Research in Gerontological Nursing

Empirical Research 

Nurses as Boundary-Spanners in Reducing Avoidable Hospitalizations Among Nursing Home Residents

Kathleen Abrahamson, PhD, RN; Christine Mueller, PhD, RN, FGSA, FAAN; Heather Wood Davila, MPA; Greg Arling, PhD

Abstract

An increasing number of nursing home quality improvement efforts are aimed at reducing avoidable hospitalizations of residents. The current study focused on the experiences of nursing home nurses as “boundary-spanners” in the implementation of initiatives aimed at this effort. In-depth, semi-structured interviews were conducted with 76 nursing staff members within 38 nursing homes. Data were analyzed using thematic analysis and an inductive category development approach. Nursing staff described multiple scenarios where they had acted to negotiate the hospitalization decision and described themselves as working both within the nursing home boundary and within the larger system of external stakeholders to avoid a hospital transfer. There is potential for role overload and strain, as nurses are required to provide for complex medical needs within facilities designed to encourage relationship-driven, home-like care. Future efforts to reduce avoidable hospitalizations may benefit by ensuring needed resources are in place to provide clinically complex care and by making efforts to reduce the challenges that emerge when nurses are in the position to span the boundary between the nursing home and outside stakeholders. [Res Gerontol Nurs. 2014; 7(5):235–243.]

Dr. Abrahamson is Assistant Professor, Purdue University School of Nursing, Purdue University Center for Aging and the Life Course, West Lafayette, Indiana; Dr. Mueller is Professor, and Ms. Davila is PhD student, University of Minnesota School of Nursing, Minneapolis, Minnesota; and Dr. Arling is Associate Professor and Research Scientist, Indiana University School of Medicine Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This research was funded by the Agency for Healthcare Research and Quality (grant 5R18HS018464-02).

Address correspondence to Kathleen Abrahamson, PhD, RN, Assistant Professor, Purdue University School of Nursing, Purdue University Center for Aging and the Life Course, Johnson Hall of Nursing, West Lafayette, IN 47907; e-mail: kaabraha@purdue.edu.

Received: February 07, 2014
Accepted: May 08, 2014
Posted Online: May 27, 2014

Abstract

An increasing number of nursing home quality improvement efforts are aimed at reducing avoidable hospitalizations of residents. The current study focused on the experiences of nursing home nurses as “boundary-spanners” in the implementation of initiatives aimed at this effort. In-depth, semi-structured interviews were conducted with 76 nursing staff members within 38 nursing homes. Data were analyzed using thematic analysis and an inductive category development approach. Nursing staff described multiple scenarios where they had acted to negotiate the hospitalization decision and described themselves as working both within the nursing home boundary and within the larger system of external stakeholders to avoid a hospital transfer. There is potential for role overload and strain, as nurses are required to provide for complex medical needs within facilities designed to encourage relationship-driven, home-like care. Future efforts to reduce avoidable hospitalizations may benefit by ensuring needed resources are in place to provide clinically complex care and by making efforts to reduce the challenges that emerge when nurses are in the position to span the boundary between the nursing home and outside stakeholders. [Res Gerontol Nurs. 2014; 7(5):235–243.]

Dr. Abrahamson is Assistant Professor, Purdue University School of Nursing, Purdue University Center for Aging and the Life Course, West Lafayette, Indiana; Dr. Mueller is Professor, and Ms. Davila is PhD student, University of Minnesota School of Nursing, Minneapolis, Minnesota; and Dr. Arling is Associate Professor and Research Scientist, Indiana University School of Medicine Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This research was funded by the Agency for Healthcare Research and Quality (grant 5R18HS018464-02).

Address correspondence to Kathleen Abrahamson, PhD, RN, Assistant Professor, Purdue University School of Nursing, Purdue University Center for Aging and the Life Course, Johnson Hall of Nursing, West Lafayette, IN 47907; e-mail: kaabraha@purdue.edu.

Received: February 07, 2014
Accepted: May 08, 2014
Posted Online: May 27, 2014

An increasing number of nursing home quality improvement (QI) efforts are aimed at reducing avoidable hospitalizations among nursing home residents. Hospitalization of nursing home residents is costly, disruptive, and frequently avoidable. There is evidence that avoiding hospitalization and providing care within the familiar environment of the nursing home can improve the resident experience and health outcomes (Castle & Mor, 1996; Ouslander et al., 2010; Saliba et al., 2000). Hospital transfers are associated with increased potential for delirium, immobility, infection, and emotional distress (Creditor, 1993; Konetzka, Spector, & Limcangco, 2008; Murray & Laditka, 2010). In addition to concerns regarding the effects of hospitalization on resident care and outcomes, nursing homes have increased financial pressure to avoid transferring residents to the hospital. As part of the Patient Protection and Affordable Care Act (2010), the Centers for Medicare and Medicaid Services reduced payments to hospitals with excess readmissions as part of the Hospital Readmission Reduction program, and a legislative proposal that would enact similar financial penalties for nursing homes with high rates of avoidable hospital transfers is included in the U.S. Department of Health and Human Services (2013) budget for 2014.

Examples of avoidable hospitalizations include cases where (a) changes in condition could have been prevented or intervened earlier before the condition worsened; (b) there is a breakdown of communication between nursing home staff and medical providers; and (c) conditions could have been treated in the nursing home with advanced clinical or diagnostic care (e.g., intravenous [IV] therapy). Poorly managed diagnoses can potentially result in avoidable hospitalizations due to dehydration, infection, congestive heart failure, and pneumonia (Young, Inamdar, Barhydt, Colello, & Hannan, 2010). Patient and family desires, resident condition, the clinical capacity of the nursing home, and available resources (e.g., laboratory or diagnostic testing) are key considerations in hospital transfer decisions (Buchanan et al., 2006; Grabowski, Stewart, Broderick, & Coots, 2008).

Although transfer from nursing home to hospital requires a physician order, nurses play a key role in avoiding unnecessary hospitalizations. Nurses assess resident condition, make crucial judgments regarding the capacity of the nursing home to address the resident’s medical needs, and communicate resident and family desires to the physician. In cases of potential hospital transfer, nurses act as the “middle man” between resident needs, resident and family preferences, nursing home capacity, and the clinical decisions of the physician. Evaluations of the Interventions to Reduce Acute Care Transfers (INTERACT) program, a QI initiative aimed at reducing transfers from nursing home to hospitals, have shown that avoidable hospitalizations can be reduced with appropriate training, tools, and support (Lamb, Tappen, Diaz, Herndon, & Ouslander, 2011; Ouslander et al., 2011). It is important to note, however, that not all hospitalizations of nursing home residents are avoidable, and each hospitalization is the result of a decision-making process. In addition, nursing home staff may perceive fewer hospitalizations as being avoidable than other stakeholders (Lamb et al., 2011). Clear criteria regarding when to hospitalize is often absent, and each resident situation is assessed individually. The decision to hospitalize a resident or provide care for an acutely ill resident within the nursing home has immediate ramifications for the nurse who is then responsible for managing the care plan of that resident. Although some research has addressed nurse perceptions of interventions designed to reduce avoidable hospitalizations, prior studies focused on the use of specific interventions or perceptions of the preventability of resident transfers (Lamb et al., 2011; Renz, Boltz, Wagner, Capezuti, & Lawrence, 2013; Young et al., 2010). To our knowledge, the current study is the first to specifically describe the experiences of nurses participating in efforts to reduce avoidable hospitalizations.

The current study builds on existing research by focusing on the experiences of nursing staff as “boundary-spanners” in the implementation of QI initiatives aimed at reducing avoidable nursing home hospitalizations. Nursing staff are in an organizational role to negotiate the input of a variety of stakeholders in the hospitalization decision (i.e., family, physicians, nursing home residents, and fellow nursing staff). A clear understanding of the nursing staff experience, including the organizational challenges of residing in the boundary space of this issue, is necessary to develop approaches that successfully reduce avoidable hospitalizations of nursing home residents.

Theoretical Framework

The theoretical framework for this study is derived from the Open System model (Katz & Kahn, 1978) of organizational structure, which describes organizational boundaries as fluid and interactive with some organizational members managing the boundary between intra-organizational functions and the organization’s environment. Programs to reduce hospital transfers directly address the interaction between nursing staff and stakeholders functioning outside of a nursing home’s organizational boundary, such as medical providers, families, reimbursement systems, and regulatory agencies. We propose that nursing work exists within the boundary system of a nursing home—the theoretical space where organizational processes interact directly with the environmental demands of outside agents. Through qualitative interviews, the current study explored the nursing staff experience in negotiating the boundary between their nursing work, organizational goals to reduce hospitalizations, and external stakeholders (e.g., medical providers, families, wider health care system) during hospital transfer decisions.

Open systems theory (Katz & Kahn, 1978) posits that organizations are living adaptive systems, and as such must maintain boundaries that are fluid enough to allow survival despite environmental shifts, yet rigid enough to differentiate the organization from its external environment. Open systems theory has been applied to manufacturing and production-based entities; institutions where the subsystems addressing production are distinct from sub-systems managing the boundary work of institutional relations (Katz & Kahn, 1978; Lysonski & Johnson, 1983; Stamper & Johlke, 2003). However, nursing homes and other health service institutions function as open systems as well, reacting and responding to the environmental context created by external stakeholders. As noted by Lawton (1970), institutions for older adults represent a unique form of open systems where the production goal focuses not on the quantity or quality of a resultant product, but on the processes and outcomes of human caring, comfort, disease management, and assistance with functional activities.

Nursing staff sit at the boundary between the organizational goals of the nursing home and external stakeholder systems. The conceptual proposition that workers in the role of boundary-spanner are at increased risk of interpersonal conflict, role conflict, and role ambiguity has been demonstrated by studies in a variety of occupational fields (Bettencourt & Brown, 2003; Honig, 2006; Lysonski & Johnson, 1983). We found little research specifically examining the role of nursing staff as boundary-spanners. Nurse-oriented boundary studies have focused primarily on the interpersonal aspects of professional boundaries, such as maintaining personal boundaries with patients or task boundaries between health care professions, with little attention to the role of nurse as an organization/environment boundary-spanner (Allen, 2001; Apesoa-Varano, 2013; Smith, Taylor, Keys, & Gornto, 1997). We found no previous research that linked the role of nursing staff as boundary-spanners within the open organizational system of a nursing home to a specific policy or QI initiative, such as reducing avoidable hospitalizations.

Study Aims

This study uses open systems theory to explore the perceptions of nursing staff working within nursing homes that implemented QI projects to reduce avoidable hospitalizations. The following research questions were addressed:

  1. What are the experiences of licensed nursing staff when organizational efforts are made to reduce hospital transfers?

  2. How does the role of the nurse as boundary-spanner within an open organizational system influence the nursing staff experience?

Method

Study Design

Semi-structured qualitative interviews were conducted with nursing home staff as part of a comprehensive evaluation of Minnesota’s Performance Incentive Payment Program (PIPP). In 2007, the state of Minnesota implemented PIPP, a unique pay-for-performance model that funds QI projects developed by nursing homes to address an area of quality concern within their facility. (For additional details on PIPP see Arling et al., 2013; Cooke et al., 2009.) Nursing home providers, comprising 46 facilities and geographically dispersed across the state of Minnesota, developed and implemented QI projects funded by PIPP and aimed at the reduction of avoidable hospitalizations. Their projects used four primary intervention strategies: (a) implementation of documentation tools aimed at improving communication between nurses and physicians; (b) implementation of methods to improve communication between licensed nurses and unlicensed caregivers; (c) implementation of tools to better document resident care choices; and (d) nursing education programs aimed at increasing the clinical capacity of the nursing home to care for acutely ill residents (e.g., IV therapy, physical assessment skills). Many of the tools were patterned after those of the INTERACT program (Ouslander et al., 2011). Facilities implementing the projects varied in the details and logistics of the intervention strategies; forms, tools, training sessions, and managerial styles differed among nursing homes. A common thread among the 46 facilities was a concentrated administrative effort to reduce resident hospitalizations through interventions aimed at nurse training, nurse communication with internal and external stakeholders, and the daily processes of nursing work.

Respondents and Data Collection

As part of the PIPP evaluation, interview data were collected regarding the perspectives of nursing home employees from a wide variety of organizational roles. Because the current research questions focus on the perspectives of nursing staff, only interviews with licensed nurse respondents (RNs and licensed practical nurses [LPNs]) were selected for this analysis. In-depth, semi-structured interviews were conducted with 76 RNs and LPNs within 38 of the 46 nursing homes participating in a QI effort to reduce avoidable hospitalizations. Two thirds (n = 47) of the interviews were obtained during day-long facility site visits to 11 of the 46 participating facilities. Facilities were selected for site visit by the research team with the intent of representing organizations that varied in terms of size, location, and QI experience. Because of practical resource limitations, the remaining (n = 29) interviews were conducted by telephone. Thus, although 38 nursing homes are represented, the facilities selected for site visit are overrepresented in the findings. As is common in nursing homes, interviewed nurses may also have had administrative duties (e.g., charge nurse, director of nursing, quality coordinator), depending on their job designation within their facility. Nurses were selected for interviews with the assistance of the nursing home project coordinator based on their experience with and knowledge of the hospitalization reduction efforts. Therefore, findings may be influenced by the high level of involvement of the sample with the hospitalization reduction projects.

The interview guide was semi-structured with open-ended responses to probes. Interview questions focused on the experiences and processes of implementing a QI initiative and addressed issues such as the respondent’s role in developing and performing the nursing home’s hospitalization reduction efforts, challenges and successes faced through implementing the effort to reduce avoidable hospitalizations, changes to daily work processes, and overall project impact on their nursing work. Average interview length was 30 minutes; all interviews were recorded and transcribed. Institutional review board approval was obtained prior to the initiation of data collection. Respondent and institutional identifying information were removed from transcripts prior to data analysis.

Analysis

Data were analyzed using a thematic analysis and inductive category development approach. Categories or themes were derived empirically from the data during analysis. Analysts cognitively and emotionally engaged with the data until themes emerged. Initially, three analysts (two coinvestigators [K.A., C.M.] and a doctoral student [H.D.]) simultaneously examined a portion of the interview data to create preliminary coding categories. Text was coded at the micro-level, allowing for codes to emerge from short statements or phrases when they comprised a complete unit of thought. Lists of emergent codes were then compared among researchers and discussed to reduce discrepancies within the coding scheme. Each investigator then re-coded a portion of the data based on the agreed-upon coding categories and discussed the findings to maximize inter-coder reliability. Investigators independently coded a selected sample of interview text data, and coding categories were further discussed and refined. Once a consensus of coding taxonomy was established, investigators coded the text independently with the understanding that codes may require additional discussion and amendment based on interviewee responses. All respondent text was allowed to be coded and entered into the analysis. Individual text fragments were coded into multiple categories when the interviewee response indicated multiple emergent themes. Identified themes were organized using open systems theory as a conceptual guide. This theoretical perspective posits that interaction between an organization and its environment is fluid and managed by multiple interrelated organizational sub-systems, with nurses at the boundary between the internal and external stakeholders.

Results

Five broad themes emerged from the data: (a) negotiating the hospitalization decision, (b) increased nurse confidence, (c) working inside the boundary, (d) doing more with the same resources, and (e) working within a system. Findings are presented as emergent themes with supporting sub-themes and evidence for each theme.

Negotiating the Hospitalization Decision

Nurses perceived that their experience with intentional efforts to reduce hospitalizations had resulted in improved openness and communication between themselves, physicians, residents, and families. Nursing staff relayed multiple narratives describing their role as the negotiator between the needs of the resident, the wants of the family, and the clinical decisions of the physician. The role of negotiator became more complex in situations where outside parties lacked confidence in the ability of the nursing home to provide the necessary care. On-call physicians and family members emerged as those having that concern, as nurses attempted to persuade stakeholders to continue care in the nursing home setting. As one respondent noted, “I think the difficulty is families who insist [on hospitalization] and an on-call physician who doesn’t really know the resident.”

On-Call Physicians. A particular challenge emerged when the decision to hospitalize was being made by an on-call physician, or one who was less familiar with the resident or nursing home. Nurses voiced that these unfamiliar physicians were more likely to underestimate the clinical abilities of the nursing home nurses and, as a result, they often hospitalized the resident:

  • Dr. S. took over…. You know she’s not familiar with the staff here…. It seemed like every visit she was sending someone to the hospital.
  • You know, sometimes the on-calls never even step foot in a nursing home so they don’t even understand what the place is.

Nurses reported they provided on-call physicians with information supporting the clinical capacity of the nursing home, thus at times preventing hospitalization. One director of nursing reported:

  • It amazes me how well nurses have communicated with the on-call [physicians]…. You know, like “the resident is leaning that they would like to go to the ER, but let me tell you what we can do here first…let me tell you what we can do.”

Family Members. Nurses described family members as key stakeholders in a hospitalization decision. Respondents shared situations where family members advocated for hospitalization because they believed the resident’s condition warranted care beyond the nursing home’s capabilities. Nurses were in the position to develop trust through explaining the capacity of the nursing home to provide care and avoid a hospital admission:

  • I had a family member who really, really felt that their family member would probably be better off in the hospital and was pushing for that, and we worked hard to let them know that we can treat that condition here, and we did and she did just fine. You know, I think that family then got a little more trust in what our capabilities are here.
  • The biggest challenge I would say is family…. Working with families and trying to get families to have a trust level that we can take care of their family member in-house rather than sending them in [to the hospital].
  • The family was really resistant for a long time, but once she had us to help her voice to them “I don’t want to go to the hospital again,”...it helped her make her family let her do what she wanted to do…and that was really nice.

Increased Nurse Confidence

Confidence in Clinical Skills. Nurses expressed increased confidence in their ability to manage clinical conditions that previously would have resulted in hospitalization within their nursing homes. They attributed that confidence to the training received as part of their projects to reduce hospitalization rates:

  • That was a huge pendulum sway, [we] thought, “We can’t manage them here….” That is not necessarily true.
  • It’s like everybody seemed to think that they are less important than a nurse that works in a hospital because of the fact they do IVs and IV meds and stuff. And I think that’s what they’ve been so excited about when we did the training and all that. Everybody was really excited about being able to learn a new skill.
  • The IV class…it was really exciting.
  • I think it makes us better. I think we’re keeping on top of our game.
  • It is helping…the nurses to be more aware, more use your skills, more like “You have these skills, now use them. You don’t just pass pills. You need to do the critical thinking from step one.”

Confidence to be Assertive. Participating in the effort to reduce hospitalizations required nurses to assert their skills, advocate for the resident, and be confident in their communication with physicians. This represented a change in the traditional relationship between physicians and nurses, and was a challenge for some nurses:

  • There is still the hierarchy that you don’t tell the doctor what to do, and we have nurses very afraid of that.
  • Nurses do not feel comfortable in leading the conversation…. I think it’s just being caught up in the same old way we do things…. The doctor…is always right. It’s hard for [nurses] to take the bull by the horns so to speak, and they don’t want to get yelled at, don’t want to get in trouble. If the doctor says send them to the hospital, then that’s what they do.
  • How do we get [nurses] to become more assertive because they need to be, but at the same time they have been slapped before for doing that and it’s pretty much a scary thing, you know?

Nurses noted that situations where they needed to be assertive were often associated with the need to advocate for a resident’s wishes, consistent with the finding that nurses negotiate the boundary between the resident and physician:

  • So when a physician says, “You need to send them to the hospital,” nurses have said “that is not consistent with what the resident wants. They really want to be cared for here. Is there anything that we can do to care for them internally?”
  • I think the biggest challenge right now is educating those health partners that we have…physicians…and understanding how much we really can do. There hasn’t been push back…. It’s been more along the lines of “Oh, we didn’t know you could do that.”
  • I had a situation where I had to call the on-call physician…. She was insistent that I send the resident to the hospital. I said, “Well, that is not consistent with their [end-of-life] plan.” She kept pushing me and I kept pushing back, advocating for the resident. “We can do a chest X-ray here. We can do lab work here.” She finally gave in…. Well, the resident stayed here…and is still here today, doing just fine.

Nurses expressed concern over situations where they attempted to assert the capacity of their nursing home and believed they were not listened to:

  • We still get the physician on the phone that when we are saying what is going on they say, “Well, send them to the ER,” and we say, “Well, we could do an IV here.” We can do all that and they still say no and want them sent out [to the hospital]. That’s a hard situation.
  • Challenges still remain around communication with the physicians and getting them to hear what the nurses are saying or what we can do. I think making sure they understand the abilities of us as a skilled nursing facility and trust in that.

Respondents noted the positive feelings that emerged from asserting their abilities to avoid unnecessary hospitalizations. Assuring that physicians “trust in the nurses” emerged as a key to successfully advocating for resident wishes:

  • As long as we are up front with them, are educated in our assessments, and they feel comfortable with us, they have no problem treating them here.
  • I think it’s empowering the nurses that we are able to do this. You are able to go and request some of these things.
  • I think some of it was just empowering the staff. I was in the role of the nightshift where it was like, you know, “You do have the right to ask other questions or to utilize some of these other resources”.... It was huge.

Working Inside the Boundary

In addition to communication with stakeholders outside of the nursing home boundary, efforts to reduce avoidable hospitalizations required nurses to change communication patterns with fellow nursing home employees. Two subthemes emerged: communication with unlicensed caregivers and the importance of involving departments other than nursing in the effort.

“It is Not Just About Nursing”: An Interdisciplinary Effort. When asked about factors that were necessary for hospitalization reduction efforts to succeed, nurses described the importance of involving the entire facility and emphasizing to other departments that efforts to reduce hospitalization are everyone’s responsibility. Respondents noted that other disciplines brought to them “a different set of eyes” and that staff members such as housekeepers “see residents in a way I’m never going to see them.” As one nurse noted, encouraging interdisciplinary input was at times challenging:

  • They are used to just being on the sidelines and not interacting with the residents.

Communication With Unlicensed Caregivers. A component of efforts aimed at reducing avoidable hospitalizations was to encourage nurses to communicate with unlicensed caregivers and respond when they noticed and reported subtle changes in resident condition. Nurses noted positive changes in communication between themselves and unlicensed caregivers, and perceived that unlicensed caregivers were having a larger voice in resident care than prior to efforts to reduce hospitalizations.

  • If a resident’s condition changes, the nursing assistant will probably notice first, and they’ll come and tell us.
  • We always tell them that they are the eyes and the ears and the nose of a nurse. They are the first who know things usually, and it’s nice to validate what they do.
  • I can tell hugely that it has empowered the nursing assistants. Because the biggest thing is “No one ever listens to me.” I think it’s a huge empowerment for them, because they are like “They are listening to us.”
  • Our nurse aides love it because their voices are being heard. They have ideas.
  • I feel that nursing assistants think that they have a voice and that they’re heard.
  • I think that the nursing assistants are much more aware of how much care they are providing. I think they are more aware of how they play such a huge role in the care of the residents. I’m hoping that they have a better understanding of the value of that. It’s a hard job. A very hard job.

Doing More With the Same Resources

Workload. Although nurses expressed that efforts to reduce avoidable hospitalizations resulted in improved clinical confidence and communication, a fourth key theme was the perception that they were being asked to do more care without additional resources, such as time or staff. Some nurses described the increased clinical responsibilities as “overwhelming” and “difficult” and “a lot more to do.” A few examples of respondent concerns include:

  • Besides everything else I have to do, it’s extra work.
  • It’s pretty hard to be effective if you are adding more work on.
  • The supervisor’s response is, you just have to do it. You have to do it. And that is pretty much what they’ve told us, you have to do it, and…we just can’t, we don’t have the time. It’s really hard for us now.
  • Floor nurses were very stressed in the beginning when this was all new and added responsibility to them.
  • The hardest part of all, is that we as organizations see we are not getting salary increases, we see that we are not getting more resources.

Staffing Challenges. In particular, nurses described situations where they were understaffed or did not have access to staff members who were trained in the clinical skills that were needed to avoid hospitalization:

  • I don’t have RNs in my building. I have some, but the people providing care in my facility are LPNs, so the challenge has been re-educating people.
  • We don’t have anybody that starts IVs in our facility.
  • Just inexperienced nurses…
  • A barrier to recommending things [in the nursing home] is if you are just not familiar, really, with what the lab is telling you.

Time. Time was another challenge that was expressed. Nurses described feeling a time burden, and the efforts to reducing avoidable hospitalization added to this burden.

  • Nurses sometimes at the end of the day, they just forget to do an extra note. Sometimes it is not intentional. It’s just exhaustion. They are tired.
  • Nurses get busy, the day just falls apart.

Working Within a System

Efforts to reduce unnecessary hospitalizations are partially driven by financial incentives to care for residents within the less expensive nursing home setting. Multiple nurses expressed that the emphasis on avoidable hospitalizations was driven by corporate or financial interests and to maintain positive relationships with hospitals that would be financially penalized if a resident returned after discharge:

  • When they first brought it forward, the nurses believed it was all about the money.
  • It’s being discussed with all of our [hospital] referral sources because they want to know what you are doing…. because it is going to affect their bottom lines.
  • They are getting pressure from their systems to keep them stable here to prevent them from going back to the hospital because the hospital is already penalized if they bounce back too quickly.

Benefiting the Larger Health Care System. Respondents saw themselves as working within the larger health care system and had positive comments regarding the effect their efforts to reduce hospitalization rates were having on the care delivery system as a whole. Nurses discussed issues such as efficiency, patient choice, and thinking more deeply about transitions within the health care system:

  • Typically, we send somebody in, and they come back with something worse than we sent them in with. And it is like this, a simple thing such as an IV, a couple of IV bags [in the nursing home] could have prevented that from happening.
  • I can get labs faster, is what I was told, if I send them to the ER, but they forget they have to sit in the ER for 4 hours, you know?
  • It has made life easier for me in regards to, let’s say if somebody goes to the hospital and comes back…that will create more admission paperwork, more time on something that would be prevented now if it could have been. So, I see, in the long run, a lot of time saved.

Identified themes and sub-themes are presented in the Table.

Emergent Themes and Sub-Themes

Table:

Emergent Themes and Sub-Themes

Discussion

This study examined the work environment of nursing home nursing staff from their own perspective; a perspective that provides insight into addressing the role expectations of residents, family members, and physicians while meeting the changing expectations of nursing home work. We proposed that licensed nursing staff (RNs and LPNs) act as boundary-spanners for the nursing home, working within the theoretical space between the nursing home organization, resident wishes, and external stakeholders. Nursing homes are under growing pressure from hospitals and reimbursing agencies to provide increasingly complex care within their institutions. At the same time, they also must prioritize the expectations and concerns of nursing home residents and family members. Our findings are consistent with the proposition that licensed nursing staff are in an organizational role that requires them to negotiate the boundary between multiple internal and external stakeholders to influence the hospitalization decision, and that role overload and strain are a lingering possibility when residing in a boundary position.

Efforts to reduce avoidable hospitalizations provide a unique opportunity to illuminate the role of nurse as boundary-spanner. Unlike other QI domains—such as falls or pressure ulcer reduction, where the interests of residents are clearer and external stakeholders are less directly involved—efforts to reduce hospitalization are more complex and often involve negotiating the interests of multiple internal and external stakeholders. In addition to demands of external medical providers and family members, nursing staff must negotiate the requests of residents whose desires to be transferred to a hospital or continue to receive care within the nursing home may differ from the opinions and desires of other stakeholders, including nursing home staff. Boundaries between the level of care provided in the hospital and the care provided in nursing homes are evolving, and licensed nurses reflected that their primary role in hospitalization efforts was to communicate the expanding limits of that boundary to residents, families, and physicians. Emergent from that role were the challenges faced when others failed to trust in the capacity of the nursing home staff. The efforts undertaken by these nursing homes were aimed primarily at improving nurse communication surrounding resident condition and expanding the nurse skill-set, with little education effort aimed at what the nurses in the study have identified as a primary barrier—the confidence of family and physicians. Lack of trust in the capacity of the nursing home appeared to have been exacerbated by structural factors outside of the control of nursing staff, such as an organization’s staffing with a low proportion of RNs and nursing staff who lacked the training and equipment to meet expectations at times. Future efforts to reduce avoidable hospitalizations may benefit by assuring that needed resources are in place to provide clinically complex care. In addition, expanding education efforts beyond the boundary of the nursing home can improve communication aimed at changing the perceptions of external stakeholders.

Many of the frustrations voiced by the respondents reflect the common challenges of nursing work: lack of time, lack of resources, a power differential between themselves and physicians, and the difficulties of assisting families during times of crisis. What is unique about the insights of our respondents is the policy context within which these challenges are emerging. Prerequisite to nurses negotiating in favor of providing care within the nursing home is development of a belief that their role as a nursing home nurse is to provide more clinically complex care. This is seen in the respondents’ discussions of their increased confidence in themselves to provide additional nursing services and to move beyond the historical power structure to assert their abilities to physicians. Efforts to reduce unnecessary hospitalizations appear to have had a spill-over effect of empowering nursing staff to take on new clinical responsibilities and assert their ability to do so. The nursing staff perception that unlicensed caregivers were also becoming increasingly empowered by these efforts is interesting and would benefit from further exploration.

Nursing home work is unique from nursing work in hospital settings: close relationships are often built over time with residents and families, and care goals expand beyond medical treatment to address long-range quality of life issues. Although not directly discussed by our respondents, there is potential for role conflict, as nursing staff are required to provide for complex medical needs within facilities designed to encourage relationship-driven, home-like care. This emerges subtly in our respondents’ reflections that they are being asked to address increasingly intense documentation and care requirements without a significant change in the organizational structure or resources of the nursing home. A limitation of our findings is that although we are able to address nurse perceptions of resources, measures of resources or resident outcomes were not integrated into our findings. An additional limitation is variation between facilities in their approaches to reducing hospitalizations. These interventions were occurring independent of the study and were not controlled by the research team. Each facility individualized its approach to meet local needs. Further, our sample is geographically limited to a single state, and resources or support for QI efforts may not be representative of all nursing homes.

Conclusion

Despite limitations, the current study’s findings contribute important insight into the experience of licensed nursing staff when nursing homes implement efforts to reduce avoidable hospitalizations. The study addresses a topic that is timely given the current policy climate surrounding reducing hospital transfers among nursing home residents. Licensed nurses described multiple scenarios where they had acted to negotiate the hospitalization decision. They described themselves as working both within the nursing home boundary and within the larger system of external stakeholders to avoid a hospital transfer. Lack of resources and the trust of those unfamiliar with their capabilities emerged as challenges, yet increased confidence to provide care and assert oneself mitigated some of these effects. Further hospitalization reduction efforts would benefit from interventions that seek to reduce the barriers that emerge when nurses are in the position to span the boundary between the nursing home and outside stakeholders.

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Emergent Themes and Sub-Themes

ThemeSub-Theme
Negotiating the hospitalization decision

On-call physicians

Family members

Increased nurse confidence

Confidence in clinical skills

Confidence to be assertive

Working inside the boundary

Interdisciplinary effort

Communication with unlicensed caregivers

Doing more with the same resources

Workload

Staffing challenges

Time

Working within a system

Benefitting the larger health care system

10.3928/19404921-20140519-01

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