focusing on their role, working together and shifting the workload (Fig. [NaN] ). Quotes were attributed to participants by using a combination of focus group number [1] , [2] , [3] and an individual participant letter designation.

The subacute programme, especially the equipment and decision‐support tools, filled a gap by providing structure and support around the management of a deteriorating resident, or residents, as more than one resident may experience health problems at the same time. As one participant noted, ‘I think it's just the structure I like.’ (2E) Nursing staff viewed hospitalisation as traumatic for residents and preferred to keep residents in their ‘home’; yet in the past they lacked diagnostic equipment, such as electrocardiogram (ECG) machines, and other resources, such as decision‐support flow charts, which guided the assessment and response to a resident's condition. As part of the subacute programme, the nursing home introduced new assessment and monitoring equipment (Table [NaN] ). The nursing staff reported this equipment was now used on a regular basis to assess a resident's situation, as one staff member explained:

…we never had bladder scanners up until what a year ago, now so you go and check people's bladders and that of course, just to be on the safe side whereas before it would be oh well we think they have a [problem] today but we don't know. (2E)

In addition, the decision‐support tools outlined the steps to follow when nursing staff noticed a change in a resident (Table [NaN] ). As described by one staff member:

The traffic light system we use too, which is a guide to know when to do things and what steps to, appropriate steps to take so … that way we know where they're at…It's a good tool for us to use. (1E)

The decision‐support tools also included SBAR (Situation, Background, Assessment, Recommendation), a communication tool used to ensure that important information about a resident's condition is relayed in an organised manner. It was unclear how many staff used SBAR, a few stated they did not use it; however, the benefits of SBAR were acknowledged:

[with SBAR] You get to the point this is what's happening, this is the condition, this is what I've done, this is what's happening and it's done in the logical fashion, it's not randomly oh well she was alright yesterday but oh she's not so good today but it's to the point, I think that's the important thing instead of waffling on, but yeah I like it. (2E)

Similarly, another staff member commented that having the decision‐support tools contributed to a more organised approach: ‘We know what to do, we know how to act upon it, know what to observe.’ (2B) Thus, having the tools eliminated some of the guesswork, as well as the stress around managing the deteriorating resident, as one participant commented:

…so there's a lot less that you've got to mentally manage. (1D)

Thus, the structure and support inherent in the programme provided the nursing staff with the tools and resources to ‘fill the gap’ between feeling something was not right and doing something to provide the resident with the option to keep them ‘at home.’ As a result, nursing staff appeared more confident in this area of their work.

When a resident's health deteriorates, nursing staff are under pressure to act quickly and correctly. Nursing staff who lack confidence in their assessment of the situation may hesitate and second‐guess their decisions, thus delaying treatment. The subacute programme, and the structure and support it provided, appeared to increase nursing staff confidence, as one staff member explained:

Well I think the sub‐acute program, workshop, that we've been having helps build your confidence, you know you're doing the right thing, you know you're thinking the right way. And you know you're doing what everyone else, the management expects you to do, meeting expectations. (1A)

Participants said the decision‐support tools helped to improve their confidence around managing a deteriorating resident by providing guidance on the ‘appropriate steps to take.’(1E) This comment provides insight into how confidence was gained:

I think that traffic light thing does give you the confidence to deal with it, even if the RN can't get down there you know you're only talking on the phone explaining, doing the SBAR thing so you're basically following that until it gets to the stage where you definitely need some more help, so I think that's a critical part I like. (2E)

In addition to supporting greater confidence, the subacute programme contributed to greater awareness of their role in managing the deteriorating resident.

An important component of managing a deteriorating resident is early detection. The sooner a problem is detected, the more quickly it can be addressed and further decline is less likely. Participants felt they were good at detecting and reporting problems, but the programme clearly defined and identified deteriorating health as an issue and made them more cognizant of their role in early recognition and response. The following statement further describes this finding:

I think sometimes when you go to somebody all the time you think ‘oh yeah that's just them being them for the day’ or something but when all this is put in front of you you look for other things that you might not have picked up on, it probably makes you more aware of what to look for. (1G)

The training component of the programme, in particular, helped to support greater awareness of their role. As one staff member stated:

I like it because it's up‐skilling people and you know it's not just relying on the RNs for everything that goes wrong, it's up‐skilling all the staff, everyone is improving their skill level. (1A)

In addition to training around the use of the equipment and the decision‐support tools, nursing staff received training on eight common conditions found in the nursing home setting (Table [NaN] ). One staff member stated the training on dehydration was useful in the wake of a cyclone that left the nursing home without electricity and air conditioning:

…that subacute program allowed us to know you know identify the signs of the deteriorating patient and that they obviously were dehydrated and then we acted upon it straight away and they were up again the next day all good. (2B)

There was also reference to the level of detection being more vigilant:

…I think it's just moved onto a different level, a more intensive sort of level now that people are aware of what to look for, a bit more scientific sort of thing. (2E)

Thus, nursing staff were more aware of what to do and who to contact when a resident's health declined. The nursing assistants, in particular, appeared to benefit from the system and the collaboration that ensued.

There was agreement that the staff had worked well together before the programme's implementation; however, some staff felt there had been closer collaboration since the subacute programme was introduced. This was most evident in statements from a few nursing assistants who felt they were now working more closely ‘with’ the nurses as a resident's health was being monitored:

…I was keeping in contact with the ENs, I was keeping in contact with the RN as we went so we didn't have to go into the red part of it [referring to the Traffic Light system]. So it was really good to you know work beside the EN as well, you know we were up there with them. (1F)

One nursing assistant described her role as being more integrated into the ‘process.’ (1G) Before the programme had been introduced, she said she would 'run to the EN or the RN and say, ‘oh look we're just a little worried about such and such…’ and leave it at that, whereas now she said she was more likely to go with the nurse to check on the resident and was therefore more a part of the ‘process,’ which she says has resulted in closer collaboration and teamwork, which was further supported by another participant:

It [the program] helps everyone to work collaboratively. (1A)

Nursing assistants also mentioned the medical support and guidance they received from the nurse practitioners (NPs). NPs had been working with the facility prior to the programme's implementation and their presence was highly valued. One nursing assistant reported that a NP was especially helpful in explaining what was going on with residents and how this collaboration had helped her to better understand the signs of deteriorating health (3B).

The workload in aged care was viewed as heavy. So when a resident's health deteriorated, and nursing staff were focused on that person's care, everyone was affected, including the other residents because it meant staff had to spend time away from them. Since the inception of the programme, nursing staff had observed that fewer residents were transferred to the hospital, and those residents who were transferred returned more quickly. As one participant noted, ‘you can keep more people here because you're making decisions about when you send them to hospital.’ (2E) Thus, fewer transfers and faster turnaround from the hospital meant that nursing staff were caring for residents who may have otherwise been hospitalised. There were concerns raised that there might be instances where residents should be hospitalised sooner but were kept at the nursing home instead. However, the nursing staff's primary concern focused on how they would manage the initial signs of deterioration and the subsequent subacute care along with other responsibilities. For the nursing assistants, subacute care often required frequent vital sign readings, one‐on‐one feeding, bathing, toileting and repositioning the resident every two hours. For the nurses, it meant focused attention on the needs of the resident, as well as possibly administering IV medications or frequent pain medication. Communication with the family and other members of the healthcare team also intensified when a resident's health deteriorated. Thus, nursing staff had a lot to manage along with their daily routine care of other residents, as one staff member explained:

… like we're always pushed for time and we don't really have a lot, if we've got someone who's really sick we really notice that time we you know we quickly end up behind on our schedule cause you have to keep going and doing the observations and everything so it really helps when the RN recognises and you know starts the treatment quickly, gets the treatment started like, yeah, because we're always short on time. (1A)

Yet when discussing the added responsibilities around caring for the deteriorating resident, nursing staff indicated their priority was to keep the residents in their own ‘home,’ even if it meant more work for them. One participant said ‘that's what we're here for.’ (3D) Yet while the workload around managing a deteriorating resident was intense, having the programme in place appeared to contribute to a shift in how nursing staff spent some of their time when a resident's health deteriorated. For example, time that may have been spent trying to organise a transfer to the hospital was now more focused on determining whether the resident needed to be transferred at all and caring for that person. As one participant explained:

… it takes a long time to prepare somebody to send them to hospital, there's an awful lot of stress on people, if you've identified somebody as deteriorating and you've tried to ring a doctor and you've got to keep phoning back and phoning back cause they're not there or haven't returned your call… there's a lot of stress management because you've got other things to deal with and you can't get assistance for this person who you see is deteriorating whereas in this program we can put some measures in place and we've got support from nurse practitioners who are actually putting actions in place. (1D)

Thus, the programme allowed nursing staff to focus more on providing care, which is what they preferred. The main benefit of the programme from their standpoint was that the programme supported their efforts to keep the residents in their ‘home.’ As one staff member explained:

… I think having the sub‐acute [the programme] operating here, the residents are in their own home so they're not, if any tiny little thing happens we're not bundling them up and sending them off to the hospital or anything like that. They're looked after exceptionally well, so not shuffling them around and the staff are confident that everybody is educated in it so we all feel confident in it. (1B)

Thus, overall the programme was well received and nursing staff felt it helped them better manage the deteriorating resident and keep them in their ‘home.’

The topic of managing deteriorating health has been primarily situated in the hospital setting where it is considered ‘complex, challenging and multifaceted’ [48] . Protocols are in place and nurses have access to decision‐support tools, diagnostic equipment and response teams for assistance. Similar support has been lacking in the nursing home setting where nursing staff struggle with how to respond to the resident who is ‘just not right’ [2] . Nursing staff are further challenged by internal and external pressure to prevent hospitalisation. This study provides evidence that nursing staff welcome and benefit from a programme that provides tools, resources and direction on how to manage a deteriorating resident and avoid hospitalisation; however, staffing to accommodate the shift in workload that requires more advanced care is a potential barrier. Previous research has found that having a course to follow gives nursing home nurses confidence they are taking the appropriate steps [36] , alleviates some of the stress they often experience and supports better outcomes for the residents [2] .

In this study, the decision‐support tools aided staff in their assessments and communications and gave them confidence. Similar benefits have been identified previously; for example, the SBAR tool was found to remove some of the stress around reporting and helped nursing home nurses to ‘organise their thinking’ and ‘feel more confident in their communication’ [49] . Nurses need to feel confident regarding their decisions and actions when a resident's health deteriorates, as hesitation and insecurity can delay treatment [48] . In particular, less experienced nurses [50] , [51] and unregulated nurses, such as nursing assistants, who are able to measure and record vital signs but have limited interpretation skills, prefer tools that are prescriptive [52] . However, while information on nursing staff preference is desirable, usage of the tools should also be evaluated. Positive feedback regarding comparable tools has been provided alongside reports that the tools were underutilised in the nursing home because the paperwork was considered cumbersome [53] . Similarly, Terrell and Miller [54] reported communication between the emergency department and nursing home improved with the introduction of standardised forms yet consistent use of the forms was not sustained. Since communication is an important component of patient safety, especially when handing over information to another healthcare professional [55] , close monitoring of the use and effectiveness of decision‐support tools should be ongoing. Though the tools aid in early detection and provide guidance, familiarity with health issues common to older persons is also required.

In this study, the training included eight health issues commonly experienced by residents of nursing homes. Dehydration was one of the topics and there was evidence training on this topic contributed to early detection and response. With very old people, it can be difficult to assess whether what is observed is a normal change or potential life‐threatening problem [2] . Therefore, training on the common signs and symptoms experienced by this cohort and how to manage them is needed in the nursing home setting [56] . Collaboration amongst the staff and healthcare providers further supported gaining this knowledge. Positive inter‐professional collaboration encourages early detection and reporting [57] . Access to a clinical nurse specialist was found to support nurses in their efforts to follow a clinical pathway to avoid hospitalisation of residents with pneumonia [36] . Thus, one of the benefits of the subacute programme was that it facilitated this type of collaboration. In this study, nursing assistants felt more integrated into the treatment process and were learning from their interactions with the nurses and NPs.

Staffing to accommodate the shift in workload that requires more advanced care in nursing homes is a possible barrier. While the nursing staff in this study preferred to avoid hospitalisation, they also recognised that keeping the residents in the facility required balancing subacute care with the demands of their daily responsibilities. Moreover, there was recognition of the potential for providing emergency and subacute care to multiple residents simultaneously. Workload concerns were reported in the few studies found on nursing staff perceptions of hospital avoidance programmes [15] , [36] and in a study on nursing staff views on managing the deteriorating resident [37] . Staffing needs to be adjusted to accommodate the care needs of the residents and more nurses need to be available to manage more complex care when required [58] . Left unaddressed, staffing issues are a potential barrier to the successful implementation of clinical guidelines and protocols in nursing homes [59] . Ouslander et al. [9] suggest the costs associated with providing additional staff should be weighed against the potential savings realised through fewer hospitalisations. However, the need for more nurses comes at a time when the number of RNs working in the nursing home setting is decreasing [42] , [60] . Strategies to address staffing requirements for providing more subacute care in nursing homes need to be explored.

Purposive sampling from a single study site was accessed for this study and 28 per cent of the sample population participated. The authors acknowledge the inherent limitation of purposive sampling of specific locations; however, the emergent themes from this study are comparable to similar studies in the literature, suggesting that the findings from this study may be transferrable to similar settings. The impact of the programme was assessed just after more than one year; thus, sustainability of the positive outcomes requires further review. Additional factors may have contributed to a positive response to the programme by nursing staff.

The benefits of a hospital avoidance programme appear to go beyond preventing hospital transfers and saving healthcare dollars. This study suggests nursing staff also benefit from the structure and support these types of programme provide. However, more studies from nursing perspective are needed to support this conclusion. In terms of clinical practice, the components of this programme were valuable in determining the appropriate course of care. However, staffing to accommodate this level of care needs to be addressed. Further research into the impact hospital avoidance programmes have on nursing staff is needed to gain a better understanding of workplace issues and possible solutions.

We wish to thank the nursing staff for their participation. This research was conducted in partial fulfilment of the first author requirements for a PhD. The first author is the recipient of an Australian Postgraduate Award Scholarship from the Australian Government Department of Education and Training.

The first author is a PhD candidate and was involved in study design, data collection and analysis, and drafting the manuscript. The main author's PhD supervisors are the three co‐authors. Trudy Dwyer is the principal supervisor. The co‐authors were equally involved in study conception, data analysis discussions and critical revision of the manuscript.

Ethical approval to conduct this research was secured from the university Human Research Ethics Committee. Informed written consent was obtained from all participants. The approval number is H14/01‐012. Central Queensland University, Rockhampton, QLD AU.

This paper was supported by a $5000 AUD bursary awarded from PresCare, Inc., an Australian aged care provider. None of the authors had any financial interest in this study.

Graph: Themes and supporting quotations