Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

A meta-synthesis of factors influencing nursing home staff decisions to transfer residents to hospital

Authors: Bridget Laging, Rosemary Ford, Michael Bauer, Rhonda Nay

Journal: Journal of Advanced Nursing (2015); 71(10):2224–2236

DOI: 10.1111/jan.12652

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✅ PICO Analysis

Type of Study:

Meta-synthesis of 17 qualitative studies using Joanna Briggs Institute methods

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P – Population

• Setting:Nursing homes across international contexts (Australia, Canada, USA, Norway, etc.)
• Participants:Nursing home staff involved in decision-making regarding resident deterioration and hospital transfer:
  • Registered nurses (RNs)
  • Enrolled nurses (ENs) / Licensed practical nurses (LPNs)
  • Nurse assistants (NAs) / personal care workers (PCWs)
  • Directors of nursing, nurse managers, and administrators

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I – Intervention (Exposure)

• The decision-making process used by nursing home staff when determining whether to transfer a resident to hospital in response to acute deterioration or palliative situations
• Factors explored include:
  • Staff skill mix and confidence
  • Resource availability
  • Access to multidisciplinary support
  • Family pressure
  • Legal considerations
  • Use (or absence) of advance care plans (ACPs)

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C – Comparison

• No formal comparator group;However, comparative synthesis across studies identified key differences in:
  • Homes with vs. without access to physicians and diagnostic equipment
  • Staff with varying levels of clinical training and confidence
  • Facilities with vs. without ACP integration
  • Instances of proactive planning vs. reactive transfer decisions

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O – Outcomes

Person-Centred Outcomes:

• Limited consultation with residents during deterioration
• Staff described difficulties advocating for resident wishes when ACPs were absent or vague
• Transfer decisions often driven by family preferences or legal fears rather than the resident’s known choices 

Process Outcomes:

• Five key synthesized themes:
  1. Lack of skills/confidence to manage on-site: Many staff lacked assessment skills or confidence to treat acute issues without external support
  2. Limited access to multidisciplinary services and resources: Including difficulty reaching GPs, limited palliative care, diagnostics, or medication access
  3. Negotiating who decides: Hierarchical communication often excluded residents and frontline staff; physicians and families dominated decision-making
  4. Use of ACPs: Staff viewed ACPs as helpful in theory but rarely used them in practice during emergencies
  5. Unclear nursing home role: Inconsistent expectations about which acute interventions should be managed in situ vs. transferred out 

System Outcomes:

• Transfers were frequently initiated due to:
  • Legal liability fears
  • Absence of local protocols or standard definitions of “appropriate transfer”
  • Communication breakdowns between NHs and hospitals
• Staff often felt unrecognised for their judgment or efforts in managing residents on-site

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Summary Conclusion

This meta-synthesis revealed that nursing home staff play a pivotal role in hospital transfer decisions but operate in a complex landscape marked by inconsistent expectations, limited authority, and inadequate resources. Decisions are influenced by legal pressures, resource constraints, skill mix, and family dynamics, often more than by clinical need. Despite acknowledging the value of advance care planning, few facilities systematically used ACPs to guide decisions. The study highlights the need for clearer policy, better clinical training, and structural investment to support in-place care and reduce potentially avoidable transfers .

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