Why reducing avoidable hospital readmissions is a ‘wicked’ problem for leaders: A qualitative exploration of nursing and allied health perceptions

Abstract

Aims:To investigate nursing and allied health professional perceptions of the interrelationship between avoidable hospital readmissions and fundamental care delivery. Design:A qualitative, exploratory study using a critical realist approach.Method: One-to-one semi-structured interviews with 14 nursing and allied health professionals conducted between May and September 2019.Results: Several tensions and contradictions were identified in the data, which demonstrated clinicians' perceptions about the priority of both fundamental care and two avoidable readmission conditions (aspiration pneumonia and constipation). These tensions are illustrated in two major themes: Avoidable versus inevitable; and everyone versus no one. The first theme demonstrates clinicians' perceptions that readmissions for aspiration pneumonia and constipation are not common, despite acknowledging that they generally lacked knowledge on readmission rates; and that these conditions may not be preventable in acute settings. The second theme demonstrates clinicians' perception that preventing readmissions is everyone's responsibility, however, this was coupled with a lack of articulation around how this multidisciplinary approach could be achieved, leading to a distinct lack of agency for care delivery.

The Relationship between Nursing Leadership and Patient Readmission Rate: A Systematic Review

“…All of the 5 studies were published between 2015 and 2022. The studies were conducted in different countries including Norwegian (Glette et al, 2018), Dublin (Coyne et al, 2016), Canada (Okoniewska et al, 2015; Udod et al, 2022), and Australia (Feo et al, 2022). The total sample in the included studies was 221 participants including nurse leaders, staff nurses, midwives, physicians, and allied health providers.…”

“…Of these studies, detailed assessments resulted in the review of 15 studies meeting all inclusion criteria. Out of the 15 studies, 10 studies utilized quantitative design (Carthon et al, 2015;Gilbert et al, 2021;Hoyer et al, 2018;Kara et al, 2015a;Lasater & Mchugh, 2016;Ma et al, 2015;Mathews et al, 2014;McHugh & Ma, 2013;Oliver et al, 2022;Shirey et al, 2019), and five utilized a qualitative approach (Coyne et al, 2016;Feo et al, 2022;Glette et al, 2018;Okoniewska et al, 2015;Udod et al, 2022). For search strategy, see Figure 1.…”

“…The most common weakness was the lack of using a theoretical framework in majority of the studies (3 out of 5). One study utilized Donabedian's framework to highlight the role of nursing leadership in transition of care to reduce readmission rate (Udod et al, 2022) and the other study utilized the Critical Realist framework (Feo et al, 2022).…”

“…Leadership indirectly influences patients' readmission rate through various processes, including developing effective care plans (Carthon et al, 2015), participating in interdisciplinary rounds that set clear patient discharge goals (Kara et al, 2015b), improving the documentation process (Glette et al, 2018), involving effective interprofessional collaboration and teamwork in which nurses have autonomy to make decisions regarding patients' readiness for discharge (Mathews et al, 2014;McHugh & Ma, 2013;Shirey et al, 2019), and establishing coordination between various health services (Glette et al, 2018). In addition, researchers (Feo et al, 2022;Hoyer et al, 2018;Gilbert et al, 2021) found that nursing leadership can reduce the patient readmission rate by designing a transition programs to ensure appropriate follow up after discharge. Udod et al (2022) conducted focus group interviews with 16 nurse leaders in acute and post-acute care facilities in order to identify the role nursing leadership plays in transitional care for cardiac patients.…”

Leadership for fundamental care: The whole is greater than the sum of the parts

“…Moreover, these realities are compounded by observations that registered nurses are not confident in what they can delegate to assistants in nursing (Crevancore et al, 2022), nor do they demonstrate an understanding of who is responsible for preventing avoidable rehospitalization of patients for constipation or hospital-acquired pneumonia (Feo et al, 2022). This brings to light the important leadership role of the nurse to explicate what nursing's contribution to the team is and how to role model this behaviour to nursing and other healthcare colleagues (Mudd et al, 2022).…”