Referrals to Emergency Departments— The Processes and Factors That Influence Decision-Making among Community Nurses

Abstract

The aim of the study was to describe the basis on which municipal care registered nurses (RN) make decisions and their experiences when referring older persons from nursing homes to emergency departments (EDs). RNs in the community are to ensure that older adults receive good care quality in nursing home. This study used a descriptive design with a qualitative content analysis. The analysis of the data from the 13 interviews revealed one theme "Shared responsibilities in the best interests of the older person reduce feelings of insufficiency". The content was formulated, which revealed the RNs' feelings, reasoning and factors influencing them and their actions in the decision-making situation, before the patients were referred to an emergency department. Complex illnesses, non-adapted organizations, considerations about what was good and right in order to meet the older person's needs, taking account of her/his life-world, health, well-being and best interests were reported. Co-worker competencies and open dialogues in the "inner circle" were crucial for the nurses' confidence in the decision. Hesitation to refer was associated with previous negative reactions from ED professionals. The RN sometimes express that they lacked medical knowledge and were uncertain how to judge the acute illness or changes. Access to the "outer circle", i.e. physicians and hospital colleagues, was necessary to counteract feelings of insecurity about referrals. When difficult decisions have to be made, not only medical facts but also relationships are of importance. To strengthen the RNs' and staff members' competence by means of education seems to be important for avoiding unnecessary referrals. Guidelines and work routine need to be more transparent and referrals due to the lack of resources are not only wasteful but can worsen the older persons' health.

Pathways for older patients in acute situations and involved actors' experiences of decision-making in ambulatory care

“…Healthcare professionals felt that decision-making in acute situations involving older patients was uncertain and demanding (22,47,(158)(159)(160). Age-related physiological changes, comorbidity, and polypharmacy meant it was important to grasp the whole picture of an older patient's health status (47).…”

“…This knowledge is important in acute situations where several healthcare professionals have no relational continuity with an older patient. However, CHNs have been described as having insufficient knowledge during acute situations (160), and that additional education improves their knowledge of, for example, performing systematic assessments (124). During assessments, GP specialists' are described as achieving a comprehensive view and aiming on treating all of the symptoms an older patient has (250) and concentrating on the most common diagnosis (172).…”

“…The results show that individual dialogue possibly supports decisions of care adapted to unique older patients; that is the goal of decision-making (V). Previous research states that healthcare professionals strive to decide upon a level-of-care that is adapted to unique older patients (160,166). The goal of decisions is generally described as achieving the best outcome, and when more factors are involved, the difficulty of making an optimal decision increases (183).…”

“…Beslutsprocessen om var äldre patienter som drabbas av akutsjukdom eller skada ska vårdas beskrivs i vissa situationer som osäker och krävande för vårdpersonal inom den ambulerande vården (22,47,(158)(159)(160). Vårdpersonal upplever osäkerhet om vilken vårdnivå som patienten bör vårdas på (21)(22)(23).…”