Background
Aim and research question
Methods
Study design
Context
Nursing home | Nurse to Patient ratio | Certified Nurse assistant to Patient ratio | Assistant to Patient ratio | Total healthcare worker to patient ratio | |
---|---|---|---|---|---|
Municipality A | Short-term | 1.09:1 | 0.42:1 | 0.18:1 | 1.69:1 |
Long-term | 0.45:1 | 0.96:1 | 0.12:1 | 1.54:1 | |
Municipality B | Short-term | 1.18:1 | 0.56:1 | 0.61:1 | 2.36:1 |
Long-term | 0.46:1 | 0.79:1 | 0.52:1 | 1.82:1 |
Sample and recruitment of municipalities
Municipality A | Municipality B | |||
---|---|---|---|---|
Nursing home | Short-term | Long-term | Short-term | Long-term |
Beds | 33 | 31 | 60 | 69 |
Wards | Palliative care, Municipal emergency bed units (MEBU), Hospital emergency bed units (HEBU), short term placements | Dementia and somatic wards | Palliative care, Municipal emergency bed units (MEBU), Hospital emergency bed units (HEBU), short term placements, rehabilitation | Dementia, somatic wards, short term bed |
Total nursing homes in the municipalities | 7 | 5 |
Data collection
Data analysis
Theme | Sub-themes | Category | Sub-category |
---|---|---|---|
T1: High nursing demands – variation in staffing and competence | Disparity in staffing and competence (Municipality A) | Tired nurses (NLT) |
Increased workload leading to de-prioritizing of important tasks
|
Complex patients (NLT) |
Seriously ill patients in need for complex treatment
| ||
Elderly patients are not prioritized
| |||
The patients don’t need to be hospitalized as often as before
| |||
Insufficient staffing (LLT + NLT) |
RN staffing not satisfactory - RNs confer with each other by telephone
| ||
More nurses are needed, but there has been a staff reduction which increases sick leave among nurses
| |||
Low physician coverage
| |||
Trying to keep the balance between resource usage and patient safety
| |||
Sicker patients gives new challenges
| |||
Acceptable staffing (LST) |
RN staffing is satisfactory in most wards
| ||
Physician coverage is satisfactory
| |||
Unpredictable staffing (NST) |
Good physician coverage during weekdays
| ||
There is not always enough RN staffing during weekends
| |||
Varying competence (LLT) |
Nurse competence is varying, but there is a focus on increasing it
| ||
High demands in care leads to high demands in competence
| |||
Fulltime positions is a way to increase competence
| |||
To many assistants
| |||
Reorganization can be positive in regards to competence
| |||
Sufficient competence (LST) |
The competence is high and have increased – increasing competence is encouraged
| ||
The patient group makes need for high competence
| |||
High competence (NST) |
RN competence and staffing are high, but at the expense of LPNs
| ||
Capacity building in focus (NLT) |
Working towards increased competence
| ||
Reasonable staffing and competence (Municipality B) | Satisfactory staffing (LST) |
Staffing is satisfactory, but vulnerable during weekends
| |
Good physician coverage and cooperation
| |||
RN density is increasing, which is positive for further recruitment
| |||
Acceptable staffing (LLT, NLT) |
The staffing is good as long as there is no sick leave
| ||
There is a lot of assistants in some wards
| |||
Competence is good, but capacity building on all stages are in focus
| |||
There is a need for more LPNs
| |||
Sufficient competence (LLT) |
RN coverage and RN competence is high in accordance to more complicated patients
| ||
Satisfactory competence and staffing (NST) |
Physician coverage is good
| ||
Nurse competence is varying, but several have continued educations
| |||
There is focus on capacity building on all levels
| |||
Varying competence (LST |
Capacity building is in focus
| ||
Capacity building in focus (LST, NLT) |
Courses and guidance are not always provided but capacity building is organized internally
| ||
The nursing home patients are more complex and sicker when discharged from the hospital
| |||
Internally organized capacity building (NST) |
Frustration in regard to discharge routines
| ||
Complex patients (LLT, NLT) |
The nursing home patients are more complex and sicker when discharged from the hospital
| ||
The patients are more complex
| |||
Frustration in regard to discharge routines
|
Common Themes | T1: High nursing demands – variation in staffing and competence | T2: Disparate Perceptions of Organizational Conditions | T3: Economic limitations | T4: Perceived Predictors of hospital readmissions | ||||
Sub-Themes | ST1: Disparity in staffing and competence (Municipality A) | ST1: Reasonable staffing and competence (Municipality B) | ST2: Organizational challenges on several levels (Municipality A) | ST2: Well-functioning organization on macro levels, challenges on micro levels (Municipality B) | ST3: Economic limitations do not affect access to medical equipment (A) | ST3: Opposing thoughts on economic limitations (Municipality B) | ST4: Predictors of hospital readmissions as perceived by nurses and leaders (Municipality A) | ST4: Predictors of hospital readmissions as perceived by nurses and leaders (Municipality B) |
Results
T1: High nursing demands – Variation in staffing and competence
Complex patients
(…) We get new patients, they live for a month, and then there is new patients and then they live…well, they live for a very short time [after arrival]. And the month that they are here [at the nursing home], they require an extreme amount of follow-up. (Leader LTNH, Municipality A)
We got an admission to the MEBU. A lady with malnutrition and dehydration. When she came here, she both ate and drank herself and didn’t need any fluid treatment. She just needed the care (…) She thrived at the MEBU and was flourishing. Then she got discharged, and we were thinking, we need to be a little bit on the alert in this case. So we notified the need for close nutritional follow-up to the home care service. A week passed, and the patient was readmitted here at the ward, malnourished and dehydrated (nurse STNH, Municipality B).
Capacity building
Competence
It’s people – like in other societies there are variations (…) some are fierce and seek new knowledge constantly, while others are at work, and then they go home… and… it varies. (leader STNH, Municipality, A).
Staffing
Your gut feeling tells you that this is not okay. There should have been more personnel, but you are feeling the pressure from both the leader and the municipality; that we should manage without hiring extra people in … that can be hard sometimes (leader STNH, Municipality A).
(…) I am working my way out of the ward. I’ve taken out the trash, I’ve wiped, and then I’m supposed to do the administrative work … so I work like a horse. I am totally beat when I get home. I’m starting to feel that this isn’t right! It shouldn’t be like this at a work place (nurse LTNH, Municipality A).
Physician coverage
In terms of planned interventions, the patient follow-ups and the regular tasks, there is enough hours [physician coverage] in my opinion. But it would have been all right to have a physician available at all times… because there are those things that happen right after the physician leaves… (leader, LTNH, Municipality B).
T2: Disparate perceptions of organizational conditions
Inadequate admission routines
It is fun [ironically] when they arrive [from the hospital] a Friday night and there is no physician on call during weekends … Yeah, and on Monday they get readmitted to the hospital, or the next day, on Saturday. (nurses STNH, Municipality A).
Patient flow and patient composition
We are a reception ward [MEBU] and are supposed to take care of all kinds of patients. That can be a challenge sometimes. Patients with disruptive behavior inside a ward where… where people [have] chronic obstructive pulmonary disease (COPD) for example. People are terminal, they’re having panic attacks, and they hear people in the hallway screaming and shouting and … yeah … yelling at the staff. (leader STNH, Municipality A).
Organization and cooperation
I remember last time, when we were learning how to use the BiPAP [Bi level positive airways pressure] machine. The patient was hospitalized and they were waiting to discharge the patient until we let them know that we’ve had training in using the machine… It helps when they give us time (nurse LTNH, Municipality B).
T3: Economic limitations
Finances and professional soundness are always a theme and a dilemma. To find a resource use that secures a good night’s sleep and at the same time doesn’t cost so much that it destroys your sleep, I guess that is what it is all about (leader LTNH, Municipality B).
In this job, I early on sensed that the nursing profession and the healthcare services’ economy often are in conflict. And I am realizing how fast we are adapting to the economic constraints. We become very obedient to the organization, and sometimes we are in conflict with ourselves and we are contradicting our own professional assessments based on the economy we have … (nurse STNH, Municipality B).
T4: Perceived predictors of hospital readmissions
I believe that competence is alpha omega [fundamental] in avoiding hospital readmissions. The more competence we have, the more [patients] we can take care of here [in the nursing home]. And we have the equipment to do so! (leader LTNH, Municipality A).
When I started to work here last year, we had physiotherapist and an occupational therapist present every day. We sensed that this was a good tool in preparing the patient for discharge. Now, we only have them here a couple of hours a week, and that is very little. Things are being discontinued in regards to rehabilitation and preparation for discharge and in preventing hospital readmissions (nurse STNH, Municipality B).
If they [patients] had been sent home straight after [a hospital stay], they wouldn’t have had the strength to, in a way, do that much, they would have been in a greater risk of being readmitted if they were to come home [instead of STNH] (leader STNH, Municipality A).