Geriatric Nursing xx (2015) 1e8

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Geriatric Nursing journal homepage: www.gnjournal.com

Feature Article

Nursing home nurses’ perceptions of emergency transfers from nursing homes to hospital: A review of qualitative studies using systematic methods Barbara O’Neill, BA, BSN, GCNursED a, *, Lynne Parkinson, BSc (Hons), PhD b, Trudy Dwyer, PhD a, Kerry Reid-Searl, PhD a a b

Central Queensland University, School of Nursing and Midwifery, Bruce Highway Bldg 18, Rockhampton, QLD 4702, Australia Central Queensland University, School of Human Health and Social Sciences, Bruce Highway Bldg 32, Rockhampton, QLD 4702, Australia

a r t i c l e i n f o

a b s t r a c t

Article history: Received 10 March 2015 Received in revised form 25 May 2015 Accepted 1 June 2015 Available online xxx

The aim is to describe nursing home nurses’ perceptions around emergency transfers to hospital. Transfers are costly and traumatic for residents, and efforts are underway to avoid hospitalization. Nurses play a key role in transfers, yet their views are underreported. A systematic review of qualitative studies was undertaken, guided by Joanna Briggs Institute methods. From seven reviewed studies, it was clear nursing home nurses are challenged by the complexity of the transfer process and understand their need for appropriate clinical knowledge, skills and resources. Communication is important, yet nurses often use persuasive and targeted communication. Ambiguity, strained relationships and negative perceptions of residents’ experiences around hospitalization contribute to conflict and uncertainty. Nurses are more confident when there is a plan. Transferring a resident is a complex process and special skills, knowledge and resources are required, but may be lacking. Efforts to formalize the transfer process and improve communication and collaboration amongst all stakeholders is needed and would be well received. Ó 2015 Elsevier Inc. All rights reserved.

Keywords: Nursing homes Nurses Geriatric nursing Nursing personnel Nursing staff Homes for the aged Health knowledge, attitudes, practice Hospital emergency service Preventable hospitalizations Transfers, hospital avoidance

Introduction Nursing home residents in the United States made more than 2.2 million visits to the emergency department (ED) in one year.1 Within a 90-day period, eight percent of nursing home residents visited the ED once, and 15 percent visited twice or more.2 In some cases the rates of admission to hospital were higher for nursing home residents than for elderly living in the community.3 Nursing homes are being pressured to reduce hospital transfers with cost as the major factor.4 Approximately $972 million was spent on nursing home resident hospitalizations in New York in one year.5 Infections managed in the ED cost United States Medicare thousands of dollars more than those managed in nursing homes.6 In addition to these financial implications, hospital transfers are also stressful for

* Corresponding author. Central Queensland University, School of Nursing and Midwifery, Bruce Highway Bldg 18, 1-16, Rockhampton, QLD 4702, Australia. Tel.: þ61 749232617, þ61 0437100091. E-mail address: [email protected] (B. O’Neill). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.06.001

residents and their family members. Hospitalization can contribute to further decline and lead to complications unrelated to the admitting diagnosis, such as falls, incontinence and adverse drug reactions.7 Nursing home nurses initiate and manage hospital transfers and care for residents when hospitalization is avoided; therefore, their perceptions around transfers must be sought and considered when discussing hospital avoidance efforts. Nurses’ perspective A frequently cited example of a program designed to reduce hospitalizations is Interventions to Reduce Acute Care Transfers (INTERACT) II, a quality improvement program that trains and supports nursing staff in the early detection and care of a deteriorating resident to avoid hospitalization.8 When staff at 26 nursing homes participating in INTERACT II were asked to use a Quality Improvement tool to review data on hospital transfers, they determined 76% of the transfers reviewed were unavoidable.9 The findings differed from previous retrospective and prospective

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studies that suggested that many transfers were avoidable.10,11 This discordance with previous studies proved insightful because the INTERACT II study captured areas of the transfer process not previously considered, such as missed opportunities to prevent the transfer, resident or family input, gaps in communication, staff knowledge and skill deficits.9 This contribution underscores the value of gaining nurses’ perspectives around any transfer or hospital avoidance discussion. A systematic literature review of nursing staff practices in managing a deteriorating patient in the hospital setting concluded that the context within which deterioration is identified and communicated is critical to ensuring the effectiveness of any educational or support strategies.12 Understanding nurses’ concerns contributes to a hospital avoidance program’s success.13 However, research regarding nurses’ perceptions around transfers and hospital avoidance is lacking. Aim of this review A recent systematic review made an important contribution to better understanding nursing home nurses’ perspectives by identifying factors that influenced nursing staff decision-making behind transfers to the emergency department, such as: limitations in staffing, lack of support from other disciplines, and problems communicating with decision-makers.14 Laging, Bauer, Ford and Nay (2014) reported nursing home nurses were unclear about their roles and responsibilities when a resident’s health deteriorated, indicating a closer look at how they viewed their current situation was needed.14 To obtain the perspective of the nurses involved with resident transfers a review of qualitative studies was done. Hence this systematic review takes a broad approach, reviewing qualitative studies to obtain a greater understanding of the perspectives of the nurses involved with resident transfers, and describing nursing home nurses’ experiences and overall perceptions around ED transfers. Methods The types of participants considered for this review were nursing home nursing staff, which includes registered nurses (RNs), enrolled nurses (ENs), licensed practical nurses (LPNs), nurse assistants and their international equivalents; nurse managers, directors of nursing, and nurse practitioners (NPs). The area under study was nursing home nurses’ perceptions regarding emergency transfers from nursing homes to hospital. The computer databases searched for qualitative studies on the topic included Cumulative Index of Nursing and Allied Health Literature (CINAHL) with full text, health business elite, Health Source: Nursing Academic Edition, MEDLINE and Joanna Briggs Institute (JBI) Library of Systematic Reviews. Only studies published between 2000 and 2014 that were in English and peer reviewed were considered. There were no exclusions according to country. Systematic reviews, expert opinion papers, reports, discussion and opinion papers were not considered. Search terms included: (“nurs*” AND “aged care” or “nursing homes” or “long-term care” OR “residential aged care” OR “residential aged care facilities”) AND (“nurs* knowledge” OR “nurs* perceptions” OR “nurs* attitudes” OR “nurs* beliefs” OR “nurs* behav*”) AND (“hospital avoidance” AND “deteriorat*” AND “avoiding hospital*” AND “hospital admission”). Additionally, a review of selected reference lists was conducted to further enhance the search. This systematic review of the literature was guided by the Joanna Briggs Institute (JBI) approach to qualitative systematic review but is not a formal JBI review, as it was performed by one researcher only (BO).15 This type of review required meta aggregation, a method that includes an assessment of the

methodological quality of the chosen literature, data extraction of findings and illustrations, and data synthesis.15 The JBI Qualitative Assessment and Review Instrument (JBIQARI) was used to assess the methodological validity of the studies.15 The standardized JBI QARI data extraction tool was used to collect data regarding methodology, methods, phenomena of interest, setting, geographical location, cultural concerns, participants, data analysis and author conclusions. Qualitative research findings, which are the author’s explanation of the data, were collated.15 Illustrations of the findings, such as direct participant quotes or observations, were identified to support the findings.15 A rating of credibility of the findings was assigned to reflect the reviewer’s perception of the degree of support each illustration provides. The three levels of credibility defined by JBI include: Unequivocal (U), Credible (C) and Unsupported (NS).15 After the findings were rated for credibility, they were categorized according to their shared meaning, the initial step in meta-aggregation. The categories were then subjected to a meta-synthesis whereby similar categories were combined and statements formulated to explain their meaning.15 Results There were 394 potential papers identified in the primary search (Fig. 1). The titles were reviewed for relevance and 349 articles were excluded because they were not considered relevant to the topic area. The abstracts of the remaining 45 articles were reviewed for alignment with the topic, type of participants, originality, and data sufficiency. Eight qualitative studies and two mixed-methods studies were chosen for inclusion in the review because they contained qualitative data on nurses who work in nursing homes perceptions surrounding emergency transfers; however, only the qualitative sections of the mixed-methods studies were considered.9,16e24 Upon closer examination, three studies were excluded because: nursing home staff voices were not clearly identifiable21; pre and post training carer role changes were the main focus22; nursing staff perceptions beyond views on symptomology were not prominent.23 Seven studies were included in the final review (Table 1). The majority of the data presented in the included studies was collected using interviews; other methods included focus groups, observation, conference calls and narrative summaries. Narrative findings from a quality improvement review tool were included in the qualitative analysis of one study and therefore considered in this review.9 The studies chosen focused on the decision-making process around hospital transfers, perceptions of hospital avoidance, the transfer experience, including experiences around coordination and communication. Three studies were conducted in the United States,9,19,20 two in Australia,17,18 and one each in Sweden24 and Canada.16 Participants ranged from nursing home residents, aged care nurses, hospital nurses, physicians, physicians assistants, nursing home managers and supervisors; however, responses from nurses working in nursing homes, including nurses who were managers or supervisors, were the only responses considered for the review. The seven articles were deemed to be of satisfactory methodological quality (Table 2). Scores ranged from 6 to 9 out of 10. Three authors defined their methodology as hermeneutic phenomenology,20 grounded theory19 and institutional ethnography16 and the others were not defined. Findings and categories The findings and illustrations from each study were summarized verbatim and organized in NVivo 10. A total of 92 findings were extracted and assigned a credibility rating of Unequivocal (U),

Identification

B. O’Neill et al. / Geriatric Nursing xx (2015) 1e8

Records iden fied through database searching (n = 384)

Addi onal records iden fied through other sources (n = 10)

Eligibility

Screening

Records a er duplicates removed (n = 394)

Included

3

Records screened (n = 45) Abstracts

Full-text ar cles assessed for eligibility (n = 10)

Records excluded (n = 349) Titles indicated ar cles not relevant to study

Records excluded (n = 35) Quan ta ve; nursing home percep ons uniden fiable

Full-text ar cles excluded, (n = 3) Nurses voices not iden fiable; pre and post carer role change was focus; nursing staff percep ons beyond symptomology not prominent

Studies included in qualita ve synthesis (n = 7)

Fig. 1. Flow diagram of article selection.

Credible (C) and Unsupported (NS).15 After multiple readings and reviews, nine categories were created. Findings were assigned to more than one category where applicable. A summary of each category, along with one finding and illustration, are found in Table 3. Synthesized findings The categories were selectively grouped into three metasynthesis statements based on their related content and meaning, as described below. Meta-synthesis 1: The decision to transfer is complex. Nursing home nurses require clinical knowledge, skills and resources to assess and manage the deteriorating resident. This meta-synthesis (70 findings) was comprised of three categories: Clinical Skills and Knowledge, Staffing and Support, and Deciding to Transfer. The transfer decision-making process was considered complex and a number of variables were considered, including acuteness of the condition, legal considerations, family

member input, physician directives, and medical support. However, nursing staff viewed clinical knowledge, skills and resources, including staffing and support, as being important considerations from nursing’s perspective. When a resident’s health status changes clinical knowledge and skills were needed to determine the type of care and treatment required. As Lopez explained, nurses began by “weighing the significance” of the situation.19 Some conditions, such as respiratory distress, were always considered significant enough to send the resident to hospital, whereas at other times the circumstances were less clear.19 But without the appropriate equipment and resources, the information nurses could collect to support their decisions was limited.18 X-ray equipment and electrocardiogram (ECG) were usually not available. Lamb et al reported on a transfer that could have been avoided if staff had been equipped to suture a laceration.9 The availability of skilled nursing staff to care for and manage a deteriorating resident was seen as important. One nurse manager reported sending unwell residents to hospital when there was not enough staff to manage them at the facility.17 Another nurse spoke to the challenge of managing an unwell resident along with other responsibilities:

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Table 1 Characteristics of the studies. Author(s)

Participants

Data collection methods

Phenomena of interest

Authors’ conclusions

Jablonski et al (2007)20

(n ¼ 42) includes NH nurses, family members, physicians (n ¼ not specified by role)

Interviews

Decision-making process around transfers to ED

Kirsebom et al (2013)24

(n ¼ 6) NH RNs (n ¼ 14) Hospital RNs

Focus groups

Coordination and communication between nursing home and hospital

Lamb et al (2011)9

(n (n (n (n (n (n (n (n

Conference calls, narratives, survey

Perceptions on avoidability of hospital transfers

Semi-structured and informal interviews, observation

Decision-making and behaviors regarding acutely ill NH residents

Nurses play a major role in decisionmaking process around transfers. Consensus occurs when there is similar or shared understanding; conflict occurs with dissimilar interpretations of the problem; cogency is used to persuade others to reach agreement. Communication and coordination needs improvement; care plans need to be updated and followed; organizational factors contribute to unnecessary transfers. Staff found 76% of the transfers not avoidable and this is contrary to findings in other studies; staff reasons for transfer are complex and merit further study. Four phases in the decision-making process identified: weighing the significance, notifying the family, feeling it out, playing the middleman. Nurses aim to create a plan of care acceptable to all parties; however, indirect communication is often utilized. Communication amongst all the stakeholders is complex and not necessarily effective. Roles and responsibilities need to be better understood and an integrated model of care developed. 6 themes regarding reasons for transfer: staff level of competency, physician availability, lack of equipment, resident and family member requests, communication difficulties, poor attitudes towards NH staff. Factors include: resident acuity, available medical care and support, family role, staffing numbers and skill mix, fear of criticism and litigation, advance care planning, community health resources.

Lopez (2009)19

¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼

21) RNs 1) LPN 2) social workers 1) medical director 1) administrator 4) LPNs 3) RNs 3) NPs

McCloskey (2011)16

(n ¼ 7) NH nurses (n ¼ 3) Non-nursing staff (n ¼ 7) ED staff

Interviews, observation

Resident transfer experience, focusing on coordination and communication

O’Connell et al (2013)18

(n ¼ 7) NH nurses (nurses in charge or nursing supervisors) (n ¼ 4) ED nurses

Semi-structured interviews

Nurses’ perceptions as to why residents are transferred to ED

Shanley et al (2011)17

(n ¼ 41) NH managers (all RNs)

Semi-structured interviews

Factors that influence the transfer decision

RNs ¼ Registered nurses; LPNs ¼ Licensed practical nurses; NPs ¼ Nurse practitioners; NH ¼ Nursing homes; ED ¼ Emergency Department.

“Often when it is 2 or 3 in the afternoon and you haven’t been able to deal with what’s happened it feels safer to just send the patient in [to the ED].”24 Meta-synthesis 2: Families maintain a position of power and this underlies nurses’ actions and interactions. Communication issues can cause delays and problems. Nursing home nurses use persuasive and targeted communication techniques to manage and direct possible transfer situations. This meta-synthesis (43 findings) was comprised of two categories, Communication and Knowing the Family. When a transfer was imminent a number of stakeholders were contacted, including family members, physicians, and ED staff. Nurses served as intermediaries in the process and were often challenged in their interactions. Gaps in written and verbal communication were apparent, especially between nursing home nurses and ED nurses. For example: “If we even get a copy of the ER [emergency room] notes; they don’t tell us anything. What we really need is to talk to the ER.”16 There were references to back-and-forth conversations causing delays. One transfer was delayed because the family wanted to travel to the nursing home to see for themselves

whether the resident needed and wanted to go to the hospital.20 Family members were seen as holding a position of power, as evidenced by statements such as “Full codes get sent out quicker than DNRs [do not resuscitate] because if they are full code it means the family is expecting the person to make a recovery. The family expects that everything will be done to keep them alive.”19 There were more references in the literature to what the family wanted and expected than there was to the resident’s concerns. Nurses used persuasive and targeted communication techniques to persuade and influence family members, physicians and residents, as evidenced by this statement: “Sometimes even the doctor, if you present . too much information, will want to go a whole other gamut and that’s not the families’ or patients’ wishes. Sometimes you have to hold back.”19 Meta-synthesis 3: Ambiguity, strained relationships and nursing home nurses’ negative perceptions of residents’ experiences around hospitalization create conflict and uncertainty. Nurses are more decisive and confident when a “plan” is in place, such as advance directives. This meta-synthesis was comprised of four categories (70 findings) including, Conflict and Uncertainty, Working with Others,

Y

6

Hospital Experience, and Having a Plan. Although hospitalization was often seen as necessary, conflict and uncertainty around resident hospitalization was evident and appeared related to nurses’ perceptions of how residents were treated in the hospital, as well as their own experiences sending residents to the hospital and their return back to the nursing home. There were references to residents not being treated the same as younger patients, and returning to the nursing home with “newly developed bed sores” and medication issues.24 Negative interactions with paramedics and ED staff around transfers appeared to contribute to the already stressful situation. One nurse “waited as long as possible before sending residents” out of fear of how hospital staff would respond to the transfer.16 Responses and reactions could be overwhelming: “. And then when they get there to the ER the doctors will call up here and act like, why are we sending her out? If they don’t have anything that’s broken or something that you can visually look at, they think there’s nothing wrong and we’re just being, gosh, how do you say it? Just overly protective, you know, just wanting to get them out for just any old thing, and that’s just not true.”20

N N

U

Y

6 Y N N

U

Y

9 9 Y Y Y Y N N

Y Y

Y Y

9 Y Y Y

Y

Y

7 Y N N

Y

Y

8 Y Y N N

Y

Do the conclusions drawn in the research report flow from the analysis, or interpretation of the data? Is the influence of the researcher on the research, and vice- versa, addressed? Is there a statement locating the researcher culturally or theoretically?

In addition to the fear of being questioned or criticized for a decision, nurses were also worried about being sued for their decisions regarding transfers. Thus, nursing home nurses appeared more confident and decisive when there was some kind of plan in place, whether it is a policy, procedure, advance directive, medical care plan, hospital avoidance program, or informal plan of care or agreement. One nurse explained: “If a resident does not have a blue dot (and is therefore for full resuscitation) I send them out immediately, no questions asked. I call the MD and ask where to send them. Usually they say yes because they don’t want a lawsuit either.”19

Y U

U

Y Y

U

U

N ¼ no; N/A ¼ not applicable; U ¼ unclear; Y ¼ yes.

Y Y

Y

Y Y Y

Y

Y Y Y Y Y Y

Y Y

Y Y Y

Y

Y Y Y

Y

Y Y Y

Jablonski et al (2007)20 Kirsebom et al (2013)24 Lamb et al (2011)9 Lopez (2009)19 McCloskey (2011)16 O’Connell et al (2013)18 Shanley et al (2011)17

Y

Y

Is there congruity between the research methodology and interpretation of results? Is there congruity between the research methodology and the methods used to collect the data? Is there congruity between the stated philosophical perspective and the research methodology?

Is there congruity between the research methodology and the research question or objectives?

Is there congruity between the research methodology and the representation and analysis of data?

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Discussion

Study

Table 2 Results of critical appraisal of selected studies, using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI QARI).

Are participants and their voices adequately represented?

Is the research ethical according to current criteria, or, for recent studies, and is there evidence of ethical approval by an appropriate body?

Total

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This meta-aggregation of existing evidence from seven qualitative studies provides a deeper understanding of nursing home nurses’ perceptions of emergency transfers from nursing homes to hospital. The three meta-synthesis statements that were developed are insightful because while it was known that nurses play a prominent role in managing emergency transfers, little was known about how they view this role. Aggregating the findings from the limited number of studies available has identified common experiences and concerns. The overarching message is that nurses need and want some structure or ‘plan’ to help them manage transfers. Having a ‘plan’, such as advance directives, a medical care plan, or hospital avoidance program, supports decision-making and confidence. This is welcome news as efforts are underway to introduce hospital avoidance programs that aim to provide this type of structure to the management of deteriorating residents. This review has also identified three areas that should be considered in any type of ‘plan’ to improve the transfer experience for this cohort: training, resources and support. Training In this review, nurses indicated that clinical knowledge and skills were needed to assess and manage the deteriorating resident. They are not alone in this regard; hospital nurses also demonstrated knowledge and skill deficits in managing deteriorating patients12 and hospitals responded with targeted training that improved their knowledge and confidence.25 Targeted educational interventions designed to improve skills and knowledge around managing the deteriorating resident must include recognizing the early signs of deterioration and health care issues associated with

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Table 3 Categories, summary, findings and illustrations. Summary

Finding/credibility rating

Illustration

Clinical skills and knowledge

Nursing home nurses need good clinical skills and knowledge to assess and manage a deteriorating resident. Communication issues between nursing home nurses and physicians, family members, residents, nursing home management and ED staff can cause delays and problems. Persuasive and targeted communication techniques are often utilized by nursing staff to manage and direct the situation. Conflict with residents, family members, physicians and ED [emergency department] staff persists when there is ambiguity about a resident’s condition, best interests, and advance directives. Nursing home nurses feel uncertainty, and perhaps fear of being criticized or sued for their decisions regarding hospital transfers. Knowing the family and keeping them informed is important. Awareness of the power residents and their families have underlies nursing home nurses’ relationships and interactions.

Missed opportunities (for preventing transfers) (U) Communication gap (U)

“Early signs were missed. Work-up for fever might have kept resident in the facility.”9 “It would have been important to communicate if the resident was symptomatic or not with [with a] BP 98/52. If asymptomatic, MD [medical doctor] might have wanted to keep resident in the facility. Covering MD does not know resident; he needs to listen to nurses’ recommendation.”9 “Today, relatives have a lot of power . My mother is going to the hospital because they have better resources there. If you don’t send her I’ll report you at once. They make threats, it’s so unpleasant.”24

Nursing home nurses are more confident and decisive when there is some kind of plan in place, be it a policy, procedure, advance directive, medical care plan, hospital avoidance program, or informal plan of care or agreement. Skilled nurses and adequate staffing, along with the appropriate diagnostic equipment and services are needed to assess and manage a deteriorating resident. Nursing home nurses recognize that hospitalization is often the best option, but share unfavorable views about their relationships with the ED staff and the care residents receive in hospital. Nursing home nurses, physicians, paramedics and ED staff work together when a resident is transferred to hospital. Nurses sense negativity and lack of respect from some of these health care professionals. The decision to transfer is multifaceted and takes into consideration the resident’s acuity, others people’s perceptions and pressures, legal ramifications, and availability of skilled staff, equipment and resources.

Support from care plans (C)

Communication

Conflict and uncertainty

Knowing the family

Having a plan

Staffing and support

The hospital experience

Working with others

Deciding to transfer

U ¼ Unequivocal; C ¼ Credible; ED ¼ Emergency Department; MD ¼ Medical Doctor; BP ¼ Blood pressure.

[Providing] satisfactory care at nursing home (NH) (C)

Notify the family (U)

Level of staffing and other resources (U) Unsatisfactory forward planning (C)

How ED staff will respond (U)

Family expectations (U)

“I would call and say, this is not alarming, but I want you to know that to be aware that your mother just fell, or just had hypoglycaemic reaction, but she is all right. I just want you to know. They [family member] would be very pleased.”19 “Some RNs reported feeling supported in their decisions not to transfer older persons to hospital if the nursing home has a palliative approach, or if documented medical care plans exist.”24 “I have just looked at them, I have called the doctor, I can see the workload is going to be not manageable either . so I have sent a couple to hospital.”17 “As soon as something has been treated they’re to be sent back to the nursing home, patients don’t have time to recover, the hospital staff don’t check to see if the patients or stable and can sit upright.”24 When transferring a resident, one nurse reported fear of getting a reaction from ED staff and: “. waited as long as possible before sending residents” whereas, another said she “exaggerated residents’ symptoms when transferring them to the ED.”16 “A full code is the scariest . They [family members] have unrealistic expectations and they can retaliate. It can cost you your job, guilt and suit. I’ve seen those commercials for Sokolove [popular television plaintiff attorney]. ‘Did your loved one get a bed sore, become dehydrated?’ It’s very scary.”19

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Category

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aging, such as delirium and syncope.26 However, training must also take into consideration the different levels of nurses employed in nursing homes and their scope of practice. For example, INTERACT II offers different training modules based on level of nursing.27 Nursing assistants comprise a large proportion of the workforce and their training focuses on basic nursing skills,28 while RNs have more advanced clinical skills training. Ashcraft and Owen suggest that nursing assistants, and their equivalents, would benefit from training in recognition of early signs of deterioration and communication, while training for RNs and their equivalents should focus on assessing and managing mental and physiological changes, as well as stabilization efforts.29 Considering that four of the seven studies found that nurses felt it was necessary to use targeted communication to persuade and influence family members, physicians, and residents, communication training should also be provided.16,19,20,24 Communication training would also help to address the lapses in communication, both verbal and written, that were identified between nursing homes and EDs.18,24 Instruction on how to effectively communicate a resident’s situation is needed.14 The introduction of standard communication tools, such as the use of Situation, Background, Assessment, Recommendation (SBAR), would be another step toward improving communication practices.30 Resources In addition to having the requisite knowledge and skills, nurses reported they needed resources, such as diagnostic equipment, to better manage this area of their work. Nursing homes are not “miniature hospitals”20 but limited access to resources such as relevant diagnostic equipment, as noted in some facilities9,18,20 can hamper nurses’ decision-making capabilities.20 In particular, lack of access to laboratory results and electrocardiograms (ECGs) can contribute to over-hospitalization.31 Nurses believed training and access to equipment would prevent some residents from being transferred to hospital.18 Clinical practice tools included in hospital avoidance programs, such as a laminated resource guides that list critical vital signs and laboratory results, should be added to the armamentarium of resources available.8 Nursing staff in facilities that utilize these types of decision-support tools report increased confidence in their assessment and reporting of deteriorating residents.32 Nursing home managers need to weigh the costs and benefits of investing in equipment and resources against the potential savings from preventing hospitalizations. Support This meta-aggregation identified that nurses experience conflict and uncertainty around transfers which can undermine appropriate response in an emergency situation. Legal concerns were prominent in five of the studies.16,17,19,20,24 Shanley et al17 considered “fear of criticism and litigation” a significant issue for nurses, and cited a nurse manager: “. we can’t not [transfer], because it’s too litigious not to transfer them”. Nurses’ concerns are not unfounded. Nurses are liable for acts of negligence and can face financial penalties.33 Clarification of nurses’ legal rights and responsibilities may help to assuage this fear. Nurses voiced uncertainty about how other health care professionals viewed them and their decisions.16,18,20 One disturbing finding was the lack of respect paid to nursing home nurses by other health care professionals. In one case, an ambulance officer refused to take a resident to hospital because he disagreed with the nurse that the resident required hospitalization.18 Jablonski also reported that paramedics’ reactions influenced the decision-making process.20 One nurse was quoted as saying: “Any decision to send

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anyone out from a long-term care facility to the ER is not easy because sometimes the paramedics don’t take the staff seriously, you know. They think we are just overreacting.”20 This is an area that requires further evaluation to identify the extent of the problem. Nurses in both the hospital and nursing home settings agreed that improved communication and collaboration is required.24 It was evident nursing home nurses and ED nurses lacked a clear understanding of each other’s roles and responsibilities.17,18,24 Shanley et al17 provided an example of a nursing home that invited hospital ED staff to visit so they could better understand the nursing home situation. Activities like this also have the potential to address nursing home nurses’ concerns about the care residents receive when hospitalized. Implications for practice The findings from this meta-aggregation have implications for nursing home nurses who are seeking to reduce resident hospitalizations and improve the hospital transfer process.  Keep your clinical skills current. Review health care issues related to ageing, paying particular attention to the early signs of clinical deterioration.  Review policies and procedures. Make sure you are clear on the steps required when a resident’s health deteriorates.  Reflect on your own communication practices to ensure you are communicating effectively. Consider the use of SBAR or other standard communication tool to support your practice.  Create opportunities to collaborate with hospital nurses so you can better understand each other’s roles and responsibilities.  Follow your organization’s protocols for dealing with inappropriate behavior from residents, family members and other health care professionals.  Work with your nursing home managers to develop hospital avoidance strategies and to improve the hospital transfer process.  Review your legal rights and nursing responsibilities around caring for the deteriorating resident.

Limitations of the review A formal JBI systematic review is comprehensive and beyond the scope and intent of this research. However, JBI systematic review methods were employed and effort was made to follow and adhere to the selected review components. Although there is always a risk that significant studies were overlooked in the search process, this search was carefully constructed to minimize this risk. Conclusion and recommendations for further research Nursing home nurses play an essential role when a resident’s health is deteriorating and an emergency transfer to hospital is being considered; therefore, it is important to continue to explore and understand their experiences around this role. This type of research is timely and necessary because nurses are, and will continue to be, at the center of any hospital avoidance efforts. The results of this systematic review identified three areas that would benefit from further investigation. First, targeted education and training is needed around managing the deteriorating resident. Nurses should be included in the development and evaluation of any educational interventions. Second, communication issues around transfers appeared to be problematic. Research into the reasons for the problems identified should be investigated so

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