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A meta-synthesis of factors influencing nursing home staff decisions to transfer residents to hospital Bridget Laging, Rosemary Ford, Michael Bauer & Rhonda Nay Accepted for publication 19 February 2015

Correspondence to B. Laging: e-mail: [email protected] Bridget Laging RN MAdvPracNsg Lecturer, PhD Candidate School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Melbourne, Victoria, Australia and Australian Centre for Evidence Based Aged Care (ACEBAC), La Trobe University, Melbourne, Victoria, Australia Rosemary Ford PhD RN Deputy Head of School School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Melbourne, Victoria, Australia Michael Bauer MGerontology PhD RN Senior Research Fellow Australian Centre for Evidence Based Aged Care (ACEBAC), La Trobe University, Melbourne, Victoria, Australia Rhonda Nay PhD RN Emeritus Professor La Trobe University, Melbourne, Victoria, Australia

L A G I N G B . , F O R D R . , B A U E R M . & N A Y R . ( 2 0 1 5 ) A meta-synthesis of factors influencing nursing home staff decisions to transfer residents to hospital. Journal of Advanced Nursing 71(10), 2224–2236. doi: 10.1111/jan.12652

Abstract Aim. To report a meta-synthesis of qualitative research studies exploring the role of nursing home staff in decisions to transfer residents to hospital. Background. Nurses and nurse assistants provide the majority of care to residents living in nursing homes and may be the only health workers present when a resident deteriorates. To inform future strategies, it is vital to understand the role of nursing home staff in decisions to transfer to hospital. Design and review methods. A systematic review identified 17 studies to be included. The process of meta-synthesis was undertaken using the Joanna Briggs Institute’s guidelines. Data sources. Qualitative research papers published between January 1989–October 2012 were identified in key databases including Cinahl, Embase, Medline and PsycInfo. Results. Nursing home staff members play a key role in decision-making at the time of a resident’s deterioration. Multiple factors influence decisions to transfer to hospital including an unclear expectation of the nursing home role; limited staffing capacity; fear of working outside their scope of practice; poor access to multidisciplinary support and difficulties communicating with other decisionmakers. Conclusions. There is a lack of consensus regarding the role of the nursing home when a resident’s health deteriorates. Nursing home staff would benefit from a clear prescription of their expected minimum clinical skill set; a staffing capacity that allows for the increased requirements to manage residents on-site, greater consistency in access to outside resources and further confidence and skills to optimize their role in resident advocacy. Keywords: decision-making, hospital care, hospitalization, literature review, nurses, nursing homes, patient transfer, qualitative research, systematic review

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Why is this research or review needed?  Nursing homes are resourced differently to the acute hospital setting and this may impact on the capacity of the nursing home to provide optimal care for residents when their condition deteriorates.  Little is known about the perspectives and actions of nursing home staff when a resident deteriorates and what factors influence a decision to transfer a resident to hospital.

What are the key findings?  Nursing home staff are in a key position to identify those residents who can be managed in the nursing home setting and those who require hospital transfer.  Variations in the skill set of staff and the resources available to nursing homes results in a lack of uniformity in the types of resident conditions managed onsite and confusion and conflict between decision-makers about what defines an ‘appropriate’ transfer.  Lines of authority and a hierarchy in communication can work against residents’ voices being heard in decision-making.

How should the findings be used to influence policy/ practice/research/education?  The role of nursing homes needs to be reviewed in light of the increasing complexity of residents’ care needs.  Nursing home staff need to engage in ongoing skills development aligned to changes in the role of the nursing home, care needs of residents and scope of practice.  All residents (with their families) should be encouraged to identify and document their end of life care wishes.

Introduction The transfer of residents from nursing homes (NHs) to the Emergency Department (ED) has received increasing attention over the past decades. Nursing care is the primary service provided in NHs, yet the number of Registered Nurses (RNs) working in NHs is declining and a substantial proportion of resident care is delivered by Nurse Assistants (NAs) (Annear et al. 2014). At the time of a resident deterioration access to physicians may be limited and therefore, NH staff may play a significant role in the decision process (Jablonski et al. 2007). Consequently, improvement in our understanding of factors that influence NH staff participation in decisions to transfer is critical.

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found that approximately 30% of residents were transferred to the ED each year for a broad range of clinical reasons with 60% of these transfers admitted to hospital for further management (Arendts & Howard 2010). Hospital transfer is considered undesirable because ED care is designed for ‘acutely ill and injured patient[s], not [the] medically complicated, slow-moving, functionally impaired geriatric patient’ (Adams & Gerson 2003; p. 271). Multiple negative health outcomes have also been associated with the hospital admission of NH residents, including fallrelated injuries, nosocomial infections and functional decline (Creditor 1993). Consequently, there is increasing pressure to reduce hospitalization of NH residents by improving the capacity of NHs to manage residents on-site. An early systematic review exploring the reasons for transfer from the NH to ED consisted mainly of retrospective quantitative studies describing factors such as the clinical reasons for transfer (Arendts & Howard 2010). Qualitative studies (n = 11) were explored in a later systematic review by Arendts et al. (2013); however, the findings included the perspectives of multiple stakeholders and limited enablers were identified to improve the decision process. Grabowski et al.’s (2008) systematic review also included the perceptions of NH staff; however, the review was limited to North American research. The inclusion of qualitative studies in these systematic reviews has enabled more useful exploration and understanding of the wider contextual elements that contribute to decisions to transfer. The perspectives of NH staff, however, have not often been considered separately from other healthcare workers (for example, physicians) and other stakeholders (for example, family and organizational management). Despite the centrality and importance of their roles, little is known about the perspectives and actions of NH staff with regard to decision-making (Carusone et al. 2006a, Lopez 2009). We have turned the focus of this metasynthesis specifically on NH staff.

The review Aim The aim of this review was to provide a substantive description of the decision-making processes that take place prior to the transfer of a NH resident to the ED, specifically from a NH staff perspective.

Background

Design

A systematic review of international studies investigating nursing home presentations at the emergency department,

To obtain a deeper understanding of NH staff decisionmaking prior to transfer, we undertook a meta-synthesis of

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and therefore, earlier facilitation of ACP discussions and documentation of residents’ wishes may assist NH staff to more easily advocate on their behalf.

highlight inadequacies in skill mix, workload and education that contribute to rates of transfer.

Acknowledgements Strengths and limitations An extensive, systematic search and quality appraisal resulted in 17 studies for meta-synthesis, thus providing a rich scope and depth to the data to address the aims of this review. While the search and critical appraisal process determined the number of papers included, meta-synthesis of the data revealed that a high level of theoretical saturation had occurred (Downe 2008). During the analysis and synthesis, careful consideration was given as to whether evolving themes were transferable across the different study contexts thereby revealing consistent factors influencing NH staff decision-making, regardless of the original study focus. This provided the reviewers with confidence that the data synthesis was able to identify and describe complimentary themes and patterns and conflicting themes across the international spread of studies, to produce a data synthesis with external credibility or generalizability (Schmied et al. 2009). Weaknesses in the original study design of each included paper were identified during the critical appraisal, enabling the reviewers to extract data that may not have been representative with caution. A weakness of the review is the limited description of NAs experiences due to the low representation of NAs in the study samples, which potentially resulted in skewed insight into the factors that influence NH staff decision-making.

Conclusion This meta-synthesis contains the first collation of qualitative studies exploring the reasons behind decisions to transfer residents to hospital exclusively from the perspective of NH staff. We identified widespread variation in the NH staff perceptions about the role of the NH when a resident deteriorates. This resulted in confusion regarding whether or not transfer was warranted. Such findings highlight an urgent need to clearly define the types of acute care interventions that will be offered to the resident in the NH setting. A prescriptive outline of the expected skill sets of RNs working in NHs needs to be developed and these standards need to be adhered to by providers. Decisions about transfer to hospital will also be improved if NH staff provide adequate information over the phone to physicians and facilitate ongoing ACP conversations with families and residents. Future research examining the role of Nursing Assistants in the recognition of early signs of deterioration may 2234

We would like to show our appreciation to the review panel of JBI, particularly Sarahlouise White for the support and guidance provided during the review process. We also acknowledge the contribution made by the research librarians at La Trobe University and the Australian Catholic University who assisted with the development of the search terms for each database and Verena Schadewaldt for her role in sifting the database results.

Funding This review was funded by the Department of Health and Human Services, Victoria, Australia.

Conflict of interest The authors have no conflicts of interests.

Author contribution BL was responsible for the study conception, design and data acquisition. BL, RF, MB and RN performed the analysis. BL, RF, MB and RN performed the critical revisions to the paper for important intellectual content. BL and RN obtained the funding. All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:

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substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.

Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site.

References Adams J. & Gerson L. (2003) A new model for emergency care of geriatric patients. Academic Emergency Medicine 10(3), 271–274. Annear M., Lea E. & Robinson A. (2014) Are care workers appropriate mentors for nursing students in residential aged © 2015 John Wiley & Sons Ltd

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the exclusion of four studies. The 17 remaining studies were included in the meta-synthesis (Figure 1).

Quality appraisal There was considerable variation in the quality of the 17 studies when critiqued using criteria adapted from the critical appraisal criteria in JBI-QARI (Supplementary Table S1). Most studies provided a clear purpose, used an appropriate methodology, provided meaningful representation of participants and cited evidence to support the conclusions drawn. Few studies provided details on the theoretical or conceptual perspectives; however, studies from a variety of standpoints including undisclosed theoretical standpoints were all included as meta-aggregation adopts a pluralist position that values phenomena from different perspectives (The Joanna Briggs Institute 2011). Studies were deemed to be less rigorous where: (1) the participants were not clearly identified in the findings of the study, such as where focus groups were used and included a combination of healthcare workers from both within and outside the NH (Arendts et al. 2010) or where there was inadequate use of participant quotations to support the researcher’s findings (Hutt et al. 2011, Shanley et al. 2011); (2) where description of the analyses were not reflected in

the findings (Bottrell et al. 2001); (3) if it was unclear if ethics approval had been obtained (Kayser-Jones et al. 1989, Shidler 1998, Bottrell et al. 2001); (4) if there was incongruity between the research objectives and the methodology (Lamb et al. 2011); or (5) where some of the conclusions drawn did not appear to flow from the findings of the study (Dreyer et al. 2010). A summary of the included studies is provided in Table 2.

Data abstraction Each study was read and re-read by the primary reviewer to gain an overall understanding of the study findings. The different methodologies and philosophical perspectives were treated in the same way that a researcher responds to perspectives of different participants in a single qualitative study (Paterson 2001). The author findings presented by each individual study were extracted, along with textual data that illustrated or supported the findings using the Qualitative Assessment and Review Instrument (JBI-QARI).

Synthesis In the second step data were categorized, which involved a process of identifying common meanings, including both

Initial search

n = 5545 Excluded papers that did not meet inclusion criteria based on title and abstract n = 5457

Papers retrieved for relevance check of full text n = 88 Excluded papers that did not meet the inclusion criteria based on assessment of the full text n = 68 Studies possible for inclusion in review

Studies retrieved from hand searching reference lists of 23 studies n=1

n = 20

Studies critically appraised by two reviewers n = 21

Studies excluded after critical appraisal n=4

Studies included in the review

n = 17

Figure 1 Selection process of studies. © 2015 John Wiley & Sons Ltd

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2228 Interviews Thematic analysis

Interviews Constant comparative analysis Interviews Hermeneutic phenomenology Interviews ‘qualitative descriptive data analytic process’ (p. 501).

Nurse Administrators (n = 9)

Nurses (n = 10)

RNs (n = 6) CNSs (n = 8)

Kayser-Jones et al. (1989) USA

Jablonski et al. (2007) USA

Hov et al. (2009) Norway Hutt et al. (2011) USA

Dreyer et al. 2010, Norway

Clinical and socio-cultural factors influencing transfer decisions.

Focus groups (n = 7) Interview (n = 1) Thematic analysis

RNs and LPNs (n = 24)

Influence of a clinical pathway on the management of NH residents with pneumonia. Influence of a clinical pathway on the management of NH residents with pneumonia. Nurses and physicians role in optimizing NH residents’ autonomy in end-of-life decisions. Nurses’ experiences in caring for NH residents at the end of life. Influence of a comprehensive approach to implementing guidelines for NH acquired pneumonia on transfer decisions Factors influencing transfer decisions.

Carusone et al. (2006b) Canada

Interviews Hermeneutic phenomenology Observation Interviews Retrospective chart review ‘Qualitative analysis’

NH nurses (mostly LPNs) (n = not stated)

Nurse (n = not stated)

NH nursing staff (n = not stated)

Focus groups Thematic analysis

Directors of Nursing (n = 13)

Factors influencing transfer decisions for dying residents.

Bottrell et al. (2001) USA

Carusone et al. (2006a) Canada

Focus groups Interviews Thematic analysis

NAs (n = 7) NH nurses (n = 5) NH managers (n = 5)

Design: data collection and analysis

Contributing participants

Factors influencing transfer decisions.

Study focus

Arendts et al. (2010) Australia

Author/year/ country

Table 2 Summary of the included studies.

NH nurses are often involved in negotiations between resident, family and physicians regarding transfer. Nurses used a variety of communication techniques and negotiation skills to influence decisions to transfer. Multiple socio-cultural factors influenced decisions to transfer including: insufficient and inadequately trained nursing and care staff; family pressure; poor communication between nurses and doctors; and a lack of support services.

NH nurses felt undervalued. Education focusing on palliative care, conflict management, cooperation and ethical reasoning was valued by NH staff Comprehensive implementation of the guidelines reduced NH staff desire to transfer; improved access to physicians and Nurse Practitioners; increased NH staff skills to recognize and manage pneumonia; and increased NH staff confidence to provide answers to families.

Residents’ wishes are not always considered in decisions to transfer to hospital

Several factors influenced decisions to transfer including: a lack of access to timely medical review; inadequate staffing numbers and skill mix; family pressure to transfer; and broader community attitudes towards end of life care NHs were believed to be capable of providing best practice palliative care. However, several factors influenced decisions to transfer dying residents including: family pressures to transfer; a lack of early discussions; and limited staffing, skills and resources in the NH A lack of confidence, skills and time influenced the implementation of the clinical pathway. Access to a clinician and/or study nurse who provided professional support and guidance and was highly valued by NH staff Nurse Administrators underestimated the need for additional training and NH staff support when implementing the new clinical pathway

Substantial findings

B. Laging et al.

© 2015 John Wiley & Sons Ltd

© 2015 John Wiley & Sons Ltd RNs (n = 7) ENs or NAs (n = 15)

DONs (n = 10) RNs (n = 16) ENs (n = 9) NAs(n = 25)

Factors influencing the delivery of palliative care in the NH setting.

NH nurses and care assistants perceptions of palliative care.

Factors influencing decisions to transfer.

Factors influencing lifeprolonging treatment decision-making in NHs.

Factors influencing the emergency care of NH residents.

Mitchell et al. (2011) Australia

Phillips et al. (2006) Australia

Shanley et al. (2011) Australia

Shidler (1998) Canada

Terrell and Miller (2006) USA

RNs and LPNs (n = 15)

Interviews Observation Document review Constant comparative analysis Focus group Interviews Thematic analysis

Observation Interviews NH policy review Institutional ethnography Discourse analysis Focus groups Audit of clinical records Thematic analysis Focus groups Thematic analysis

NH staff: Nurses (n = 7) Director (n = 1)

McCloskey (2011) Canada

RNs (n = 10) LVNs (n = 7) NAs (n = 6)

Interviews Observation Grounded theory

RNs (n = 3) LPNs (n = 4)

Nursing behaviours and processes inherent in decision-making for acutely ill NH residents. Factors influencing the transfer process and communication between NHs and EDs.

Lopez (2009) USA

Interviews Thematic analysis

Focus groups Survey Content analysis

RNs (n = 21) LPN (n = 1)

NH staff perceptions of avoidable transfers

Lamb et al. (2011) USA

NH Managers (n = 41)

Design: data collection and analysis

Contributing participants

Author/year/ country

Study focus

Table 2 (Continued).

Palliative care was considered to be a key role of NH staff. Barriers to implementing palliative care in the NH resulting in transfer included: a lack of a definitive diagnosis; an absence of an appropriate treatment plan; an inability to obtain timely access to a GP; family pressures; and communication difficulties Several factors influenced decisions to transfer including: the nurses’ perceptions of the acuteness of the resident’s condition; access to medical care; family pressures; numbers, qualifications and skills mix of staff; and fear of criticism for not transferring The role of NH staff in the decision process is underestimated. The legal guidelines identifying three key people involved in the decision-making process (the individual, his/her physician and proxy) do not adequately reflect all those actually involved in the decision process Communication difficulties were identified between the ED and NH. Previously documented advanced care decisions may change at the time of deterioration

Barriers to implementing palliative care in the NH resulting in transfer included: low ratios of RNs; limited access to GPs after hours; and communication difficulties

Several factors influenced NH staff decisions to transfer including: legal considerations; fear of retribution from ED; and lack of access to doctors.

Several factors influence decisions to transfer including delayed recognition of new symptoms; family pressure; inability to provide treatment in the NH; and differing perceptions about the types of resident conditions that NH staff were willing to manage on-site. NH staff were greatly influenced by family interests at the time of a resident deterioration with limited understanding of the resident’s wishes regarding transfer.

Substantial findings

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complimentary and conflicting findings. This provided a basis for concurrent analysis of common themes arising from the studies. In the final stage of the meta-synthesis, the primary reviewer discussed the emerging themes with a review panel to develop more refined meanings and new concepts (Walsh & Downe 2006). Study findings were synthesized into 19 categories on the basis of similarity in meaning. These 19 categories were then aggregated into five synthesized findings, namely; Lacking skills and confidence to manage the resident on-site; Accessing multidisciplinary services and resources; Negotiating who decides; Using Advance Care Plans; and Determining the Nursing Home role.

Results The majority of studies in this review reported the experiences of RNs (Shidler 1998, Carusone et al. 2006a,b, Phillips et al. 2006, Terrell & Miller 2006, Hov et al. 2009, Lopez 2009, Arendts et al. 2010, Mitchell et al. 2011) and ENs or LPNs (Shidler 1998, Carusone et al. 2006a,b, Phillips et al. 2006, Terrell & Miller 2006, Jablonski et al. 2007, Lopez 2009, Lamb et al. 2011, Mitchell et al. 2011) while two studies focused exclusively on the experiences of Nurse Managers (Bottrell et al. 2001, Shanley et al. 2011). Some studies referred to the participant sample more broadly such as nurses (Kayser-Jones et al. 1989, Jablonski et al. 2007, Dreyer et al. 2010, McCloskey 2011) or NH staff (Hutt et al. 2011); making it difficult at times to ascertain which particular NH staff were represented in the findings. Although four studies included NAs (Shidler 1998, Phillips et al. 2006, Arendts et al. 2010, Mitchell et al. 2011) the experiences of these workers were reported infrequently and were rarely presented separately from other NH staff. See Supplementary Table S2 for the contribution of each included study to the key concepts and synthesis.

Lack of consensus of the Nursing Home role Studies suggested ongoing debate among NH nurses as to the level of acute care that should be provided in the NH setting and the point at which transfer to hospital becomes necessary (Bottrell et al. 2001, Shanley et al. 2011). ‘I talk to other DONs [Directors of Nursing] about doing intravenous antibiotic therapy onsite and they said “Oh no, no, the hospital can do that”’ (Nursing Home Manager) (Shanley et al. 2011; p. 5). It was suggested that ‘Philosophically, facilities have to decide what they’re really going to get into. There is still a place in health care for acute care hospitalization’ (DON) (Bottrell et al. 2001; p. 316). 2230

McCloskey (2011) reported that nurses had differing attitudes to transfer. Some nurses described transfer as ‘automatic courses of action’, while other nurses described detailed consideration which ‘took place over several shifts and sometimes over several days’ (p. 270). When deciding whether to transfer, NH staff took into account the potential distress to residents due to unfamiliar environment and staff who don’t know the residents’ idiosyncrasies (physical and psychosocial care needs), particularly for residents with dementia (Carusone et al. 2006a, Phillips et al. 2006, Hutt et al. 2011, Mitchell et al. 2011). Two studies identified the types of clinical presentations that warranted resident transfer. Lopez reported that ‘uncontrolled bleeding, respiratory distress and broken bones, were always weighed as significant enough to warrant evaluation in an emergency room’ (Lopez 2009; p. 1003). Similar conditions were identified by nurses in Shanley et al.’s (2011) study. The anticipated reaction from ED staff potentially influenced NH staff decisions about transfer. Three studies found NH staff delay transfer due to fear of reprimand from ED staff (Jablonski et al. 2007, Hov et al. 2009, McCloskey 2011). ‘[T]he ER doctors . . . they think there’s nothing wrong and we’re . . .. just wanting to get them out for just any old thing’ (nurse) (Jablonski et al. 2007; p. 270). For NH staff, this resulted in feelings of powerlessness and decreased professional esteem (Hov et al. 2009).

Limited skills and confidence to manage the resident onsite NH staff reported that poor staffing skill mix contributed to resident transfers. Observational data revealed that inadequate clinical assessment skills to identify early signs of deterioration resulted in further decline to the point where the resident could no longer be managed in the NH setting (Kayser-Jones et al. 1989, Lamb et al. 2011). NAs do not have the clinical acumen to recognize the subtle deteriorations and instead Phillips et al. reported that ‘the care assistants described having the ability, not unlike ‘. . .a mother does with her sick children’, to detect when residents needed to be reviewed’ (p. 420). NAs reported feelings of frustration when RNs did not follow up on their concerns about a resident’s health, potentially because they did not have the medical terminology to describe the often subtle clinical changes they observed in residents (Phillips et al. 2006). Yet RNs relied heavily on NAs to report changes as they were the only RN in the facility and were ‘responsible for the care of 135 patients [residents] on the evening shift’ (Kayser-Jones et al. 1989; p. 507) and often removed from © 2015 John Wiley & Sons Ltd

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the bedside undertaking administrative tasks (Carusone et al. 2006a). When a resident deteriorated, the increased demand for nursing and care staff time, limited the capacity for staff to care for other residents, resulting in decisions to transfer (Kayser-Jones et al. 1989, Arendts et al. 2010, Shanley et al. 2011). Some RNs reported a lack of confidence in their own clinical skills and judgment and identified assessment skills that could be enhanced, such as chest auscultation, to assist with earlier recognition of residents with pneumonia (Carusone et al. 2006a). NH RNs stated they were not always comfortable to make a decision regarding transfer without the support of another health professional such as a nurse practitioner or physician. ‘It’s nice to have a second opinion, right? . . . my assessment could be wrong. I would rather send the resident to the hospital if nobody was going to check’ (RN or LPN) (Carusone et al. 2006b; p. 284). Several authors also cited legal consideration as a factor contributing to NH staff decisions to transfer (Kayser-Jones et al. 1989, Bottrell et al. 2001, McCloskey 2011, Shanley et al. 2011). One nurse said she was ‘unwilling to put her “nursing license on the line,” so she never hesitated to send residents to the ED’ (McCloskey 2011; p. 720). NH staff suggested that further development of collaborative relationships with nurses from the hospital and palliative care setting would be helpful. The provision of education sessions and access to additional equipment for NH staff to manage complex residents, such as those with tracheostomies and intravenous antibiotics was valued by NH staff (Shanley et al. 2011). NH staff also reported an increase in confidence with clinical communication when they were able to observe communication between other healthcare workers and between other healthcare workers and family (Bottrell et al. 2001, Carusone et al. 2006a).

Limited access to multidisciplinary services and resources Study findings revealed that NH RNs have limited scope to implement interventions without the support of additional healthcare workers: ‘If nursing staff do not have the authority to order the drugs, the resident goes without or is transferred to hospital’ (Mitchell et al. 2011; p. 99). However, findings from these studies revealed no real sense of a multidisciplinary team effort and difficulties accessing healthcare personnel and equipment and therefore NH nurses viewed transfer as the logical outcome. Services such as palliative care, wound care, continence care and community nurses were used by some NHs. However, access and use differed considerably between studies and there was wide © 2015 John Wiley & Sons Ltd

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variation in the medical services available to each individual NH (Carusone et al. 2006a, Jablonski et al. 2007, Shanley et al. 2011). Some NH staff were also unaware of available services or chose not to use them (Phillips et al. 2006, Shanley et al. 2011). A lack of access to resources such as radiology, laboratory and pharmacy, ECG machines, pulse oximetry and equipment to administer intravenous therapy contributed to decisions to transfer (Kayser-Jones et al. 1989, Carusone et al. 2006a,b, Jablonski et al. 2007, Shanley et al. 2011). The majority of NH staff identified the physician or General Practitioner (GP) as the most critical healthcare worker to access at the time of a deterioration, yet nurses frequently reported that ‘we can’t always get a hold of the doctor’ (RN or LPN) (Carusone et al. 2006a, p. 275). Inaccessibility to physicians, especially after hours, resulted in the transfer of residents to hospital (Jablonski et al. 2007, McCloskey 2011). One nurse stated ‘We would ring. . . but it might take 7–8 hours, so common sense prevails and we would ring an ambulance’ (Arendts et al. 2010, p.62). However, RNs also experienced difficulties providing sufficient details over the phone increasing the likelihood of transfer: ‘I think the physician gets frustrated if he’s not getting information that he wants [from the nurse]. . . then in frustration it’s, OK send them out to the emergency room’ (DON) (Bottrell et al. 2001; p. 315).

Barriers to NH staff participation in the decision process Several studies reported that nurses play a central role and often serve as the liaison between physicians, residents and family members (Jablonski et al. 2007, Hov et al. 2009, Lopez 2009). However, a consistent finding identified that there is no formal role for the NH nurse in the decision process and there is a hierarchy among decision-makers that sometimes resulted in the exclusion of key players; particularly the resident and at times the NH staff. NH staff believed that their inclusion or exclusion in the decision process relied on the relationships and trust already established with the other health professionals and the family (Bottrell et al. 2001, Phillips et al. 2006, Shanley et al. 2011). If a familiar and trusting relationship was established nurses believed their viewpoints were more likely to be taken into consideration (Hov et al. 2009); ‘. . ..we just have quite a good working relationship, the GP takes our judgment on board usually’ (High care manager) (Shanley et al. 2011; p. 4). However, NH nurses also reported feelings of powerlessness when acute care health professionals, doctors and families ignored their detailed and intimate knowledge of the resident’s condition (Phillips 2231

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et al. 2006, Hov et al. 2009). ‘We are not recognized as having a specialty . . . You would like to think that they would respect your professional judgment’ (nurse or NA) (Phillips et al. 2006, 421). To avoid exclusion from the decision process, NH nurses used ‘indirect communication’ (Lopez 2009; p. 1005) or ‘targeted communication’ (Jablonski et al.; p. 270), whereby they tailored the information that they provided to obtain the desired transfer outcome (Jablonski et al. 2007). Symptoms believed to be unmanageable in the NH resulted in NH nurses’ advocacy for hospitalization by emphasizing a resident’s discomfort, a need for rapid diagnosis, or greater expertise (Lopez 2009). In contrast, if NH nurses felt comfortable managing the resident in the NH, they highlighted the benefits of remaining where ‘everyone knows them [the resident]’ (Lopez 2009; p. 1006). When there was a disagreement about whether to transfer to hospital, Jablonski et al. reported that NH nurses used a process of cogency whereby they enlisted the support of either the doctor, family or resident to outweigh the input of another decision-maker (Jablonski et al. 2007).

Challenges advocating on behalf of the resident NH nurses described Advance Care Plans (ACPs) as potentially valuable in assisting them with the direction of care for residents: ‘I think it [ACP] would be beneficial . . . instead of waiting till the person is near death and then going into panic mode’ (High Care Manager) (Shanley et al. 2011; p. 5). It was identified that a lack of clarified goals resulted in confusion and uncertainty about the direction of care (Hov et al. 2009). ‘We didn’t manage to make a clear decision . . . we were limping around . . . Sometimes he got his medicine, sometimes we did this, sometimes that and it was exhausting’ (nurse) (Hov et al. 2009; p. 654). Several studies identified that NH staff advocated for the resident in discussions with the family or doctor (Shidler 1998, Jablonski et al. 2007, Hov et al. 2009, Lopez 2009). However, it was unclear from the study findings how NH staff made themselves aware of residents’ wishes. Findings revealed that NH nurses rarely consulted with residents at the time of a deterioration and that resident involvement in decisions ‘was far from ideal and did not always contain the basic elements and standards of informed consents’ (Lopez 2009; p. 1007). The wishes of the resident and family were rarely considered separately (Bottrell et al. 2001) and NH staff did not always resist the pressure from family to hospitalize a resident even when they judged it to be contrary to residents’ interests (Dreyer et al. 2010). ‘It is easier to go with the flow. We do pretty much what the 2232

family wants’ (RN) (Lopez 2009; p. 1005). Consequently, NH staff reported frustration at the determination of some families to transfer their family member, believing family to have unrealistic expectations of acute care in the hospital sector (Carusone et al. 2006a, Phillips et al. 2006; p. 419). Whilst ACPs were described as potentially valuable, there was no evidence that they were used during a time of a resident’s deterioration, or that they assisted with transfer decisions. Several studies found that NH staff avoided initiating and contributing to discussions about ACP. Some senior nurses were comfortable initiating end of life discussions with family (Bottrell et al. 2001, Lopez 2009), however, many NH staff ‘felt ill- prepared to facilitate this potentially difficult conversation’ (Phillips et al. 2006; p. 419) or believed that it was not part of their role (Lopez 2009). In some cases, prior discussions regarding how to manage the resident when they deteriorated were altered or reinterpreted at the time of a deterioration. One study reported the following finding: ‘While DNR [Do Not Resuscitate] orders are only meant to withhold CPR [Cardiopulmonary Resuscitation], clearly they hold additional symbolism and meaning’ (Lopez 2009; p. 1006) and influenced NH staff attitudes towards transfer. ‘If a resident does not have a blue dot (and is therefore for full resuscitation) I send them out immediately, no questions asked’ (nurse) (Lopez 2009; p. 1004). It was also identified that, at the time of a resident deterioration, the previously expressed wishes may be overridden: ‘The resident may have said, I don’t want anything done. But when push comes to shove and he can’t breathe anymore, [he says], “Send me”’ (nurse) (Terrell & Miller 2006; p. 503).

Discussion A comprehensive search of key databases revealed that the experiences of NH staff decision-making and the transfer of residents to hospital have received increasing attention over the past six years. This suggests that researchers and practitioners have recognized the important impact that NH staff may have on the incidence of resident transfers. Interestingly, the factors identified in the contemporary studies are the same as those found by Kayser-Jones et al. in 1989, suggesting that little has changed as far as the factors that influence NH staff decision-making over the past 25 years. Several areas where changes could be made to improve the decision process and optimize the management of residents at the time of deterioration were identified in the meta-synthesis. © 2015 John Wiley & Sons Ltd

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Clarification of the role of the nursing home when a resident deteriorates A key finding was the widespread uncertainty and inconsistency regarding the types of care that NHs are expected to provide for residents when they deteriorate. The differing opinions regarding the capacity to manage residents’ care needs in the NH created tension between individual decision-makers and between the hospital and NH sector. Standardization of the NH role and responsibilities would not only decrease confusion between decision-makers but also assist in identifying resources that need to be available in all NHs. This may also assist in identification of those residents who represent an ‘appropriate transfer’ which to date has not been easily defined.

Greater access to staff and resources at the time of a resident deterioration The inadequate resourcing of NHs contributed to decisions to transfer. Meta-synthesis of the data revealed that NH staff were unable to access a medical review, diagnostic equipment or medication in a timely manner. A Cochrane review of interventions such as ACPs, geriatric and palliative care specialists found that such services reduced hospital transfers (Graverholt et al. 2014). Such findings support the need for additional access to outside support services but also revealed that low staffing numbers and poor skill mix contribute to NH staff decisions to transfer. Onerous workloads and limited skills reduced NH staffs’ ability to appropriately assess residents for potential or actual deterioration. This resulted in delayed recognition and further resident deterioration, to the point where transfer became necessary. However, the ability to demonstrate the impact of ratios and higher numbers of RNs in the skill mix on resident outcomes has been insufficiently supported in the findings of most studies to date and therefore remains a matter of debate (Department of Health, Victoria 2011).

Improved clinical confidence in nursing decisions RNs have the highest clinical competence in the NH, yet the findings suggest that they lack confidence in their own clinical decisions. NH nurses feared working beyond their scope of practice and were concerned about the legal ramifications if they did not transfer. It was also highlighted that NH nurses reported mixed feelings about increasing their clinical skills to include management of acutely unwell residents. However, Nurse Practitioners (NPs) in collaboration with physicians, have demonstrated that they can play © 2015 John Wiley & Sons Ltd

Nursing home transfer decision-making

a valuable role in reducing unnecessary hospital admissions and supporting the physician’s practice (Robin & Baker 2009). These finding not only suggest the need for further research to evaluate the impact of outside services in supporting decision-making, but also the feasibility of such services being accessible to every NH, 24 hours per day, seven days per week. Such findings suggest that outside services were valued by NH staff, but also highlighted the need to support a strategy that enables all NH RNs to be highly competent in their own right with specialized clinical skills to assist them to have greater confidence in their own clinical decisions.

Improving communication between NH staff and other decision-makers We identified a clear hierarchy between residents, family, NH staff and doctors, which at times worked against residents’ and nurses’ voices being heard in decision-making process. NH staff reported advocacy as a key role, however, at times NH staff struggled with their involvement and felt pressured to follow the doctor’s or the family’s wishes. Difficulties communicating with the family, particularly about end-of-life issues led to some families requesting transfer potentially due to a lack of confidence in the NH staff (Mitchell et al. 2011). There may also be an increased incidence of transfer if NH staff are providing inadequate information to physicians or the information provided by NH staff is not taken into consideration by other decision-makers. Previous studies have reported a lack of status and poor image associated with aged care nursing (Fussell et al. 2009). To optimize NH staff participation in the decision process, NH staff not only need to be competent sharing the appropriate information with other decision-makers, but their professional judgement needs to be taken into consideration when deciding whether transfer is necessary. ACPs are reported to ‘allow individuals to have control over the level of health care they receive at the end of life’ (Silvester et al. 2013, p. 349) and studies have demonstrated a reduction in hospital transfers when an ACP is in place (Caplan et al. 2006, Badger et al. 2009, Teno et al. 2011). Whilst ACPs were theoretically described by NH staff as a useful tool, their use in practice was not demonstrated in the findings of this meta-synthesis. This suggests that ACP discussions need to be more fully embraced and incorporated into the decision-making process. However, it is also important to highlight that the ability to differentiate between the preferences of family and resident may be difficult by the time an older person reaches NH level of care 2233

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and therefore, earlier facilitation of ACP discussions and documentation of residents’ wishes may assist NH staff to more easily advocate on their behalf.

highlight inadequacies in skill mix, workload and education that contribute to rates of transfer.

Acknowledgements Strengths and limitations An extensive, systematic search and quality appraisal resulted in 17 studies for meta-synthesis, thus providing a rich scope and depth to the data to address the aims of this review. While the search and critical appraisal process determined the number of papers included, meta-synthesis of the data revealed that a high level of theoretical saturation had occurred (Downe 2008). During the analysis and synthesis, careful consideration was given as to whether evolving themes were transferable across the different study contexts thereby revealing consistent factors influencing NH staff decision-making, regardless of the original study focus. This provided the reviewers with confidence that the data synthesis was able to identify and describe complimentary themes and patterns and conflicting themes across the international spread of studies, to produce a data synthesis with external credibility or generalizability (Schmied et al. 2009). Weaknesses in the original study design of each included paper were identified during the critical appraisal, enabling the reviewers to extract data that may not have been representative with caution. A weakness of the review is the limited description of NAs experiences due to the low representation of NAs in the study samples, which potentially resulted in skewed insight into the factors that influence NH staff decision-making.

Conclusion This meta-synthesis contains the first collation of qualitative studies exploring the reasons behind decisions to transfer residents to hospital exclusively from the perspective of NH staff. We identified widespread variation in the NH staff perceptions about the role of the NH when a resident deteriorates. This resulted in confusion regarding whether or not transfer was warranted. Such findings highlight an urgent need to clearly define the types of acute care interventions that will be offered to the resident in the NH setting. A prescriptive outline of the expected skill sets of RNs working in NHs needs to be developed and these standards need to be adhered to by providers. Decisions about transfer to hospital will also be improved if NH staff provide adequate information over the phone to physicians and facilitate ongoing ACP conversations with families and residents. Future research examining the role of Nursing Assistants in the recognition of early signs of deterioration may 2234

We would like to show our appreciation to the review panel of JBI, particularly Sarahlouise White for the support and guidance provided during the review process. We also acknowledge the contribution made by the research librarians at La Trobe University and the Australian Catholic University who assisted with the development of the search terms for each database and Verena Schadewaldt for her role in sifting the database results.

Funding This review was funded by the Department of Health and Human Services, Victoria, Australia.

Conflict of interest The authors have no conflicts of interests.

Author contribution BL was responsible for the study conception, design and data acquisition. BL, RF, MB and RN performed the analysis. BL, RF, MB and RN performed the critical revisions to the paper for important intellectual content. BL and RN obtained the funding. All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]:

• •

substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.

Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site.

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