Predictably unpredictable: The effect of acute admissions on perceived nursing workload

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Predictably unpredictable: The effect of

acute admissions on perceived nursing

workload

A case study at a Dutch non-academic hospital

Master thesis

27 October 2020

Daniël Voortman (s3652181) MSc Business Administration Health

Faculty of Economics and Business University of Groningen

Supervisor: Prof. dr. J.T. van der Vaart Co-assessor: Dr. M.A.G. van Offenbeek

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Abstract

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1. Introduction

The utilization of emergency services is increasing (George, Jell, & Todd, 2006), leading to emergency department (ED) crowding (Di Somma, et al., 2015). This crowding places pressure on health systems and decreases the quality of care (Bernstein, et al., 2009). Traditionally, hospitals responded by providing additional resources, such as beds or staff. Today, however, many hospitals can no longer afford such a solution. Moreover, according to Haraden and Resar (2004), the answer to the problem lies not in providing additional resources but in redesigning the process. Factors related to the outflow of patients are acknowledged to be the main cause of ED crowding (Boyle, Beniuk, Higginson, & Atkinson, 2012).

To address these outflow problems, Dutch hospitals are increasingly implementing acute medical units (AMUs). In 2010, six AMUs were implemented in the Netherlands (Bokhorst & Van der Vaart, 2018). Since then, there has been a steady growth in the number of hospitals implementing AMUs. By 2017, 33 out of 93 Dutch hospitals had implemented an AMU or similar ward, and many Dutch hospitals have plans to start one (Van Galen, et al., 2017). What makes implementing an AMU so popular? According to review studies, AMUs are associated with reduced in-hospital length of stay (LoS) and, as a result, fewer bed-days (Reid, et al., 2016; Van Galen, et al., 2017), as many patients from the AMU will not be further admitted to a ward. A recent implementation of an AMU in a Dutch academic hospital shows both improved patient and employee satisfaction (Hermans & Van Liebergen, 2019). For the patients in a medical ward, there are fewer disturbances in the evening and night due to branching off the admissions to the AMU (Schipper, 2017). Employee satisfaction increases because nurses in the other departments are less interrupted during the treatment of patients (Rubio, 2019). However, a systematic review of Reid et al. (2016) shows that findings relating to staff satisfaction are inconclusive as there are both positive and negative effects. Based on the patients admitted to an AMU, it could be estimated which patients need to be further admitted to a ward. Acute patients can then be scheduled in advance, alike elective patients. When a hospital has implemented an AMU, the moment acute patients arrive at the ward may become more predictable.

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To answer this research question, a single-case study was conducted at a large non-academic hospital in the Netherlands. This study primarily focused on soft performance indicators of perceived workload associated with acute admissions and staff perceptions concerning implementing an AMU. The answer to this research question expands the knowledge base regarding the soft effects of acute admissions the factors influencing nursing workload. The practical implication is that the findings presented in this study may support managers’ decision-making whether or not to implement an AMU or, in general, to improve acute admission processes or managing nursing workload.

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2. Theoretical background

This theoretical background presents relevant literature concerning the main concepts addressed in the research question to provide a clear understanding of these concepts and to thus assist the reader to follow the remainder of this thesis. Firstly, the concept of an AMU is defined as this is the central focus of this study. Secondly, acute admissions are described from the perspective of both an ED and receiving wards. Thirdly, insights from both perspectives are linked to nursing workload. Finally, at the end of this chapter, the various aspects of the research question are illustrated in a conceptual framework.

2.1 Acute medical unit

From the introduction, it became clear that Dutch hospitals are increasingly implementing AMUs to address ED outflow problems. The configuration of AMUs can differ significantly among hospitals in terms of both the organization of the unit and the number of beds. Most AMUs were placed near the ED and diagnostic facilities. The number of beds can differ from 5 to 54. Where some AMUs only admit internal medicine patients, other AMUs admit all medical and surgical specialties. Additionally, the schedules differ from only one doctor being available to intensive supervision (Van Galen, et al., 2017). Beyond the differences in terms of configuration, many hospitals have implemented wards with synonymous names, like acute medical admission unit, acute medical ward or medical assessment unit. In this study, the term AMU is used, as it is most frequently used in literature. An AMU is defined as a hospital ward ‘specifically staffed and equipped to receive medical inpatients presenting with acute medical illness from the ED, outpatient clinics and/or the community for expedited multidisciplinary and medical specialist assessment, care and treatment for up to a designated period (typically between 24 and 72 h) prior to discharge or transfer to other wards’ (Scott, Vaughan, & Bell, 2009, p. 398; Van Galen, et al., 2017).

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beds is decreased (Moloney, Smith, Bennett, O'riordan, & Silke, 2005; Scott, Vaughan, & Bell, 2009), while neither the quality of treatment nor patient safety is compromised (Vork, et al., 2011). In addition, the dynamics between multidisciplinary physicians and nurses seem to improve as a result of the implementation of an AMU (Van Galen, et al., 2017; Vork, et al., 2011).

The Medical Centre Haaglanden, The Hague, the Netherlands, has opened a flexible acute admission unit. This unit consists of 15 inpatient beds located in different wards. These beds are set aside exclusively for ED patients. A qualitative evaluation has revealed that the implementation of this unit reduced emergency nurses’ workload and allows more time for seeing and treating patients (Van der Linden, Van der Linden, & Lindeboom, 2011). It is, however, unknown how it affects the receiving wards. In general, limited attention has been devoted to the hospital-wide effects of implementing AMUs. Hospitals frequently transfer resources from existing wards to new AMUs since the former receive fewer admissions. However, this leads to lower economies of scale and higher variability in elective care, which may harm the flow performance of elective patients (Bokhorst & Van der Vaart, 2018).

2.2 Acute admissions

The implementation of AMUs inherently has implications for the process of acute admissions, as acute admissions would not take place between the ED and medical ward anymore. Patients frequently go to EDs when acute care is required. According to Higginson, Whyatt and Silvester (2011), it is difficult to determine what resources are required for acute care, as it is unplanned and unpredictable but usually less variable than elective care. Acute admissions are patients who need to be admitted to a ward after visiting an ED. Whereas acute patients require rapid admission, diagnoses and treatment in a safe environment, elective patients (those who are scheduled in advance) require reliable care without excessive disturbances. Acute admissions are often considered disruptive to the flow of elective patients (Bokhorst & Van der Vaart, 2018). A hospital may thus implement an AMU to improve patient flow, which is the ability to efficiently move patients through stages of care (Ezzat, Hamoud, & Fadlallah, 2014). Patient flow can be influenced by both intrinsic factors, such as departmental layout and staffing levels and extrinsic factors, such as the lack of inpatient bed availability and fluctuating demand (Jarvis, 2016). Hindered flow can result in boarders, which are admitted patients who occupy an ED bed while waiting for an inpatient bed (Mustafa, et al., 2016). Boarding is considered to be a key contributor to outflow problems at EDs (Boyle, Beniuk, Higginson, & Atkinson, 2012).

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aspect is not included in the figure. As this figure shows, there is an additional decision point at an AMU where staff assess whether patients are ready for discharge or need to be further admitted to a medical ward.

Figure 1: Traditional acute admission process including an AMU, adjusted from Van Galen et al. (2017)

Patient turnover (the inverse of LoS) is considered an important factor affecting nursing care intensity, as an increase in patient turnover implies that nursing care must be delivered in a shorter window of time during each patient stay. As a result, admission, transfer, and discharge procedures, as illustrated in Figure 1, account for an increasing proportion of a patient’s stay. In general, this reduced LoS still includes high resource use days, ultimately leading to increased nursing intensity. Despite this increased intensity, nurse staffing, in general, does not often seem to be adjusted in response to increased patient turnover (Unruh & Fottler, 2006). The failure to adjust staffing to address increased patient turnover contributes to an unstable work environment, which potentially leads to negative patient outcomes (Duffield, et al., 2011).

2.3 Nursing workload

Given the potential adverse effects discussed above, nursing workload is important to consider. The process of acute admissions can be disturbing for both the ED and the receiving wards. EDs can experience outflows problem in terms of boarding patients, whereas the elective care process of medical wards can be disrupted. A study conducted by Jennings, Sandelowski and Higging (2013) found that nurses know that acute admissions will occur but not when. The authors use the term predictably unpredictable to refer to this uncertainty. Unlike discharges and elective admissions, for which nurses can proactively plan, nurses cannot anticipate acute admissions. Therefore, acute admissions are considered to cause more interruption to nurse workflows than discharges and elective admissions. In addition, clustered admissions have been found to be more disruptive than staggered admissions. The workload is perceived to be less manageable when events occur in close succession or simultaneously (Jennings, Sandelowski, & Higging, 2013).

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nursing workload to be a function of not only patient characteristics but also organizational and environmental factors (Myny, et al., 2011). Morris et al. (2007) developed a model intended to clarify the relationships among nursing workload concepts. The model is presented in Figure 2 below. Nursing workload comprises direct, indirect and non-patient care-related nursing activities, following the definition of Myny et al. (2011). An example of a direct care-related nursing activity would be assessing a patient’s blood pressure, whereas indirect care-related nursing activities may include organizing a referral. Finally, non-patient care-related nursing activities can include, for example, attending a staff meeting. Nursing intensity refers to the amount of direct and indirect care. Nursing intensity is influenced by the dependency of the patient on the nurse, the severity of the patient’s illness, the time taken to administer patient care and the complexity of care required. The level of a nurse’s workload is additionally directly influenced by the non-patient-care-related nursing activities that they must carry out during the course of any given nursing shift (Morris, MacNeela, Scott, Treacy, & Hyde, 2007).

Figure 2: A model of nursing workload (Morris, MacNeela, Scott, Treacy, & Hyde, 2007)

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implementing an AMU (Van der Maas, 2011). An approach involving questionnaires can be dangerous in the unstudied context investigated in Van der Maas’ research as the results may lack a proper context. In this study, this design was only used as input for qualitative interviews. Moreover, interviews allow more for questions related to participants’ perceptions.

Despite Van der Maas’ (2011) conclusion, a cross-sectional study conducted by Myny et al. (2012) revealed that the number of work interruptions is the most important factor in perceived nursing workload. Therefore, avoidable work interruptions should be prevented. Such interruptions may include nurse calls, to need to walk considerable distances or poor unit layout. Lower qualified staff could be used to perform selected tasks, such as helping patients or specific administrative tasks (Defloor, et al., 2006). Beyond work interruptions, a high number of unplanned admissions was also found to significantly impact on nursing workload (Myny, et al., 2012).

2.4 Conceptual framework

In summary of the above, acute admissions potentially impact nursing workload perceptions, while this relationship might be moderated by the presence of an AMU. Figure 3 illustrates the conceptual framework. The perceived effect of acute admissions on nursing workload is qualitatively researched in this study. The next chapter describes in more detail how this research is conducted.

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3. Methodology

The goal of this study is to investigate the effect(s) of acute admissions on perceived nursing workload. The approach adopted in this research was that of a single-case study at a large Dutch non-academic hospital. This section outlines the approach adopted to answer this study’s research question.

3.1 Single-case study

The research design consisted of a single-case study. A case study enables the researcher to study the embeddedness of a phenomenon in its real-life setting and to develop an understanding of the complexity and nature of that phenomenon (Blumberg, Cooper, & Schindler, 2014; Karlsson, 2009; Meredith, 1998). In addition, a case study is considered suitable to describe and explore an unstudied situation and subsequently contribute to theory development (Eisenhardt, 1989). Although AMUs are associated with reduced nursing workload, as the impact of acute admissions on ED outflow problems and disturbances to elective care may be smoothed, it has often been disregarded in AMU effectiveness studies. Therefore, a case study could explore this situation and subsequently make it possible to contribute to theory development. The present study focused on a single case. Despite the limitations of such an approach in terms of the generalizability of the findings, it does provide a greater likelihood of obtaining in-depth insights (Karlsson, 2009).

3.2 Case description

The case study was initiated by and conducted at the Medisch Centrum Leeuwarden (MCL), a non-academic hospital in the Netherlands. MCL’s ED generally has between 80 and 100 patients per day, of whom around 50% will be admitted. Recent numbers on acute admissions indicate that the following four areas of specialisation had high acute admission rates: surgery, internal medicine, lung diseases and neurology. These four areas of specialisation together accounted for nearly 75% of all acute admissions in a sample period (Komdeur, 2019). Based on this information, internal medicine and orthopaedics and trauma surgery were selected for this case study. Internal medicine had around 20% elective care and 80% acute inflow, where orthopaedics and trauma surgery has a more balanced patient population, with around 50% elective and 50% acute. The orthopaedic patients are usually planned ahead, while trauma surgery patients are generally received via acute inflow.

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Figure 4: Acute admission process MCL

At the period in time in which the research was conducted, MCL did not have an AMU, but the implementation of such a unit had been a point of discussion. Several feasibility studies were performed, both internally and externally. A previously conducted simulation study specifically focused on the logistical impact of the design choices regarding the proposed AMU. The hospital’s management concluded that the implementation of an AMU would not benefit the hospital to the extent that they hoped. They expected more benefits, in terms of bed savings, from introducing an AMU than the results suggested. Therefore, hospital management decided to put the proposed implementation on hold (Bokhorst & Van der Vaart, 2018).

Since MCL is facing upcoming budget cuts, they began to consider the concept once again (K. Komdeur, personal communication, November 22, 2019). It is possible that more factors played a role than were included in the situation study at that time. In addition, simulation modelling may have been inadequate for all factors that were of interest. The hospital additionally expected ‘the work pressure experienced by ward staff to be reduced’ (Bokhorst & Van der Vaart, 2018, p. 77), but this was not further elaborated on in this study. It was also unclear whether the decision to open an AMU would receive support from staff. In addition, recently, MCL’s nurses engaged in a strike and various activities intended to strengthen collective labour agreements and reduce excessive workloads. MCL has a high turnover of staff who cannot cope with high physical and mental workloads (Leeuwarder Courant, 2019). As acute admissions might contribute to increased perceptions of nursing workload, compared to elective admissions, this contributed to the practical relevance of this study.

3.3 Data collection

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Data was collected in two phases. The first phase consisted of interviews with nurses, both from receiving wards and the ED, as the process of acute admissions could prove disruptive for both groups. The interviews were conducted between 30 April and 15 May 2020. The second phases of data collection consisted of interviews with unit heads of the involved departments, with the aims being to validate and possibly explain the results from Phase 1. Therefore, in the second phase, the analysis from the Phase 1 interviews was used as input. Data for Phase 2 was collected between 20 and 27 May 2020. The interviews focused on ED boarding problems, acute admissions, nursing workload related to acute admissions and prevailing perceptions concerning implementing an AMU. The combination of the perspectives of both groups of stakeholders made it possible to obtain comprehensive insights into the research question.

In general, the number of interviews to be conducted was determined by the point at which theoretical saturation was reached; however, the coronavirus outbreak was also a limiting factor. Tables 1 and 2 provide an overview of the characteristics of the nurses interviewed in Phase 1 and Phase 2, respectively. In total, seven semi-structured interviews were conducted among nurses from three departments, including two from the ED.

Table 1: Interviewee characteristics nurses

Interviewee phase 1, nurses

Gender Department Years of

experience

1 M Emergency department 15

2 M Emergency department 32

3 F Internal medicine 20

4 F Internal medicine 4

5 F Orthopaedics and trauma surgery 10

Table 2: Interviewee characteristics unit heads

Interviewee phase 2, unit head

Gender Department

1 F Emergency department

2 F Internal medicine

3 F Orthopaedics and trauma surgery

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collection in Phase 1, the resulting data was directly analysed. In this way, the data provided input for setting up questions used for the interviews in Phase 2. The protocols for these interviews were largely based on the results of the Phase 1 interviews. However, the overarching interview protocol for the semi-structured interviews with unit heads is included in Appendix B. (Note that the interview protocols are in Dutch.) The interviews had an average duration of 25 minutes and were all conducted via telephone. The same interview protocol was used for all interviewees in the first phase to enhance the reliability of the data (Karlsson, 2009). As the interviews were semi-structured, the sequence of the questions could, however, differ. Following the collection of qualitative data, the outcomes were analysed; the analysis procedure is described in the next section.

3.4 Data analysis

All interviews were audio-recorded and anonymously transcribed to ensure generalizability. The transcripts were sent to the interviewees for validation to avoid observer bias (Karlsson, 2009). Based on the approved transcripts, it was qualitatively determined whether the type of workload, the type of patient admission and the effect of ward occupation or degree of ED boarding differed. The data analysis was conducted by using Atlas.ti. Firstly, inductive coding was used, to identify similarities and differences among multiple data categories (Gioia, Corley, & Hamilton, 2013). Inductive coding was considered appropriate because knowledge concerning the exact relationship between acute admissions and nursing workload was limited.

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4. Results

This section presents relevant observations from the data analysis, as well as recurring aspects, patterns and trends. This section is structured based on the outcomes of the selective coding process. Firstly, the perceptions towards the process of acute admission are described Secondly, data regarding perceived nursing workload is presented, followed by results concerning perceptions of AMUs. This results section purely discusses the findings. The interpretation of the results and how they fit with existing theory is discussed in Section 5.1.

4.1 Perceptions of acute admissions

The respondents expressed several different perceptions of the various process steps and characteristics of acute admissions discussed in Section 3.2. This section presents the most relevant perceptions to acute admissions emerging from this data, both from the perspective of the ED as from the two receiving departments.

ED crowding

As a result of a recent bed shift plan, the case hospital had been reducing beds, the Unit head ED stating that ‘the ward has fewer beds available for admissions’. As a result, she indicated that ‘much more effort is needed to find a free bed’. This could have adverse consequences for the ED: ‘If a patient is ready but has no room yet, he will occupy a bed and we will have one bed less available for emergency care’ – Unit head ED. In addition, ‘you still need to take care of the patient at that time, so it costs personnel’ – ED Nurse 2. To prevent a situation in which the ED was overcrowded and unable to cope with additional inflow, an escalation protocol would be activated: ‘You will then focus on ED outflow to ensure that a patient will be transferred to the right place as quickly as possible’ – Unit head ED.

Clustering admissions

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in interviews with respondents from O&TS, which can be due to less experienced nurses or just less experience with acute admissions.

Unpredictable disturbance?

Perceptions of acute admissions were difficult to grasp and depended on several factors. For example, an answer to the question of how a nurse experiences the process of acute admissions was that ‘it all depends on how busy it is’ – Nurse 2 O&TS. However, many respondents indicated that acute admissions were unpredictable and could, therefore, be a disturbance. ‘I often notice that nurses are being pulled out of their process’ – Unit head O&TS. There seemed to be disagreement on the perception of unpredictability, however, as a respondent from the ED noted the following: ‘I think you can very well steer on the acute flow because you know the inflow every day, with those averages, and that is a big part of your capacity’ – Unit head ED. In other interviews, a paradox was noted in that receiving departments knew acute admissions would come but usually not when or how many. This uncertainty made the admissions process unpredictable. For instance, one respondent stated the following: ‘We know roughly that there will be an average of two in a day, but it can go up to nine or 10. That makes the pressure on the nurses quite high’ – Unit head O&TS. It was additionally noted that this unpredictability had implications for the work process. One respondent stated that ‘you never know what’s coming, so let’s work ahead’ – Nurse 2 IM. Despite this uncertainty, they saw opportunities to overcome it: ‘If you have a dashboard where you can see that there are 10 IM patients at the ED, then you know you can expect four or five to be admitted later on’ – Unit head IM. However, currently, receiving departments do not have this opportunity.

Time efforts

Next to unpredictability, the time required for certain tasks regarding acute admissions also seemed to play a role. When admitting a patient, ‘you do miss some hands at the ward that you may well need’ – Nurse 2 IM. Additionally, one nurse believed that safety was regularly compromised because ‘you already have the patients at your ward, and then you have to pick up too many patients at once’ – Nurse 1 IM. This issue was widely recognized, and patients would occasionally be taken to the ward instead. A nurse from IM noted, when patients are taken to the ward, ‘that makes a difference in your transport time, but the question remains whether you have enough capacity at the ward to receive and observe the patient well’ – Nurse 1 IM.

Interestingness acute flow

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Nonetheless, many respondents indicated that the combination of elective care and acute care is interesting: ‘The combination between planned and unplanned makes it interesting, despite that fact it yields workload’ – Nurse 3 O&TS. A nurse from IM, a department with a large volume of acute admissions, stated the following: ‘I would miss the acute flow if I worked in such a stable department where everything is as it is. I don’t think I would be happy then’ – Nurse 1 IM. A possible reason for this could be as follows: ‘If someone is really sick, it is very interesting to apply clinical reasoning’ – Nurse 2 IM.

4.2 Nursing workload

The previous section described the perceptions involved in the process of acute admission. As acute admissions could influence nursing workload perceptions, this section outlines perceptions of nursing workload and its relation with acute admissions.

Three main groups of determinants of nursing workload seemed to emerge from the data, which are further elaborated on in the remainder of this section:

1. Increased patient complexity and turnover; 2. Staffing levels; and

3. Acute admissions

Increased patient complexity and turnover

Firstly, given the interview data, there seemed to be a tendency for two macro developments: increased patient complexity and increased patient turnover. A nurse from O&TS stated that for both acute and elective admissions, ‘people today are more complex, more comorbidities’ – Nurse 2 O&TS. Another nurse observed that ‘The workload also increases because the complexity increases enormously’ – Nurse 2 IM. As one respondent stressed, ‘You can be busier with one patient than with six patients’ – Nurse 1 IM. A nurse from O&TS saw an increase in elderly patients with hip fractures, some of whom were suffering from dementia. Care of patients with dementia frequently involves taking over care to a large extent. As she noted, ‘That is often almost one-to-one care. This increases the burden of care’ – Nurse 2 O&TS. While both departments seemed to experience increased complexity, in terms of both the quantity and quality of codes, the unplannable component of patient complexity seemed to mainly impact workload at O&TS. For the ED, patient complexity also seemed to be an important factor in perceived nursing workload. As an ED nurse stated, ‘You don’t know how sick a patient is. […] sometimes you need three people on one patient’ – ED Nurse 1. While flow was considered to be crucial for the ED, a nurse felt that ‘it is mainly the inflow that determines the pressure’ – ED Nurse 2.

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down a lot lately. This is also the trend in recent years, and turnover has therefore increased’ – Unit head IM. As one nurse noted, the higher turnover held for both acute and elective admissions.

Staffing levels

Secondly, staffing levels were believed to be an important factor impacting workload. On average, IM had nine nurses during a day shift and seven during an evening shift. A nurse believed that evening shifts were busier given the acute admissions and smaller teams. This opinion was supported by a nurse from O&TS: ‘Especially in the evening, you have a lot of emergency admissions, and you are with less staff, which makes the workload high.’ – Nurse 3 O&TS. The perceived workload was additionally believed to be correlated with experience. ‘It also depends on how much experience you have’ – Unit head IM. However, ‘if you are very experienced, you can also experience a lot of work pressure, because you feel responsible for a much larger whole than just your own piece’ – Unit head IM.

Increased nursing workload was also believed to influence the quality of care delivered: ‘At a certain point, the workload was so high that you did not feel like you can still provide good quality care’ – Nurse 2 IM. To cope with this workload, IM has, for several years, been part of a collaborative agreement where beds and personnel could be redistributed between departments in cases of crowding: ‘In this way, you can better absorb the peaks with each other […] If you are very busy, you like it when you have help […] then you also want to help someone else another time’ – Unit head IM. Through adopting this approach, they seemed to have successfully coped with workload peaks. O&TS started making use of helping assistants as a creative way of coping with increased nursing workload: ‘They are not allowed to do any nursing activities, but they can provide support […] It does provide relief. I am working on expanding that’ – Unit head O&TS. Such assistants could, for example, accompany a nurse when picking up an acute admission from the ED. Due to the physical distance involved, this was occasionally expensive in terms of time, as the nurses could not provide elective care at the ward. With making use of assistants, it was not necessary for two nurses to be away from the ward: ‘That is how I try to solve that creatively, without it costing too much’ – Unit head O&TS.

Acute admissions

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strengthened with increasing ED distance from the ward: ‘I think distance and time effort is a very big part’ – Nurse 1 IM. Interestingly, a respondent noted that they could ‘sometimes be quite busy with an admission that will be discharged the next day’ – Nurse 3 O&TS.

To conclude this section and summarize the findings presented above in one concise sentence, perceived workload related to acute admissions depends ‘a lot on the workload at the ward, how many acute admissions you get and what it is what you get’ – Nurse 1 O&TS. The next section focuses on perceptions regarding an AMU.

4.3 Acute Medical Unit

Having elaborated on acute admissions and nursing workload, the question remained as to what the implementation of an AMU would mean with regard to these two factors. The hospital considered in this case study did not have an AMU. However, to assess whether the implementation of such a unit would prove beneficial in the context of acute admissions and nursing workload, it was important to understand what people’s perceptions of an AMU were. In the past, there had already been plans to implement an AMU at the hospital: ‘At the time, the initiative was taken by the ED […] but the wards were not ready for that.’ – Unit head ED. There seemed to be insufficient support from the various hospital departments at that time, and the number of beds had to be reduced. According to the unit head ED, ‘beds have already been handed in, and I think that the support base for the specialisms is now also available […] I think the organization is now more ready for an AMU than five years ago.’ – Unit head ED.

4.3.1 Expected benefits

Respondents expected several benefits when implementing an AMU. Their responses were categorized into the following four categories and are further explained below:

1. Improving ED flow,

2. Allowing more rest at wards,

3. Enabling more efficient staffing, and 4. Improving the quality of care

Improving ED flow

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there’ – ED Nurse 2. This would improve outflow from the ED, which could additionally benefit inflow to the ED: ‘I think it [an AMU] has consequences for preventing time-outs and being available for the region’ – Unit head ED.

Allowing more rest at wards

While the implementation of an AMU was regarded as offering clear benefits for the ED, respondents indicated that it could also prove beneficial for the receiving wards. Since patients could be discharged after visiting an AMU, as indicated in Figure 1 in Section 2.2 and noted in the results in Section 4.1.1, ‘the short admissions do not end up in the medical wards’ – Unit head ED. The benefits of implementing an AMU was additionally recognized by respondents from both receiving departments: ‘Then you have more rest in a medical ward because you do not have all those admissions’ – Nurse 3 O&TS. In addition, the unit head IM noted that ‘It gives your department more rest because you have fewer disruptions in the evening shifts’. With regard to situations in which it was necessary to subsequently admit AMU patients to a medical ward, one respondent stated that ‘I think it is nice that everything has been arranged in those admissions. It just takes away a lot of workload’ – Unit head O&TS. In contrast, one respondent noted that should an AMU be present, it would be likely that workload would simply be shifted from the wards to the AMU: ‘If you get all the acute [patients] in there, it will also be a very busy department […] You take a lot of workload with you from the regular nursing department’ – Nurse 1 IM. In the end, both the ED and the receiving departments could potentially benefit from the implementation of an AMU: ‘The stable what is already there and the acute what is added – that match is often not very good’ – Nurse 1 IM. Since, should an AMU be implemented, it would be focused on providing acute care, medical wards could be tailored to the elective setting.

Enabling more efficient staffing?

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Improving the quality of care

Lastly, the respondents mentioned additional expected benefits in terms of quality of care. ‘I also think that we would have a quality improvement […] for the patient at the ward who then gets his medicines and nutrition on time, and not too late because an acute patient arrived’ – Unit head ED. A nurse from IM felt that she could ‘provide the care that is needed much better without having all those acute cases. I think it [an AMU] improves the quality of care for the patients at the ward – Nurse 1 IM.

4.3.2 Expected challenges to its implementation

In contrast to the benefits identified above, respondents also mentioned potential challenges associated with the implementation of an AMU. Three main challenges were distinguished which are further explained below:

1. Structure and guidelines, 2. Knowledge and experience, and 3. Interestingness of acute inflow

Structure and guidelines

Firstly, AMUs can be structured in different ways. When opting to implement an AMU, clear agreements and guidelines have to be established. As noted by respondents from the ED. ‘It must have a clear structure, as otherwise, your AMU will be full in no time’ – Unit head ED. There need to be strict arrangements for an AMU: ‘The AMU must be empty in the morning. […] If you don’t arrange that properly, those people will lie there endlessly’ – ED Nurse 2. As noted in the previous section on nursing workload, the physical distance to the ED was considered to be a burden for wards receiving multiple admissions per shift. To a certain extent, this also held for the position of the AMU: ‘In any case, the positioning, you want it to be near your department’ – Unit head IM. In contrast, from the perspective of the ED, ‘the best thing would be that it would be very close to the ED’ – ED Nurse 2. In addition, having the AMU located close to the ED would allow them to use each other’s staff: ‘If it is quieter in the ED and busier in the AMU, you can also deploy your staff there and vice versa’ – ED Nurse 2. A question concerning the structure remained, namely that of ‘whether you have a diagnostic and surgical distinction in the AMU’, which was put forward by the head unit IM. As for the codes of the interviews from O&TS, none of the respondents addressed particular challenges that could be labelled as structure, guidelines or agreements.

Knowledge and experience

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receive training’ – Unit head ED. Working in the AMU could also be seen as a stepping stone towards working in intensive care or the ED, as indicated by the unit head O&TS: ‘We often have people who want to work up to intensive care or ED. An AMU can be a nice step towards this’ – Unit head O&TS. All of these findings can be summarized in the form of a statement made by a nurse from the O&TS department: ‘Experience and knowledge make things easier and you can provide better care’ – Nurse 1 O&TS.

Interestingness of acute inflow

Thirdly, as elaborated on in the final part of Section 4.1, which focused on perceptions of acute admissions, many nurses viewed the acute setting as interesting compared to the more stable elective care. This was true for both receiving wards. With regard to the question of whether it would impact workload if patient flows were to be further separated, one answer was as follows: ‘I think that would certainly affect the workload, although I think that the acute patient makes it interesting for a nurse […] I find the variety so important in the department’ – Unit head O&TS; this statement was made by an individual in charge of a department with a ratio of acute to elective care of 50:50. From the interview data, it was unclear whether this perception was also shared by the nurses from this department. However, a valid concern was identified: ‘I just don’t know if work at a nursing department would be still interesting if all acute care goes the AMU’ – Unit head O&TS.

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5. Discussion

This study aimed to investigate the effect(s) of acute admissions on perceived nursing workload, concerning AMU effectiveness. In this chapter, first, the key findings are summarized and interpreted. Thereafter, the second section elaborates on the strengths and limitations of this study. In the third section, the implications for theory and further research are described, while the final section is dedicated to discussing the practical implications of this study.

5.1 Findings: Interpretation and meaning

In this section, the first paragraph summarizes the findings from Chapter 4. Thereafter, the findings are interpreted and linked to theory, where a subdivision has been made into acute admissions, nursing workload and AMU. The last paragraph sums up all interpreted findings. The ED frequently experiences outflow problems, resulting in a tendency to cluster admissions, which had adverse effects for the wards concerned. The data suggested that acute admissions were perceived as disruptive, time-intensive and unpredictable. Despite these perceptions, however, the acute inflow was considered an interesting part of the job. The results indicate three main forms of perceived nursing workload: increased patient complexity and turnover, inadequate staffing levels and the presence of acute admissions. Respondents expect that the implementation of an AMU improve ED flow, allow more rest at wards, enable more efficient staffing, and, ultimately, to improve quality of care for both acute and elective patients. However, respondents indicated that implementing an AMU would require a clear structure and sufficient knowledge; in addition, individuals working in the wards would no longer be exposed to the interesting aspects of dealing with acute patients.

Acute admissions

The results of this study indicated that ED crowding is caused by the inability to regulate both inflow and outflow, in contrast to Boyle et al. (2012) stating that it is mainly the outflow. ED outflow problems were found to relate more to discharge and acute admissions. Future studies could consider that ED crowding can also be caused by an inability to regulate inflow. Advances in regulating ED inflow could reduce the urge to adopt outflow innovations, such as implementing an AMU, to regulate ED crowding.

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workload, possibly because of the bullwhip effect. In accordance with Jennings et al. (2013), the results also indicated a predictably unpredictable nature of acute admissions. Nurses knew there would be acute admissions during the afternoon/evening, but not when or how many. This predictable unpredictability was considered a large contributor to increased workload, while perceived more at O&TS, which had an acute to elective inflow ratio of 50:50, whereas IM primarily had acute inflow (80%). Departments with more acute admissions may be more accustomed to the predictably unpredictable nature of such admissions.

Nursing workload

Morris et al. (2007) described four aspects of nursing intensity impacting nursing workload, of which patient complexity, patient dependency and time needed to carry out nursing work were all found in this present study. Both receiving wards experienced increased patient complexity. In terms of patient dependency, the nurse-to-patient ratio could vary significantly when nurses needed to take over care to a large extent. Both were believed to have a significant impact on nurses’ workload. In addition, acute admissions and lower staffing levels increased the time needed to carry out nursing work in evening shifts. Interestingly, while several nurses mentioned this issue during interviews, the unit heads did not. This can be due to a different perspective. Regardless, it is important that staffing is adjusted to the number of acute admissions.

Myny et al. (2012) argue that avoidable work interruptions should be prevented because they can add to nurses’ workload. The results indicate that IM patients were occasionally brought to the ward when the latter was busy. However, bringing patients to the ward adds to ED nurses’ workload so cannot be considered an optimal solution. According to Defloor et al. (2016), lower qualified staff can be used to perform selected tasks such as helping patients. This study showed that the O&TS department made use of assistants to pick up patients, meaning that only one qualified nurse had to leave the ward instead of two. Another way of reducing workload was a collaboration between medical wards. In times of high workload, IM requested support from other departments that were possibly calmer at the time and vice versa. This approach seemed to lead to efficient use of resources among departments and was considered effective in coping with workload peaks for which no AMU is needed.

AMU

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admissions (Bokhorst & Van der Vaart, 2018). The workload would likely only be shifted from the wards to the AMU, which would not solve the problem of nursing workload. Additionally, some nurses from the wards are also likely moving to the AMU. It should be taken into account that this way of shifting both workload and personnel to the AMU leads to lower economies of scale, therefore, higher variability and may even harm flow performance. Implementing an AMU also results in an additional decision moment for admission or discharge. It, therefore, seems unlikely that the presence of an AMU would eliminate the predictable unpredictability concerning when and how many patients would be admitted. Based on the results of the study, Figure 5 is created to display the perceptions of acute admissions believed to increase nursing workload, for both the current situation and the expected situation with an AMU.

Figure 5: Acute admission perceptions on perceived nursing workload with and without an AMU

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5.2 Strengths and limitations

This study comes with several strengths and limitations which need to be taken into account when interpreting the results.

The approach adopted in this research was that of a single-case study. This approach was considered suitable since the effects of acute admission on nursing workload perceptions had not been studied previously. Through several interviews with different functions and departments, this approach made it possible to answer the research question concerning this particular hospital, while the results have limitations in terms of generalizability. To partially address this concern, a large number of respondents were interviewed from two receiving departments with a relatively high number of acute admissions, IM and O&TS. It could also have proven interesting to include a department with significantly fewer acute admissions. Moreover, the respondents for the interviews were selected in consultation with the respective unit heads. This choice may have had implications in terms of selection bias, but due to the coronavirus situation at that time this research was conducted, this approach was considered the most feasible.

As this research employed semi-structured interviews, the results were only based on the perception of the respondents. Objective data supporting these perceptions was missing. Initial exploratory conversations and a proposed observational component of the study could not be conducted due to the coronavirus outbreak. Although the similar interviews protocols used allowed for improved comparison of responses and suited the exploratory nature of this study, a mixture of data collection methods could help increase the reliability of the results. All interviews were recorded, transcribed and validated by the interviewees to enhance the validity of the data. Given limitations related to the coronavirus outbreak, all interviews were conducted via telephone. This limited possibilities of more in-depth discussion and observation of non-verbal communication but also reduced the potential influence of the researcher on the answers of the respondents.

The practical motive for this study was initially to evaluate the efficiency and effectiveness of AMUs. This was proved difficult, as there was no AMU to evaluate in the given case. Several interview questions were aimed at exploring respondents’ perceptions of AMUs, while, concerning construct validity, this concept was (naturally) largely novel to the respondents. To ensure internal validity, the results section was developed based mainly on quotations from the interviews. All interviews were conducted in Dutch, while English codes being assigned to certain text phrases. During the process of translation, certain shades of meaning may have been overlooked, and the results have become more susceptible to interpretive bias.

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A study conducted by Myny et al. (2012) found that work interruptions were the most important factor in terms of impacting nursing workload (with unplanned admissions being in seventh place). Despite these findings, it remained largely unknown what the perceived impact of acute admissions on nursing workload is and how this impact affects perceptions towards implementing an AMU. The main theoretical implication of this study is that the results enhance the understanding of the effect of acute admissions on perceived nursing workload and indicates prevailing perceptions concerning implementing an AMU, from the perspective of both an ED and medical wards. Both implications are explained below.

In a quantitative study by Van der Maas (2011), it was found that experienced nursing workload for acute admissions was only somewhat higher than for elective admissions. Despite having a different (i.e. qualitative) research approach, the results of the present study did not fully agree with these previous findings. The characteristics of specifically acute admissions, disruptive, time-intensive and predictably unpredictable, were all found to increase perceived nursing workload, as opposed to elective admissions. It could be concluded that a qualitative research approach revealed specific differences between acute and elective admissions not observed quantitatively. To address the limited generalizability of the findings, it would be useful should future studies explore the effects of acute admissions on nursing workload perceptions in different hospital contexts or departmental characteristics.

As noted in the introduction, there are opposing views on whether AMUs increase staff satisfaction (Hermans & Van Liebergen, 2019; Reid, et al., 2016). Although staff satisfaction was not particularly measured in this study due to the absence of an AMU, the results showed both positive and negative perceptions towards implementing an AMU. Both nurses and unit heads indicated that an AMU would be ideal in terms of regulating workload in evening shifts, which would increase staff satisfaction. However, the implementation of an AMU might result in remaining ward tasks becoming less interesting to nurses. This study thus contributes to this discussion and identifies a trade-off which should be considered. From this study, it remains unclear what would be more important, regulation of the workload or interests of remaining tasks. Future research could focus on investigating this trade-off and thus provide valuable input on deciding whether or not to implement an AMU.

5.4 Practical implications

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Based on the results, acute admissions are perceived to increase nursing workload more than elective admissions do. Implementing an AMU would reduce the pressure on medical wards, as there would be no disruptions of eventual acute inflow and less acute patients would ultimately be sent to the wards. As a result, the time-intensity would also be reduced. However, implementing an AMU would presumably not change the predictably unpredictable nature of acute admissions in general. An AMU might also prove beneficial in terms of reducing the ED workload, as contemporary outflow problems might be resolved should there only be one department to admit patients to. Test results and specialist consults can be awaited at the AMU, thus improving throughput. Nonetheless, advances in regulating ED inflow could reduce the urge to adopt outflow innovations, such as implementing an AMU, to regulate ED crowding.

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6. Conclusion

This research aimed to answer the following research question: What is the effect of acute admissions on perceived nursing workload? Figure 6 below presents the relationship between acute admissions and perceived nursing workload on the one hand and the potential effects of the implementation of an AMU on the other, to illustrate to findings of this qualitative case study. The nursing workload reflects the perceived workload solely of nurses at the ED and wards, as the effect on AMU nurses’ is unknown and could only be speculated.

Figure 6: Acute admissions, nursing workload and AMU

Acute admissions, which can, based on this study, be characterized as disruptive, time-intense and predictably unpredictable, are perceived to increase nursing workload more than elective admissions do. In contrast to the conceptual framework in Section 2.4, an AMU is considered to impact perceptions of acute admissions rather than to moderate the relationship between acute admissions and perceived nursing workload. The implementation of an AMU is expected to reduce the disruptive and time-intensive perceptions of acute admissions, as less acute patients would ultimately be sent to the wards, thereby indirectly reducing nursing workload. However, implementing an AMU would presumably not change the predictably unpredictable nature of acute admissions. So, implementing such a unit could be a means to reduce nursing workload related to acute admissions as it addresses perceptions of disruption and time-intensity. However, it should also be accounted for that implementing an AMU would likely just shift the workload from the wards to the new AMU and possibly comes at the expense of nurses’ interest in remaining ward tasks and thereby adversely affect staff satisfaction. In addition, advances in regulating ED inflow could also reduce crowding and, thereby, the urge to adopt outflow innovations, such as implementing an AMU.

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Appendices

Appendix A – Interview protocol nurses (Dutch)

The following interview protocol will be used for phase 1, semi-structured interviews among nurses. There where information or questions will differ for the ED nurses and nurses from receiving departments, this is indicated in italic.

Informatie en toestemmingsverklaring

- Daniël Voortman, master student Business Administration: Health, Rijksuniversiteit Groningen.

- Afstudeeronderzoek in het MCL naar het effect van acute

opnames/uitstroomproblemen naar verpleegkundige afdelingen op verpleegkundige werkdruk.

- Het interview duurt zo’n 30 minuten en wordt getranscribeerd en geanonimiseerd. - Is het goed als ik dit interview opneem om dit later te kunnen uitwerken?

- Verzoek om toestemmingsverklaring te tekenen. Uitleg interviewtechniek en procedure

- U bent de expert. Vertel uw verhaal; kies wat u wil vertellen en hoe - Reflecteer op gebeurtenissen en leer mij hoe deze te interpreteren Achtergrond

- Zou u een korte omschrijving kunnen geven van uw functie? - Hoe lang werkt u hier al?

Acute opnames

- Hoe verloopt het proces wanneer een acute patiënt moet worden opgenomen? - Hoe ervaart u dit proces van acute opnames?

- Welke factoren zijn van invloed op acute opnames/uitstroomproblemen naar verpleegkundige afdelingen?

o Drukte op spoed/verpleegkundige afdeling o Complexiteit patiënten belasting

o Type patiënt

o Samenwerking met de spoed/verpleegkundige afdeling? Verpleegkundige werkdruk

- Hoe ervaart u uw werkdruk op de afdeling?

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o Lichamelijke belasting o Tijdsbelasting

o Beperking in uitvoering werkzaamheden o Moeite die u moet doen

o Frustratieniveau Heeft u zelf nog iets toe te voegen?

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Appendix B – Interview protocol unit heads (Dutch)

The following interview protocol will be used for phase 2, semi-structured interviews among unit heads. There where information or questions differ for the ED and receiving departments, this is indicated in italic.

Informatie en toestemmingsverklaring

- Daniël Voortman, master student Business Administration: Health, Rijksuniversiteit Groningen.

- Afstudeeronderzoek in het MCL naar het effect van acute

opnames/uitstroomproblemen naar verpleegkundige afdelingen op verpleegkundige werkdruk.

- Het interview duurt zo’n 30 minuten en wordt getranscribeerd en geanonimiseerd. - Is het goed als ik dit interview opneem om dit later te kunnen uitwerken?

- Verzoek om toestemmingsverklaring te tekenen Uitleg interviewtechniek en procedure

- U bent de expert. Vertel uw verhaal; kies wat u wil vertellen en hoe - Reflecteer op gebeurtenissen en leer mij hoe deze te interpreteren Achtergrond

- Zou u een korte omschrijving kunnen geven van uw functie? - Hoe lang werkt u hier al?

Input fase 1 Nader te bepalen

Acute Opname Afdeling (AOA)

- Er zijn onderzoeken gedaan om een AOA te starten in het MCL. Bent u hiervan op de hoogte?

- Wat is uw mening hierover?

- Wat denkt u dat belangrijk is in een AOA? Heeft u zelf nog iets toe te voegen?

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Appendix C – Coding tree

Internal Medicine (IM)

Open coding Axial coding Selective

coding • Admission

• Actual admission

Actual admission Acute admission process • 20% elective

• 80% acute

• Acute = high complexity • Mostly acute inflow • No/little elective

Acute/elective IM

• Admittance/discharge review Admission review

• anamnesis Anamnesis

• Acute admission evening and night • Elective = lower complexity

Complexity

• Informing Informing patient

• Admission department

• Evening head pre-announcement • No pre-announcement if too busy

• Notification upcoming admission shortly before • Phone call patient at ED

• Weekend/evening/night head

Leading admissions

• Acute admission in night shifts Night/day • Pick up patient

• Pickup straight after call • Transfer

Pick up patient

• Antibiotics • Catheter via ED • Infuse

• Often arrive when stable

• Often medication, infusion, antibiotics • Preparations

• Regular checks • Stabilizing

Preparations/checks

• Deploy policy at ED Treatment plan

• Elective only is more stable work process • No match elective-acute

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• Multiple acute admissions at once • Multiple admission at once

• Multiple at once

• Multiple pickups at once

• Unable to prepare multiple acute admissions

Clustered admissions

Acute admission perception

• Daily meeting admission department - care units

Leading admissions • Nice working

• Prefers acute

Likes acute

• Assembly line Patient turnover

• Handover

• Mutual expectations ED-ward

Pick up patient • Attention

• Patient safety at stake

Quality of care • Acute admission: loss of valuable time

• Saving pick up time

Time effort • Busier since more unpredictable

• Dashboard what to expect • Highly variable acute admissions • Know in advance = working ahead • Longer in advance

• More predictable is better steering • Separate streams = more predictable • Take into account beforehand

Unpredictability

• Acute admissions • Night shifts

Acute admissions Nursing workload • Lower workload acute admission more spread Clustered

admissions • Between department collaboration

• Redistribute care or personnel

Collaboration • Comorbidities

• Complexity

• Complexity = informative • Complexity patients

• High workload: number + complexity • Instability patients

• Severity of care • Severity of patients

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• Disturbances acute admissions Disturbance • Burn-out

• Experience estimate

• Experience workload perception • Increased workload

• More experience broader view • New, unexperienced colleagues • Well experienced team

• Workload more experience more responsible • Young and unexperienced unable acute

admissions

• Young, unexperienced

Experience

• Daytime calmer

• Evening busier all together • General daily care lower • High workload acute inflow

Night/day

• Decreasing LoS

• High turnover patients

Patient turnover • Reduced quality of care Quality of care • Busier since smaller team

• Day = 9 nurses • Helping

• High personnel turnover • Hire extra people

• Late = 7 nurses • Late occupied well • Nursing team

• Smaller team evenings • Staffing

• Team composition

• Workload: high personnel turnover

Staffing

• Support from unit head • Training

Support • Bring along, saves time, not effort

• Distance • Distance time • Loss of time • Physical distance

• Physical distance ED - ward

Predictably unpredictable: The effect of acute admissions on perceived nursing workload