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RESEARCH FOR NURSING PRACTICE

Decisions about transferring nursing home residents to hospital: highlighting the roles of advance care planning and support from local hospital and community health services Christopher Shanley, Elizabeth Whitmore, David Conforti, Janine Masso, Sanjay Jayasinghe and Rhonda Griffiths

Aims and objectives. To explore current practice and opportunities to improve practice in decision-making about transfer of nursing home residents to hospital. Background. Nursing home staff are often faced with the decision of whether to send a resident to hospital for medical treatment. While many residents will benefit from going to hospital, there are also several risks associated with this. This study sought to add to the existing body of research on this issue by seeking the views of nursing home managers, who are the persons most frequently involved in making these decisions. Design. Qualitative design using purposive, quota sampling. Method. Qualitative interviews with 41 nursing home managers from south-western Sydney, Australia. Results. Factors affecting the decision to transfer a resident to hospital include acuteness of their condition; level and style of medical care available; role of family members; numbers, qualifications and skills mix of staff; and concern about criticism for not transferring to hospital. Two factors that have not featured as strongly in previous research are the roles of advance care planning and support from local hospital and community health services. Conclusion. While transferring a nursing home resident to hospital is often necessary, there are many situations where they could be cared for in the nursing home; therefore, avoid complications associated with being in hospital. Apart from a range of factors already identified in the literature, this study has highlighted the important role that advance care planning and support from local health services can play in reducing unnecessary transfers to hospital. Relevance to clinical practice. There are several strategies that nursing homes and local health authorities can adopt to promote advance care planning and build better support systems between the two sectors, thereby reducing the numbers of residents who need to be transferred to hospital for their health care. Key words: advance care planning, Australia, hospitalisation, nurses, nursing home Accepted for publication: 21 October 2010

Authors: Christopher Shanley, EdD, Conjoint Senior Lecturer, Aged Care Research Unit, Liverpool Hospital, University of New South Wales; Elizabeth Whitmore, MPH, Research Officer, Aged Care Research Unit, Liverpool Hospital; David Conforti, MBBS, Senior Staff Specialist, Aged Care Research Unit, Liverpool Hospital, University of New South Wales, Liverpool; Janine Masso, BHS (Gerontology), Clinical Nurse Consultant, Aged Care, Bowral Hospital, Bowral; Sanjay Jayasinghe, MBBS, Senior Policy Officer,

National Centre for Immunisation Research and Surveillance, Westmead Hospital, Westmead; Rhonda Griffiths, DPH, Dean, School of Nursing and Midwifery, University of Western Sydney, Sydney, Australia Correspondence: Christopher Shanley, Conjoint Senior Lecturer, Aged Care Research Unit, Liverpool Hospital, LMB 7103, Liverpool BC, NSW 1871, Australia. Telephone: +61 2 9612 0646. E-mail: [email protected]

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2897–2906 doi: 10.1111/j.1365-2702.2010.03635.x

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Introduction Transfer to hospital of nursing home residents can be a positive move that allows for the treatment of acute illness, an increase in function, symptomatic relief of chronic problems and a reduction in mortality. However, in many cases, appropriate care could also be provided in the nursing home, thereby avoiding risks associated with hospitalisation – such as disruption of care plans, infections, disorientation and delirium, pressure sores and deconditioning (Saliba et al. 2000, Charette 2003). Transfer to hospital may also occur in the final stages of a resident’s life, although more appropriate palliative care may have been provided in the nursing home (Travis et al. 2001, Lamberg et al. 2005). The challenge is differentiating those situations where the resident needs to go to hospital from those when the risks of hospitalisation will outweigh the benefits (Teno 2004).

Background A wide range of factors that have an impact on the decision to transfer a nursing home resident to hospital have been identified. Broadly, these can be grouped into resident factors, structural factors, physician factors and family factors. In terms of resident factors, key issues include the acuteness of the illness, its impact on the quality of life of the resident and the likelihood of it causing death or disability (Buchanan et al. 2006, Cohen-Mansfield & Lipson 2006, Marcantonio et al. 2006). Another important issue is resident preferences and whether these are known to staff (Bottrell et al. 2001, Buchanan et al. 2006). Structural issues play an important role in decisions about transferring a resident to hospital (Carter 2003, Cortes et al. 2004, Intrator et al. 2004, Porell & Carter 2005, Finn et al. 2006, Marcantonio et al. 2006). These include the number and skill levels of nursing home staff; the capacity and willingness of these staff to care for residents with high-level needs; alternatives to hospital such as outreach services to the nursing home or ambulatory care clinics; case-mix levels and bed supplies in local hospitals and nursing homes; and clinical support for staff, especially after hours. Further issues include concern about being accused of malpractice or negligence for not transferring a resident to hospital and poor communication systems between hospitals and nursing homes. Regarding physician factors, several issues are discussed in the literature. One is the generally low availability of physicians in the nursing home setting (Shield et al. 2005, Finn et al. 2006). Another issue is the poor communication 2898

from physicians that is reported by family carers of nursing home residents (Wetle et al. 2005). A further issue is the variability in attitudes of physicians about the importance of aggressive treatments and their confidence in nursing home levels of care (Buchanan et al. 2006, Marcantonio et al. 2006). This point is illustrated by Cohen-Mansfield and Lipson (2006), who compared the decision-making by several physicians in the one nursing home and found the rates of hospitalisation varied from 91–20%. The family of the resident may play a strong role in decisions about transferring a resident to hospital (Bottrell et al. 2001, Buchanan et al. 2006, Marcantonio et al. 2006). In some cases, family members may insist on hospitalisation even if the resident is in a palliative condition. This will be influenced by the family’s perceptions of the level of care available in the nursing home as well as the amount of information and support provided to the family by staff. It will also be influenced by whether there is decision-making cohesion in the family. The authors of this paper set out to investigate the factors that influence the decision to transfer nursing home residents to hospital. The scope of the investigation was any transfer to hospital – which might occur for a range of reasons, such as assessment of an acute illness, management of an ongoing chronic problem or the need for end-of-life care. The aims of this project were to gain a greater understanding of current practice and to explore ways that nursing homes might be able to reduce transfer to hospital while maintaining optimum care in the nursing home setting. In Australia, nursing homes receive the bulk of their funding from the Federal Government. Funding is provided in terms of the level of need of each resident as determined by a standard funding instrument that classifies residents on a scale from high- to low-care needs (Travers et al. 2008). Nursing homes may be owned and operated by private companies, not-for-profit organisations or government. In the past, there was a Federally funded hostel sector that catered to residents who still had some level of mobility and independence. As there has been a significant shift to caring for frail older people in their own homes, residents coming into hostels now have a greater level of dependence from admission (Australian Government Department of Health and Ageing 2009). This demographic shift has meant that many of the old ‘hostels’ now cater to residents who would have previously been transferred to nursing homes. This has led to a merging of the old hostels and nursing homes into a single residential aged care sector (Commonwealth Department of Health and Ageing 2002). For ease of communication, the remainder of this paper will use the term ‘nursing home’ to refer to all

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2897–2906

Research for nursing practice

facilities in this integrated sector, although it is acknowledged that some facilities still cater to mainly low-care residents and consequently have lower numbers of staff overall and less qualified nursing staff. The geographical area covered by this project contained 66 nursing homes. Nursing homes do not employ their own medical staff. Residents receive their medical care from private primary care physicians, called General Practitioners (GPs). The resident may have the same GP looking after them as they had previously in the community, or else have a new GP allocated who already has some patients in the nursing home. There is a big variation in how regularly and for how long each GP will spend with their patient who is a nursing home resident (Australian Society for Geriatric Medicine 2001). The non-residential health-care needs of older persons are mainly provided by the public hospital and community health services, which are funded by the State Government and managed through local Area Health Services. In the sector covered by this project, these hospitals include a 700-bed tertiary trauma referral centre and university teaching hospital, three smaller university teaching hospitals ranging from 216–400 beds and two hospitals in more rural settings with 80 beds each (Sydney South West Area Health Service 2008). As well as the hospitals, the Area Health Service provides a range of community health services such as medical, nursing and allied health consultation in persons’ homes, community health centres and nursing homes. For the remainder of this paper, the term ‘Area Health Service’ (AHS) will be used to describe this range of hospitals and community health services.

Methods The research project was granted ethics approval by the Human Research Ethics Committee of Sydney South West Area Health Service (Western Zone). The study adopted a qualitative methodology (Czarniawska 1998, 2003, Schwandt 2000), and data collection was by one-to-one interviews with the managers of nursing homes in the study area (Shanley et al. 2009). The managers are responsible for the overall clinical care of residents in their nursing homes and are often directly involved in decisions about transferring residents to hospital. Apart from small facilities catering to low-care residents, all managers are registered nurses. Some have postgraduate qualifications, and all have considerable experience in the aged care sector. The study area was the Western Zone of the Sydney South West Area Health Service, in New South Wales, Australia, which contains 66 nursing homes. The intention

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of the sampling strategy was to interview managers from the majority of nursing homes until a point of data saturation was reached, while also achieving a sample that was broadly representative of the study population of 66 facilities in terms of facility size, high/low care and type of ownership. Letters were sent out in batches to randomly selected nursing home managers informing them about the project and inviting them to take part in a research interview. Four rounds of letters were sent out until managers of 41 facilities had been interviewed. This number was considered to be at saturation point as there were no new issues arising from the interviews. No further invitations were issued at this point. The proportions of nursing homes that provide predominately high and low care, the type of ownership and the number of beds held by the facilities are given in Table 1. The details of the study sample are compared with the population of facilities in the study area and national figures where these are available. The format of the interviews involved a semi-structured approach. This is based on an interview schedule with several preset questions, but flexibility in how these are asked (Minichiello et al. 1995, Quine 1998). The interview schedule was informed by key issues and gaps in the literature. A range of questions was developed to elicit current practice around decisions to transfer to hospital, innovative approaches in this area and opportunities that the interviewees saw for improving practice. All interviews were transcribed verbatim, and the transcripts were all checked by the researcher while listening to the interview recording. The transcripts were then loaded into the NVivo 7 software program (Bazeley & Richards 2000). This allowed for extensive content and thematic coding, which became the basis of the data analysis (Miles & Huberman 1994, Flick 1998, Glesne 1999, Marshall & Rossman 1999). The beginnings of a set of content-related coding were suggested by the topics that formed the basis of the semistructured interview schedule. After reading all the transcripts, this first set of coding was further developed by the first two authors and applied to the transcripts. The first two authors then read all transcripts separately and discussed what they saw as common themes in the data before discussing these further with other authors. Thematic analysis is interested in uncovering similarities and differences in responses to questions, what connections there may be between different responses and what explanations there may be for these connections. The reliability and validity of this process is appropriate for this form of qualitative research, as demonstrated by a systematic and rigorous approach, the transparency and detail of the data collection


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C Shanley et al. Table 1 Characteristics of study sample in terms of type of ownership, number of beds and provision of predominately high or low care National figures

Type of ownership Private Not for Profit Government Total Number of beds 1–40 41–80 81–120 120+ Total High or low care High care Low care Total

SSWAHS-WZ

Study sample

Number

Percentage

Number

Percentage

Number

Percentage

776 1811 344 2931

26Æ5 61Æ8 11Æ7 100Æ0

22 43 1 66

33Æ3 65Æ2 1Æ5 100Æ00

11 29 1 41

26Æ9 70Æ7 2Æ4 100Æ0

1064 1382 363 122 2931

36Æ3 47Æ1 12Æ4 4Æ2 100Æ0

15 26 20 5 66

22Æ7 39Æ4 30Æ3 7Æ6 100Æ0

7 12 19 3 41

17Æ1 29Æ3 46Æ4 7Æ2 100Æ0

Not available Not available

Not available Not available

31 35 66

47Æ0 53Æ0 100Æ0

22 19 41

53Æ7 46Æ3 100Æ0

and the different stages of analysis, going beyond description to develop explanations and corroboration of the analysis by members of the research team.

I think because we just have quite a good working relationship, the GP takes our judgement on board usually. (High Care Manager 2) I might have all the policies and procedures in the world here, but a GP walks in and says ‘Oh, I want her to be sent to hospital’. It happens,

Results

it doesn’t matter what I’ve got here. (High Care Manager 35)

Participants were asked how they would decide to transfer a resident to hospital. What emerged from the responses is that some decisions are fairly straightforward, while others are not so clear cut. All participants suggested they would always transfer a resident who needed immediate, acute care that was only available in a hospital setting. Examples included injury from falls, chest pain not responding to medication and oxygen, acute shortness of breath, uncontrolled bleeding and a rapid unexplained deterioration in their condition. Apart from these acute scenarios where the decision is fairly automatic, there were several factors that affected the managers’ decisions about transferring a resident. These factors are outlined elsewhere.

Medical support As explained in the introduction to this paper, Australian nursing homes do not employ their own medical staff. Residents receive their medical care from private primary care physicians, called general practitioners (GPs). Interviewees’ responses indicated that many GPs have developed a close and collaborative relationship with facility staff while others maintain a more detached position and make decisions about hospitalisation without much consultation: 2900

Interviewees also suggested that there was a big range in the level of involvement that GPs had with their patients in nursing homes. Many knew their residents well and were keen to help them avoid hospitalisation if possible. Others were seen as fairly removed and not willing or able to spend the time to undertake the assessment and follow-up of their sick patients that would be necessary if they were not transferred to hospital.

The role of the resident’s family The way that family are involved in decisions about transferring to hospital is partly determined by the urgency of the situation. In acute emergencies where the priority is immediate treatment, the decision will be made by the staff and the family will be informed as soon as practicable. Apart from urgent situations, where staff will make the decision and inform the family, the ways that family are involved in decisions about transfer will vary considerably. This will be influenced by how often the family visits and how open their ongoing communication is with the staff; the faith that family have in the facility being able to provide appropriate care to the resident; and internal dynamics in the family. Some family members are dealing with the guilt of



having a loved one in a facility and feel obliged to send the person to hospital if there is any doubt, as they do not want to feel they have not done everything they could for the person. There can also be problems if there is conflict in the family where one member is happy for the resident to stay in the nursing home and others want medical intervention in a hospital setting.

Availability and skill levels of registered nurses Facilities that had registered nurses – especially if they were available 24 hour – reported that they were more likely to keep the resident in the facility and try some preliminary treatment while they wait for a medical visit, rather than send them straight to hospital. Facilities with more low-care residents have minimal access to registered nurses, which means that, outside normal business hours, personal care assistants often have the responsibility of making such decisions. Interviewees considered that it was unreasonable to expect such staff to take on this responsibility, so the most common approach in this situation was ‘if in doubt, ship them out’. Even in facilities with all high-care residents, which have 24-hour registered nurse coverage, there was variation in the complexity of medical problems that the staff were prepared to manage in the facility. Some registered nurses had maintained and developed skills in areas such as tracheostomy management, peritoneal dialysis and administration of intravenous antibiotics. Staff in other facilities did not have the skills or confidence in such areas and were therefore more inclined to send residents to hospital if they had problems that required this type of care: I talk to other DONs (Directors of Nursing) about doing intravenous antibiotic therapy onsite and they said ‘Oh we would not do that’ and I said ‘Why not?’ ‘Oh no, no, the hospital can do that’. Well the way we look at it, is usually the resident is going to be far better off staying with us, we can care for them better. (High Care Manager 2)

Level of staffing and other resources available Apart from the role of registered nurses, another factor influencing the decision was the number and skill levels of other staff. This was particularly significant in facilities with mostly low-care residents, which have fewer staff per resident than nursing homes with mostly high-care residents. Even if the person might have been able to be managed in the facility, it would have required many of the staff time, making it difficult to care for other residents:

Transferring nursing home residents to hospital 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. (Low Care Manager 22)

Fear of criticism and litigation A significant issue affecting decisions about transferring residents to hospital is the fear of criticism and complaints being made. The majority of managers recounted stories of either informal or formal complaints about residents not being transferred to hospital. Formal complaints are investigated by a government authority and can be very timeconsuming and stressful for staff, even if the complaints are not upheld: We can’t not [transfer], because it’s too litigious not to transfer them …. and that’s gone to the Complaints Resolution scheme on a few, on a couple of occasions. (High Care Manager 1)

Advance care planning processes used in the facility Advance care planning (ACP) is the process of discussing and documenting the type and levels of treatment a person may want in the future in the event they cannot speak for themselves at the time. Ideally, it should involve the resident making their own views known. However, for some highcare residents who have already lost decisional capacity, the process will be carried out by their substitute decisionmakers. The study found that there was large variation across the nursing homes in how systematically they approached ACP (Shanley et al. 2009). Managers that took a more deliberate and systematic approach indicated that they were less likely to have unplanned transfers to hospital than other nursing homes. Managers suggested this occurred through several mechanisms. First, it means there has been an open recognition of the resident’s condition and prognosis, and this allows the resident and their family to have a clearer idea about possible future scenarios. This helps them come to terms with difficult decisions about care they may have to make in the future. If these discussions have not taken place, the family may be making decisions without any preparation and are likely to err on the side of caution by sending the person to hospital: I think it is, I think it’s important one because we have a choice in life why can’t we have a choice in the way we die. I think it [ACP] would be beneficial for the person, for their family....the families would have a clear idea of what their mum or dad wanted instead of waiting till the person is near death and then going into panic


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Second, having advance care planning in place helps to put the resident’s views and wishes at the forefront. It means that residents who do not want unnecessarily intrusive interventions at the end of their life will not be subjected to these just because nobody can make a clear decision not to transfer them to hospital: I think advance care planning is vital….. I believe in autonomy for people and I believe they shouldn’t lose that because they’re in an Aged Care Facility. (Low Care Manager 38)

Third, it means that staff have clearer guidelines and directions about how to deal with the deterioration in the health of a resident. This is particularly relevant if decisions have to be made by either casual or less experienced staff. Previous discussions and decisions will be documented so that staff will not have to make decisions about hospitalisation in a vacuum of information.

Availability and awareness of support services from local hospital and community health services Study participants were asked whether any clinical staff employed by the AHS came into their nursing home to provide support to them in the care of residents. A range of AHS staff are already going into the nursing homes to provide a consultation service to staff that prevents several residents from having to be transferred to hospital. The services that go into nursing homes most frequently are community aged care assessment, psychogeriatrics, palliative care, wound care, continence care and community nurses. While some nursing homes make use of several AHS staff, other facilities either do not know about or else do not use these services at all. Provision of services varies greatly across the different sectors in the AHS and across different clinical streams. There is no common source of information or communication between and across the hospitals and nursing homes, although most hospitals have some form of network meetings with nursing homes in their local area. While the communication between hospitals and residential care facilities has varied across localities and is somewhat fragmented, there are several current initiatives that are trying to improve this situation. The challenge is to make these initiatives more consistent across the AHS and more sustainable. Innovative approaches that were mentioned by the interviewees could be described under the headings of collaborative and shared care, education and 2902

professional support of nursing home staff, alternatives to Emergency Department and inpatient care and the use of technology. There were several examples that demonstrated a willingness to collaborate and share care between the nursing homes and the AHS. One nursing home, in collaboration with the local hospital, organised a visit to the facility by staff from the hospital’s Emergency Department to provide staff with a better understanding of the conditions and constraints of the nursing home environment. Another nursing home had made an effort to develop relationships with staff in specialist hospital units such as dialysis and respiratory units. Because they were prepared to take residents that other facilities might not, such as people with tracheostomies, peritoneal dialysis and intravenous antibiotics, the hospital staff were quite happy to provide advice and education as well as lending equipment when necessary. Several managers said that they liaised with their local hospital to get residents who had undergone surgery back to the nursing home as soon as possible as a way of preventing hospital-related complications such as infection, confusion and restricted mobility. Several nursing homes had arrangements with local hospitals where they kept two respite beds free for hospital patients who were not well enough to go home but not sick enough to need to be in hospital. The hospital staff would help with providing equipment and consultation on care needed. A second group of initiatives involved education and support of registered nurses working in the nursing homes. Several nursing homes took part in education programmes for registered nursing staff conducted by community nurses on advanced nursing skills such as changing percutaneous endoscopic gastrostomy (PEG) tubes and suprapubic catheters, management of subcutaneous and intravenous fluids and management of dementia and delirium. Increasing the skills and confidence of the nursing home staff in this way allows them to care for some residents in the facility rather than immediately transferring them to hospital. A third group of initiatives involved the development of alternatives to inpatient transfer. Some hospitals offer an outpatient or ambulatory care clinic where people can come in for relatively simple procedures as an alternative to going to the Emergency Department. The AHS had also established a telephone support line to nursing homes where the nursing home could get advice about residents they were concerned about and organise alternatives to hospital transfer such as a medical or nursing consultation in the nursing home or an urgent outpatient appointment the next day. The use of technology was seen in one nursing home which made use of



email to send digital photographs of complex wounds to medical and nursing specialists at the hospital, who would advise on appropriate treatment.

Discussion Results from this study reinforce the findings from previous research (Bottrell et al. 2001, Cohen-Mansfield & Lipson 2006, Finn et al. 2006) that the decision to transfer a resident to hospital can be a complex one that is potentially influenced by many factors. The study has found many of the same issues raised in other research – the acuteness of the resident’s condition; the level and style of medical care available; the role of family members; the numbers, qualifications and skills of staff; and concern about criticism for not transferring to hospital. Two factors emerging from this study that have not featured in previous research are the role of advance care planning and the role of support from local hospital and community health services. The qualitative study design does not allow the authors to measure or estimate exactly the relative importance of these two factors, in comparison with the other factors that have been identified. However, their importance has been raised by the managers interviewed, who discussed these factors as significant issues that influence their decisions and that also have the potential for improving outcomes. The authors suggest that the two factors should be highlighted and further explored on the basis that they have been seen as significant by the participants and they have not been considered in detail in other literature on the issue. Advance care planning is an important aspect of practice in residential aged care that can help to avoid unplanned and unnecessary transfer to hospital. This is supported by Teno (2004), who suggests that health-care providers are reasonably comfortable with using ‘Do Not Resuscitate’ orders but much less comfortable with decisions about whether to hospitalise a frail nursing home resident. She advocates advance care planning that engages the views of residents and family members and then provides recommendations based on the health-care providers’ understanding of the person’s and family’s wishes. This may include comfort care and avoidance of hospitalisation. The importance of advance care planning has also been highlighted by Travis et al. (2001) who compared dying nursing home residents who were either transferred or not transferred to hospital shortly before death. They found the hallmarks of care among non-hospitalised cases in their study were as follows: ‘open communication between all decisionmakers (family, physician staff and resident when possible);

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knowledge of the resident’s wishes by a responsible party; physician and staff commitment to following the wishes of the residents and families; explicit notes in the medical records about care decisions; and a commitment to stay the course of care’ (Travis et al. 2001, p. 158). A second factor highlighted in this study is the importance of nursing homes getting clinical support from their local hospitals and community health services. Greater levels of support mean that at least some residents who would have otherwise been transferred to hospital will be able to be cared for in the nursing home. The availability of this support will vary considerably across and in jurisdictions and organisations. In Australia, for example, hospitals are funded through the State Government, while nursing homes are funded through the Federal Government (Travers et al. 2008). In the past, this has meant that the hospital and residential care systems have run quite separately and it has been difficult to develop innovative programmes that bridge the two systems. Recently, some of these structural barriers have been challenged and breached, as illustrated in some of the examples presented earlier in this paper. This often occurs when individuals who are committed to improving outcomes are prepared to work collaboratively on local solutions. Another factor that was found to be important in bridging the two systems is the willingness and ability of the nursing home managers to be outward-focused, to find out about available resources and to develop relationships with other service providers. Some strategies to help build stronger support from the hospitals to the nursing home sector are outlined in the examples already provided. Other strategies include supporting GPs in medical care of residents through a medical helpline and clinical pathways for medical diagnoses and treatments; improving systems for reviewing residents making multiple presentations to the Emergency Department; developing consistent communication systems between the AHS and nursing home sector; promoting local programmes and initiatives aimed at reducing hospitalisation of residents; and providing positive information and support to patients and families about entering residential care so they can develop confidence in the nursing home’s capacity to provide appropriate care. There are several significant limitations to this study. The first is that data were drawn only from interviews with nursing home managers, rather than a range of stakeholders. This group was chosen as playing a pivotal role in decisionmaking as they are most likely to have contact with residents, family members and GPs. They also have the day-to-day responsibility for clinical care in the nursing home, including decisional processes about transferring residents to hospital.


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The second limitation is that the design does not allow the authors to measure the importance of the two highlighted factors relative to other factors influencing the decision to transfer a resident to hospital. The findings are put forward as qualitative and exploratory. They have been strongly proposed by the facility managers interviewed and several suggestions to improve practice have been put forward that the authors believe are worthy of further study. A third limitation to the generalisability of the findings is that the study was carried out in one location, with particular structural, funding and health-care characteristics that are different to other locations and countries. The paper has clearly acknowledged that decisions about transferring residents to hospital will be influenced by these variable characteristics and does not propose a single model that is directly relevant for all settings. However, the findings are put forward as positive proposals that nursing home and hospital managers and clinicians can consider when reviewing their own policy and practice setting.

Conclusion While the decision to transfer a nursing home resident to hospital is often clearly necessary, there are many situations where the resident could be cared for in the residential care facility and therefore maintain continuity of their care and avoid complications associated with being in hospital. This study has demonstrated that there are many factors impacting on the decision to transfer a resident to hospital. Most of these factors have been reflected in other researches on this issue. Two factors that this paper has added to the existing literature are the roles of advance care planning and support from local hospital and community health services.

help them when making decisions about whether certain conditions require transfer to hospital, rather than having to make these decisions at the last moment and with no preparation. There are several ways that nursing homes and local health authorities can promote a more systematic approach to advance care planning. Local hospital and community health services can support nursing homes by providing consultation services as well as a range of other collaborative programmes. This will enable the facilities to manage residents with higher-level medical requirements rather than transfer them to hospital. The availability of this type of partnership will vary depending on local funding and administrative structures. This study has provided some practical examples of this type of support being successful at a local level.

Acknowledgements This project was supported by funding from the Australian Government Department of Health and Ageing through the Pathways Home Program. Other investigators who were involved in the project include Professor Colleen Cartwright, Dr Angela Khoo, Dr Amanda Walker and Professor Robert Cumming.

Contributions Study design: CS, EW, DC, JM, SJ, RG; data collection and analysis: CS, EW, DC and manuscript preparation: CS, EW, DC, JM, SJ, RG.

Conflict of interest There are no conflicts of interest associated with this study or publication.

Relevance to clinical practice Advance care planning can help residents, family and staff to anticipate future treatment scenarios and choices. This will

References Australian Government Department of Health and Ageing (2009) Report on the Operation of the Aged Care Act 1997: 1 July 2008–30 June 2009. Commonwealth of Australia, Canberra. Australian Society for Geriatric Medicine (2001) ASGM Position Paper No. 9. Medical care for people in residential aged care services. Australasian Journal on Ageing 20, 204–208.

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Bazeley P & Richards L (2000) The NVivo Qualitative Project Book. Sage, London. Bottrell MM, O’Sullivan JF, Robbins MA, Mitty EL & Mezey MD (2001) Transferring dying nursing home residents to the hospital: DON perspectives on the nurse’s role in transfer decisions. Geriatric Nursing 22, 313–317. Buchanan JL, Murkofsky RL, O’Malley AJ, Karon SL, Zimmerman D, Caudry DJ &

Marcantino ER (2006) Nursing home capabilities and decisions to hospitalize: a survey of medical directors and directors of nursing. Journal of the American Geriatrics Society 54, 458–465. Carter MW (2003) Variations in hospitalisation rates among nursing home residents: the role of discretionary hospitalisations. Health Services Review 38, 1177–1206.


Research for nursing practice Charette SL (2003) Hospitalization of the nursing home patient. Journal of the American Medical Directors Association 4, 90–94. Cohen-Mansfield J & Lipson S (2006) To hospitalise or not to hospitalise? Theat is the question: an analysis of decision making in the nursing home. Behavioural Medicine 32(Summer), 64–70. Commonwealth Department of Health and Ageing (2002) Ageing in Place: A Guide for Providers of Residential Aged Care. Commonwealth of Australia, Canberra. Cortes TA, Wexler S & Fitzpatrick JJ (2004) The transition of elderly patients between hospitals and nursing homes: improving nurse-to-nurse communication. Journal of Gerontological Nursing 30, 10–15. Czarniawska B (1998) A narrative Approach to Organization Studies. Sage, Thousand Oaks, CA. Czarniawska B (2003) Social constructionism and organization studies. In Debating Organization: Point-counterpoint in Organization Studies (Westwood R & Clegg S eds). Blackwell Publishing, Malden, MA, pp. 128–139. Finn JC, Flicker L, MacKenzie E, Jacobs IG, Fatovich DM, Drummond S, Harris M, Holman DC & Sprivulis P (2006) Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia.[see comment]. Medical Journal of Australia 184, 432–435. Flick U (1998) An Introduction to Qualitative Research. Sage, London. Glesne C (1999) Becoming Qualitative Researchers: An Introduction, 2nd edn. Addison Wesley Longman, New York. Intrator O, Zinn J & Mor V (2004) Nursing home characteristics and potentially preventable hospitalisations of long-

Transferring nursing home residents to hospital stay residents. Journal of the American Geriatric Society 52, 1730–1736. Lamberg JL, Person CJ, Kiely DK & Mitchell SL (2005) Decisions to hospitalize nursing home residents dying with advanced dementia. Journal of the American Geriatrics Society 53, 1396– 1401. Marcantonio ER, O’Malley AJ, Murkofsky RL, Caudry DJ & Buchanan JL (2006) Derivation and confirmation of scales measuring medical directors’ attitudes about the hospitalization of nursing home residents. Journal of Aging & Health 18, 869–884. Marshall C & Rossman GB (1999) Designing Qualitative Research, 3rd edn. Sage, Thousand Oaks, CA. Miles MB & Huberman AM (1994) Qualitative Data Analysis: An Expanded Sourcebook. Sage, Thousand Oaks, CA. Minichiello V, Aroni R, Timewell E & Alexander L (1995) In-depth Interviewing, 2nd edn. Addison Wesley Longman Australia, Australia. Porell FW & Carter M (2005) Discretionary hospitalization of nursing home residents with and without Alzheimer’s disease: a multilevel analysis. Journal of Aging & Health 17, 207–238. Quine S (1998) Interviews. In Handbook of Public Health Methods (Kerr C, Taylor R & Heard G eds). McGraw Hill, Australia, pp. 522–526. Saliba D, Kington R, Buchanan J, Bell R, Wang M, Lee M, Herbst M, Lee D, Sur D & Rubenstein L (2000) Appropriateness of the decision to transfer facility residents to the hospital. Journal of the American Geriatrics Society 48, 154–163. Schwandt TA (2000) Three epistemological stances for qualitative enquiry: interpretivism, hermaneutics and social


constructionism. In Handbook of Qualitative Research (Denzin NK & Lincoln YS eds). Sage, Thousand Oaks, pp. 189–213. Shanley C, Whitmore E, Khoo A, Cartwright C, Walker A & Cumming RG (2009) Understanding how advance care planning is approached in the residential aged care setting: a continuum model of practice as an explanatory device. Australasian Journal on Ageing 28, 211–215. Shield RR, Wetle T, Teno J, Miller SC & Welch L (2005) Physicians ‘Missing in action’: family perspectives on physician and staffing problems in end-of-life care in the nursing home. Journal of the American Geriatric Society 53, 1651– 1657. Sydney South West Area Health Service (2008) SSWAHS: Annual Report 2007/ 08. Sydney South West Area Health Service, Sydney. Teno JM (2004) Do-not-resuscitate orders and hospitalization of nursing home residents: trumping, neglect, or shared decision-making at the eleventh hour. Journal of the American Geriatrics Society 52, 159–160. Travers CM, McDonnell GD, Broe GA, Anderson P, Karmel R, Duckett SJ & Gray LC (2008) The acute-aged care interface: exploring the dynamics of ‘bed blocking’. Australasian Journal on Ageing 27, 116–120. Travis SS, Loving G, McClanahan L & Bernard M (2001) Hospitalization patterns and palliation in the last year of life among residents in long-term care. Gerontologist 41, 153–160. Wetle T, Shield R, Teno J, Miller SC & Welch L (2005) Family perspectives on end-of-life care experiences in nursing homes. The Gerontologist 45, 642– 650.

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