The Frontline Nurse's Experience of Nursing Outlier Patients

The frontline nurses' experience of nursing with overstretched resources in acute care setting can affect their health and well-being. Little is known about the experience of registered nurses faced with the care of a patient outside their area of expertise. The aim of this paper is to explore the phenomenon of nursing the outlier patient, when patients are nursed in a ward that is not specifically developed to deal with the major clinical diagnosis involved (e.g., renal patient in gynecology ward). Using a hermeneutic phenomenological approach, eleven individual face-to-face in-depth interviews were conducted with registered nurses in New South Wales, Australia. The study identified that each nurse had a specialty construct developed from nursing in a specialized environment. Each nurse had normalized the experience of specialty nursing and had developed a way of thinking and practicing theorized as a "care ladder". By grouping and analyzing various "care ladders" together, the nursing capacities common to nurses formed the phenomenological orientation, namely "the composite care ladder". Compared to nursing specialty-appropriate patients, nursing the outlier patient caused disruption of the care ladder, with some nurses becoming less capable as they were nursing the outlier patient. Nursing the outlier patient disrupted the nurses' normalized constructs of nursing. This study suggests that nursing patients in specialty-appropriate wards will improve patient outcomes and reduce impacts on the nurses' morale.

Analysis of frequency, type of complications and economic costs of outlying patients in general and digestive surgery

INTRODUCTION

The shortage of available beds and the increase in Emergency Department pressure can cause some patients to be admitted in wards with available beds assigned to other services (outlying patients). The aim of this study is to assess the frequency, types of complications and costs of outlying patients.

METHODS

Using a retrospective cohort model, we analysed the 2015 general and digestive surgery records (source: Minimum Basic Data Set and economic database). After selecting all outlying patients, we compared the complications, length of stay, costs and consequences of complications against a randomized sample of non-outlying patients with the same DRG and date of episode for every outlying patient, obtaining one non-outlying patient for each selected outlying patient. Thirteen outlying patients with no non-outlying patient pair were excluded from the study.

RESULTS

From a total of 2,915 patients, 363 (12.45%) were outlying patients. A total of 350 outlying patients were analysed versus 350 non-outlying patients. There were no significant differences in complications (9.4 vs. 8.3%), length of stay (4.33 vs. 4.65 days) or costs (€3,034.12 vs. €3,223.27). Outlying patients men presented a significantly higher risk of complications compared to women (RR=2.10). Outlying patients presented complications after 2.5 or more days.

CONCLUSIONS

When outlying admissions become necessary, the selection of patients with less complex pathologies does not increase complications or their consequences (ICU admissions, readmissions, reoperations or mortality), hospital stays or costs. Only in cases of prolonged outlying stays of more than 2.5 days, or in males, may more complications appear. Therefore, male outliers should be avoided in general, and patients should be transferred to the proper ward if a length of stay beyond 2.5 days is foreseen.

Barriers to effective, safe communication and workflow between nurses and non-consultant hospital doctors during out-of-hours

Objective

This study aimed to evaluate the nature and type of communication and workflow arrangements between nurses and doctors out-of-hours (OOH). Effective communication and workflow arrangements between nurses and doctors are essential to minimize risk in hospital settings, particularly in the out-of-hour's period. Timely patient flow is a priority for all healthcare organizations and the quality of communication and workflow arrangements influences patient safety.

Design

Qualitative descriptive design and data collection methods included focus groups and individual interviews.

Setting

A 500 bed tertiary referral acute hospital in Ireland.

Participants

Junior and senior Non-Consultant Hospital Doctors, staff nurses and nurse managers.

Results

Both nurses and doctors acknowledged the importance of good interdisciplinary communication and collaborative working, in sustaining effective workflow and enabling a supportive working environment and patient safety. Indeed, issues of safety and missed care OOH were found to be primarily due to difficulties of communication and workflow. Medical workflow OOH is often dependent on cues and communication to/from nursing. However, communication systems and, in particular the bleep system, considered central to the process of communication between doctors and nurses OOH, can contribute to workflow challenges and increased staff stress. It was reported as commonplace for routine work, that should be completed during normal hours, to fall into OOH when resources were most limited, further compounding risk to patient safety.

Conclusion

Enhancement of communication strategies between nurses and doctors has the potential to remove barriers to effective decision-making and patient flow.