Background Nurses in skilled nursing facilities (SNFs) play a key role in initiating/transitioning care for the >5 million patients who transition from hospitals-to-SNFs annually. Although hospital discharge processes are well studied, little is known about the SNF nursing processes or the SNF-based consequences of variation in transitional care quality. Objective To examine how SNF nurses transition the care of patients admitted from hospitals, the barriers they experience, and the outcomes associated with variation in the quality of transitions. Design Qualitative study using grounded dimensional analysis, focus groups and in-depth interviews. Setting 5 Wisconsin SNFs. Participants 27 registered nurses. Results SNF nurses rely heavily on written hospital discharge communication to effectively transition patients into the SNF. Nurses cited multiple inadequacies of hospital discharge information, including regular problems with medication orders (including the lack of opioid prescriptions for pain), little patient psychosocial/functional history, and inaccurate information regarding current health status. These communication inadequacies necessitated repeated phone clarifications, created care delays (including delays in pain control), increased SNF staff stress, frustrated patients/family members, directly contributed to negative SNF facility image, and increased a patient's rehospitalization risk. SNF nurses identified a specific list of information/components that they need to facilitate a safe, high-quality transition. Conclusion Nurses note multiple deficiencies in hospital-to-SNF transitions, with poor quality discharge communication being identified as the major barrier to safe and effective transitions. This information should be used to refine and support the dissemination of evidence-based interventions which support transitions of care, including the Interventions to Reduce Acute Care Transfers II (INTERACT) program.

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Background Functional decline has been identified as a leading negative outcome of hospitalization for older person. Functional decline is defined as a loss in ability to perform activities of daily living including a loss of independent ambulation. In the hospital literature, a patient’s loss in ability to independently ambulate during the hospital stay varies between 15 and 59%. Lack of ambulation and deconditioning effects of bed rest are one of the most predictable causes of loss of independent ambulation in hospitalized older persons. Nurses have been identified as the professional most capable of promoting walking independence in the hospital setting. However, nurses do not routinely walk patients. Objective The purpose of this study was to explore the relationship between nurses’ attributions of responsibility for ambulating hospitalized patients and their decisions about whether to ambulate. Methods A descriptive, secondary analysis of data gathered for a parent study was conducted. Grounded dimensional analysis was used to analyze the data. Participants consisted of 25 registered nurses employed on medical or surgical units from two urban hospitals in the United States. Results Nurses fell into two groups: those who claimed ambulation of patients within their responsibility of practice and those who attributed the responsibility to another discipline. Nurses who claimed responsibility for ambulation focused on patient independence and psychosocial well-being. This resulted in actions related to collaborating with physical therapy, determining the appropriateness of activity orders, diminishing the risk and adjusting to resource availability. Nurses who attributed the responsibility deferred decisions about initiating ambulation to either physical therapy or medicine. This resulted in actions related to waiting, which involved, waiting for physical therapy clearance, physician orders, risks to decrease, and resources to improve before ambulating. Conclusions Nurses who claimed responsibility for ambulating patients within their domain of practice described actions that promoted patient independent function and were more likely to get patient s up to ambulate.

Adults over the age of 65 years account for 60% of all hospital admissions and experience consequential negative outcomes directly related to hospitalization. Negative outcomes include falls, delirium, loss in ability to perform basic activities of daily living, and new walking dependence. New walking dependence, defined as the loss in ability to walk independently, occurs in 16%--59% of hospitalized older patients. Nurses are pivotal in promoting functional walking independence in hospitalized patients. However, little is known about how nurses make decisions about whether, when, and how to ambulate older patients. A qualitative study using grounded dimensional analysis was conducted to further explore how nurses make decisions about ambulating hospitalized older adults. Twenty-five registered nurses participated in in-depth interviews lasting 30--60 min. Open, axial, and selective coding was used during the analysis. A conceptual model, which is grounded in how nurses experience ambulating patients, was developed. Multiple categories and dimensions interact and produce an action by the nurse to either restrict mobilization to the level of the bed or progress the patient to ambulation in the hallway. Factors that seemed to have a greater impact on nurses' decisions on whether, when, and how to ambulate were the risk/opportunity assessment, preventing complications, and the presence of a unit expectation to ambulate patients.