improving networks between acute care nurses and an aged care assessment team
TRANSCRIPT
CARE OF OLDER PEOPLE
Improving networks between acute care nurses and an aged care
assessment team
Andrew Robinson PhD, RN
Senior Lecturer, Tasmanian School of Nursing, University of Tasmania, Hobart, Tasmania, Australia
Annette Street PhD
Professor of Cancer and Palliative Care Studies, Director, LTU/A & RMC Nursing Clinical School, La Trobe University,
Bundoora, Australia
Submitted for publication: 20 January 2003
Accepted for publication: 22 July 2003
Correspondence:
Andrew Robinson
Senior Lecturer
Tasmanian School of Nursing
University of Tasmania
Private Bag 121, Hobart
Tasmania 7000
Australia
Telephone: 03 6226 4735
E-mail: [email protected]
ROBINSON A & STREET A (2004)ROBINSON A & STREET A (2004) Journal of Clinical Nursing 13, 486–496
Improving networks between acute care nurses and an aged care assessment team
Background. Acute care nurses have an important role in the discharge planning of
older people from hospital to home. However, few nurses understand the changing
aged care system or the consequences of poor referral on the lives of older people
postdischarge.
Aims and objectives. This paper reports the findings of a research project, which
aimed to investigate the possibilities for facilitating the transition of older people
from hospital to home through improving the working relationship between nurses
and members of a multidisciplinary aged care assessment team (ACAT).
Design and methods. The paper reports one action research cycle from a larger
project. Action research was chosen because its focus on knowledge development
and action leads to practical solutions to clinical problems. The research approach
included interactive forums designed to facilitate effective collaboration between the
nurses and ACAT in the discharge planning of older people. Data collection strat-
egies included audiotapes of ACAT research discussions, field notes, policy docu-
ments, referral forms and an evaluation tool.
Results and conclusions. The findings illustrate that ward nurses have, at best, a
limited knowledge and understanding of the aged care system, its function, or how
to access services. They need assistance to develop their knowledge of services
available to support older people following discharge. The conduct of interactive
forums, which utilize a case study approach, facilitated such knowledge develop-
ment and empowered the nurses to become more involved in discharge planning.
Participation in the forums also facilitated new collaborative partnerships between
the nurses and ACAT, which enhanced effective discharge planning.
Relevance to clinical practice. The paper outlines practical strategies to support
collaboration between ward nurses and community providers and/or multi disci-
plinary assessment services. It provides a list of key considerations for the devel-
opment of effective ward/community networks to facilitate the discharge of older
people.
Key words: acute nursing, aged care, aged care assessment teams, discharge planning,
elderly
486 � 2004 Blackwell Publishing Ltd
Introduction
The percentage of older people in the population of countries
in the Western world is rapidly increasing. In Australia 12%
of the population was aged 65 years and over in 1996, an
increase from 9% in 1976. By 2016 it is projected that the
aged population will represent 16% of Australia’s total
population (AIHW, 2002a). The association between age and
morbidity means that older people are high users of hospital
services. Moreover, many older people experience acute and
chronic illnesses concurrently so often require both acute and
long-term care at the same time (Leutz et al., 1994; Macko
et al., 1995). Over the last decade in Australia, as in other
countries, inter-sectoral borders, for example have become
much less self-contained (according to Howe, 1996) as the
management of care has increasingly required the coordina-
ted use of services across sectors. This is evident in the
‘growing tension at the boundaries between what were once
relatively discrete systems’ (p. 1).
This has occurred at a time when acute care services have
been subject to a process of deinstitutionalization to
improve efficiencies and contain spending. Inevitably, this
has resulted in shorter lengths of hospital stay (Baulder-
stone, 1997; AIHW, 2002b). Faster turnover increases the
importance of effective discharge planning and places a
growing burden on community and residential care agencies
responsible for providing services to older people in the
postdischarge period. As in many other countries, problems
with the coordination of care between acute, community
and residential care services are endemic. This is reflective
of a growing demand to improve the level of service
integration (Swerissen, 2002).
In Australia, a key group involved in determining the
discharge needs of older people is the aged care assessment
team (ACAT). An ACAT is a multi-disciplinary group
consisting primarily of nurses and paramedical staff. ACAT’s
functions are formalized in their operational guidelines
(Commonwealth Department of Health and Family Services,
1996), which outline their roles and responsibilities. How-
ever, the function of teams is not specified absolutely. Rather,
the guidelines acknowledge the need for teams to be ‘flexible’
in their operation to account for ‘local circumstances’
(Commonwealth Department of Community Services, 1987,
p. 1).
ACAT’s responsibilities include:
1 assessing the medical, psychological, social and functional
status of older clients and making recommendations for
services;
2 determining eligibility for entry to residential care (AIHW,
2002a);
3 networking with other providers to facilitate the coordi-
nation of care for older clients, to facilitate their access to
services;
4 participate in discharge planning with hospital staff
(Commonwealth Department of Health and Family Servi-
ces, 1996).
Developing networks is deemed essential if ACATs are to
establish cooperative relations with service providers, receive
referrals and ensure clients receive appropriate services
without delay (Commonwealth Department of Health and
Family Services, 1996). Indeed, this is acknowledged as a key
strategy of the aged care assessment programme (Gibson &
Means, 1997).
ACATs function as a separate entity (Commonwealth
Department of Health and Family Services, 1996) and are
usually co-located in acute hospitals or with community
service providers. They are funded by Commonwealth and
State Governments, and are required to report to both. They
have a responsibility to provide assessment services to a
defined geographical area. In Australia, this means there are
121 ACATs servicing the population of people over 70
(AIHW, 2002a) and since its inception the number of clients
assessed through the Aged Care Assessment Program has
increased each year (Butler, 1997). It is worth noting that the
largest group of clients fall into the 80–84 age group (Lincoln
Gerontology Centre – Aged Care Group, 1996).
ACATs provide an assessment service to older people
located in multiple contexts, including acute, community and
residential care. This means they work across the interface of
acute and community-based care, which places them in an
ideal position to mediate the transition of older clients
between hospitals and the aged care system in the community
(McCallum, 1994). It also means ACATs are strategically
positioned to develop networks and linkages between other
service providers in aged care (Fine, 1997) including ward
nurses in acute hospitals.
Ward nurses play a central role in discharge planning
(Jackson, 1994; Lowenstein & Hoff, 1994), a key mechanism
in the transition of older people from hospital to home and a
‘vital link’ in facilitating continuity of care (Bull & Roberts,
2001). Shorter hospital stays add to the complexity of the
discharge process (Bendz et al., 2002). Effective discharge
planning is important because patients and their carers must
learn new information, skills and strategies for immediate
self-care within a short period of time (Cimprich, 1992).
Nurses are credited as being the most appropriate people to
coordinate these activities (Williams, 1991), given their role
in providing ongoing patient care, over time (Anthony &
Hudson-Barr, 1998). At the same time, pressures for early
discharge have given added impetus for nurses to refer to
Care of older people Networking between acute care nurses and an ACAT
� 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 486–496 487
ACATs (Howe, 1996). This is especially important for older
people, as they are most likely to have the greatest needs
following discharge (Dansky et al., 1996).
Significant issues have an impact on the effectiveness of the
nurses’ role in discharge planning. In part this relates to
philosophical interests that divide acute and community-
based health care providers (Kearney, 1994; Legge et al.,
1996; Fine et al., 1998) as well as ‘professional territoriality’
and a ‘lack of mutual trust and respect’, representing
significant barriers to cooperation (South Australian Com-
munity Health Research Unit, 1994, p. 43). Armitage &
Kavanagh (1997) report that ‘busy nurses often give dis-
charge planning a low priority… underrate the value of
discharge preparation for patients welfare,’ and are more
concerned with ‘the immediate demands of patient care and
the mechanics of discharge from hospital than with care in
the community’ (pp. 17–18). Reflecting its relative lack of
status, discharge planning is often reduced to an ad hoc
process and the discharge of many patients from hospital is
often precipitous (Fine et al., 1996).
Given these concerns it is hardly surprising to find that
discharge planning is described as a complex process (Walz
& Hakim, 2002) that is ‘fragile and vulnerable to break-
down’ (Jewell, 1993, p. 1294). For example, evidence reveals
that many nurses struggle to conduct assessments that
acknowledge the care needs of older patients (Armitage
et al., 1995; Clare & Hofmeyer, 1998), or to estimate their
coping abilities following discharge (Nixon et al., 1998).
Nurses receive little if any feedback on the effectiveness of
their discharge planning, have a poor knowledge of commu-
nity-based services, and experience difficulties accessing them
(Lowenstein & Hoff, 1994; Armitage & Kavanagh, 1996).
This is a cause for concern because, if nurses’ assessment of
patient’s needs is limited, then important information will go
unrecognized in the discharge process. Adding to these
problems is evidence that early discharge has negative
implications for referral processes from ward nurses to
community agencies (Worth et al., 1994).
After concerns were raised about the effectiveness of the
relationship between ACAT and ward nurses in facilitating
the discharge of older patients from a number of Australian
hospitals, it was decided to conduct a study to address this
issue. In this study, the focus was on the practice of the
involved health professionals. There was a deliberate decision
not to involve older people in the research directly and nor
was this appropriate. In general, older people were involved
in a one-off assessment by the ACAT and in the vast majority
of cases there was no ongoing relationship or continuity with
the Team. This reflected the fact that as an organization
ACAT did not provide an ongoing assessment service to a
specific group of older people over time, but rather a one-off
assessment to large aged care population within a defined
geographical area. The intention in the study was therefore to
develop strategies to ensure this one-off assessment encounter
was effective. As such, in the first instance, the focus of the
research was on identifying the issues and implementing
strategies. To this end, after careful deliberation, action
research was chosen as the most appropriate method to
analyse and improve the capacity of ACAT and ward nurses
to network effectively in the discharge planning process. As
will be seen below in the findings, utilizing this process
actually meant that the effect of the change in practice on the
older people was documented.
Method: action research
Action research is a label that is loosely applied to a range of
research methods and processes that share a common interest
in the relationship between knowledge and action; that values
the participation of all stakeholders in the conduct and
decision making of the research; as well as addressing
practical problems to improve a situation (Street, 2002). In
this study a critical action research method was employed
with members of an ACAT to improve inter-sectoral
networks. This approach is marked by an emancipatory
interest and a particular concern with the concurrent devel-
opment of theory and practice, promoting collaboration
between researcher and participants, and collective con-
sciousness raising through the process of critical reflective
discussions (dialogue/narrative). In this sense, as Kemmis
(2001) notes, emancipatory action research ‘aims not only at
improving outcomes, and improving the self-understanding
of practitioners, but also at assisting practitioners to arrive at
a critique of their… work and work settings’ (p. 92). The
interest of critical action research is fuelled by a desire to
disrupt dominant power relations in an effort to recreate new
and just social situations in a ‘project of possibility’ (Simon,
1988, p. 1), to provoke a ‘transformative’ endeavour in a
‘partisan struggle for a better world’ (Kincheloe & McLaren,
1994, p. 140). Such a project affirms the place of practice and
opens an opportunity for practitioners, like the members of
the ACAT involved in this study, to address injustice through
developing networks that improve the coordination of care
and outcomes for their older clients.
The outcomes of action research in health care are context-
specific and may be focused on a clinical problem (Koch
et al., 2000) or take a wider approach to changing health care
culture (Jirapaet, 2000). Reflective of the critical intent of this
study the aim was to develop a cultural change in the
professional relationships that existed between members of
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488 � 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 486–496
the ACAT and nurses in acute settings. To do this, the study
was structured around an action research process following
the work of Street and Robinson (Street, 1995; Street &
Robinson, 1995).
Unlike linear research designs, action research uses a
circular or spiral design to depict the process. After a
preliminary investigation has been undertaken to explore
the literature and the health care context, strategic action is
planned, implemented and monitored. Analysis of the
findings is followed by collaborative reflection on the success
of the plan or the need to modify it and begin another cycle of
planning, implementation, data collection, analysis and
reflection. This cyclical process continues until the situation
has improved. In this instance the study comprised six action
cycles and a series of subcycles. This paper reports the
findings of one action cycle (the first nurses networking cycle)
as illustrated in Fig. 1. However, a short overview of the
larger project on ACAT developing linkages with service
providers is offered below to explain the context for this
cycle.
Short overview of ACAT linkages project
The ACAT linkages project began after an ACAT member
contacted the first author to discuss her concerns around poor
relationships between ACAT and various service providers.
Both authors then met with the ACAT Manager and the
Director of Aged Care services in the Health Department and
agreement was reached to establish an action research project
to address this concern. A number of key stakeholders were
invited to become members of a project steering group.
Meetings were held with the ACAT members and the first
author outlined the proposed project and the action research
process. Seven members of ACAT volunteered to join the
research as co-researchers. The Human Research Ethics
Committee of the Faculty of Health Sciences at La Trobe
University approved the study (no. FHEC 95/072). All ethical
guidelines adhering to confidentiality, anonymity and
informed consent were observed.
The ACAT co-researchers met on 30 occasions over a
period of 20 months and participated in planning, imple-
mentation, data collection, individual interviews and colla-
borative reflection. During these meetings an array of
concerns emerged regarding the professional working rela-
tionships between ACAT staff and service providers, primar-
ily general practitioners and nurses in acute hospitals. These
concerns were addressed in the planning for three cycles of
the action research process (see Fig. 1). The team collected
data both continuously as each cycle progressed and at their
conclusion. Data collection strategies for the cycles included
audiotapes of ACAT research and reflection discussions.
These were developed into case notes by the first author and
circulated to the co-researchers and reported to the steering
committee. The co-researchers also kept field notes of their
Figure 1 Represents the complete
sequence of action research cycles involved
in the larger project. The dark shaded areas
represent the ‘First Nurse Networking
Cycle’, which is the subject of this paper.
Care of older people Networking between acute care nurses and an ACAT
� 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 486–496 489
implementation strategies and participated in interviews.
Policy documents, guidelines and referral forms were also
analysed. An evaluation tool was administered to all partici-
pants to ascertain their feedback on the success of the
strategic action.
The paper does not report the whole story of the research.
It represents a report of the first of three action cycles, which
had a focus on developing the ACAT’s networks with
hospital nurses and general practitioners. In total, 56 nurses
from five wards at three hospitals participated in two
sequential networking cycles, with a further 16 general
practitioners involved in the third action research cycle. As
outlined above, the subject of this paper is the first nurses
networking cycle.
The nurses networking cycle
Objective
This first nurses networking cycle was designed to improve
the working relationship between nurses in two small
hospitals and members of ACAT to facilitate more effective
collaboration in assessment, referral and discharge planning.
Rationale
The rationale for this cycle emerged during the preliminary
investigation of an earlier cycle (see Fig. 1), sometimes called
a reconnaissance stage. A series of meetings had been
conducted where it became plain that ACAT members were
troubled about the impact of their poor relationship with
nursing staff in acute hospitals concerning the transition of
older clients from hospital to the community. Evidence
collected during this process indicated that the ward nurses
had, at best, limited knowledge of, or involvement in, the
assessment process. This was apparent in the limited number
of referrals to the team from hospitals, as well as the late and
inappropriate referrals received by the ACAT. Further, team
members perceived that hospital staff members were often
hostile to the ACAT, symptomatic of what they believed to be
unrealistic expectations of their capacity to link clients to
services, in the context of service shortages. The nurses’ lack
of basic knowledge of the community-based services avail-
able to older people exacerbated the situation; as did their
limited interest in discharge planning and the consequences
for their older clients following a period of hospitalization
Further investigation during this stage revealed that the
processes employed by the team members to develop
networks and linkages with nurses were ineffective because
they utilized a prescriptive and controlling approach.
Effective networks are predicated on developing collaborat-
ive relations based on mutual trust and respect in the context
of a collaborative relationship (Legge et al., 1996). Addi-
tional analysis revealed that the ACAT took no responsibility
for working with or encouraging hospital staff to facilitate
client access to services. Rather their ‘core business’ was
concerned with conducting assessments and making recom-
mendations for services, despite their operational guidelines
(Commonwealth Department of Health and Family Services,
1996) indicating a clear responsibility to work with other
providers to facilitate client access. This preliminary investi-
gation formed the basis for the decision to embark on an
action strategy in acute settings.
Context
Fortuitously, one co-researcher had been assigned as the
ACAT assessor servicing two small hospitals. Consistent with
the team’s preliminary findings she reported that the ward
nurses were ‘extremely negative about ACAT’. Furthermore,
problems with discharge planning and client assessment were
exacerbated because of an expectation that the charge nurse
would assume responsibility for these activities. It was, in her
words, ‘obviously something that was historical, they were
used to doing it’ (A2). In the context of a busy ward it was
apparent that the charge nurses’ primary concerns centred on
overseeing the biomedical care, rather than preparation for
discharge. Additionally, it was evident that a prevailing ethic
existed within each ward that if clients experienced problems
following discharge ‘it would be picked up in the community’
(A2).
Planning action
It was decided that the most effective strategy would be for
this ACAT co-researcher to establish a series of interactive
forums on two wards in the two small hospitals. These
interactive forums were designed to enable the ACAT
members and nurses to explore their concerns with:
• the nurses’ role in discharge planning;
• the operation of the aged care system;
• the interrelationship between aged care services and the
acute care system;
• ways that ACAT assessors could collaborate with nurses to
facilitate the transition of their older clients to community
and residential care contexts.
Consistent with the collaborative intent of this project the
ACAT co-researcher posted a suggestion sheet on each ward
that asked the nurses to identify relevant issues for discussion
at the forums.
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490 � 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 486–496
Implementation: interactive forums
Following meetings with both charge nurses and informal
discussions with the nurses on each ward, the interactive
forums commenced in the two hospitals with interested
nurses attending. The forums spanned a period of 4 months
and all 27 nurses participated in this cycle. Between 10 and
15 interactive forums were held in each hospital. Attendance
was facilitated by conducting the forums during the double
staff period between day and evening shifts, so that some
nurses provided patient care while others left the ward to
attend sessions. Additionally, the forums were generally
‘short and sweet’, which meant the nurses were more inclined
to leave the ward to attend even on ‘busy days’. However, the
problems associated with fluctuating workloads and rotating
shiftwork meant it was impossible for every nurse to attend
every session.
Despite a planned agenda, the content of forums was
flexible and informed by comments made on the suggestion
sheets posted on each ward. However, as the forums
progressed and other issues arose, they too were addressed.
For example, at the nurses’ request, staff from a number of
agencies, such as the Home and Community Care Program
(key providers of services to older people in the community)
also participated in some sessions. In this way the programme
was responsive to the nurses’ needs.
The structure of the forums also reinforced the colla-
borative approach. In general, they were conducted in an
informal manner and the ACAT co-researcher reported that
the nurses actively participated in the discussions. Impor-
tantly, regular attendance by a few highly motivated
nurses served to encourage participation among their
colleagues.
To promote the nurses’ active participation in the forums
the issues under discussion were related directly to clients
nursed on their ward. This process involved drawing on case
scenarios of particular clients and examining their postdis-
charge needs in relation to particular services. The nurses
were then able to explore how specific services might, or
might not, meet patient needs and how they could facilitate
their patient’s access to these services during the discharge
process. Thus the nurses made direct links between a
particular service and the needs of their patients.
Adopting this strategy was important for several reasons.
Firstly, because the nurses were generally very busy and
worried about ‘getting behind with their work’, the interac-
tive forums had to be of immediate relevance if the nurses
were to make the effort to attend. Secondly, the use of case
scenarios meant that the ACAT co-researcher was able to
demonstrate to the nurses the importance of targeting clients
to refer to the ACAT and her role in the process of matching
client needs to the admission criteria employed by individual
service providers.
Evaluation, analysis and reflection
Effectiveness of case scenarios
Evaluation of the cycle revealed that the use of case scenarios
was highly effective. The ACAT co-researcher reported that
when she drew on case scenarios the nurses were often
astounded when they realized how these criteria were applied
to their patients. However, despite the team’s preliminary
analysis she was shocked by what she found and reported:
I was really surprised at their lack of knowledge. I assumed they had
a greater knowledge than they did and I was continually astounded as
to how ill informed they were! (A2)
Comments made by nurses such as the forums ‘clarified the
services available and how to access them’ (RN3) and ‘the
maze (that is the aged care system) is more familiar now so I
am now aware of services available and how to access them’
(RN6), indicate that participation improved the nurses’
understanding of the aged care system.
Not surprisingly, evaluation indicated that because of their
involvement in the forums the nurses developed an improved
understanding of ACAT’s role and the decision making
processes that informed an ACAT assessment. One partici-
pant commented: ‘It now makes more sense why some
(patients) are able to be placed easier than others’ (RN5).
Changes to the practice of discharge planning
Analysis of the data also revealed that improved understand-
ing of services helped to build the nurses’ confidence to
participate in discharge planning. Written comments such as
‘We are able to advise patients more confidently of services
available’ (RN17), ‘Knowing the services that can be offered
to patients has helped me with discharge planning’ (RN2)
and ‘Information discussed (in the sessions) helps me to
answer questions and give advice to patients’ (RN11),
supported this finding.
The direct involvement of the ward charge nurses in the
forums facilitated this change. Recognizing the benefits
associated with the nurses participating in discharge plan-
ning, as the forums progressed, the charge nurses of both
wards encouraged their staff to take more responsibility in
this area. In the process, hierarchical power relations were
changed as the charge nurses took a more participatory
approach to these activities.
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� 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 486–496 491
However, the nurses did not take on this new responsibility
in isolation. There was a concurrent increase in the level of
collaboration between the ACAT co-researcher and the ward
staff in discharge planning. She reported re-negotiating her
role in the discharge process, saying that:
I’ve been meeting with them and working out what services they
think the person should need. I’ve been saying what I think they
should need, then (after some discussion) reaching an agreement and
clearly documenting ‘I will refer to family-based care, you will refer
for an OT assessment, I will do this, you will do that’ and it has been
collaborative in that regard. (A2)
Changes to referral patterns
The ACAT co-researcher found that part of the problem with
the limited number and often inappropriate referrals from
ward nurses related to the fact that they were ‘scared’ of filling
out the ACAT referral form incorrectly. At one meeting of the
larger ACAT research team, another ACAT co-researcher
confirmed this. She reported that she had received ‘wonderful
feedback’ on the project when she commented to involved
nurses on the quality of a referral she had received. They spoke
of attending a networking forum that addressed the ACAT
referral form. This co-researcher reported that ‘they were really
thrilled and positive (about the forum) and they said it’s been
really helpful because they really didn’t know how to fill out the
form’ (A4).
The nurses newfound confidence in using the ACAT
referral form became evident when members of the larger
ACAT research team reported that the quality of referrals
sent to ACAT had improved and that the generation of
referrals from the two involved hospitals to a programme
providing postacute care for older people, associated with the
ACAT, increased by 38% (Tasmanian Department of Com-
munity and Health Services, 1996). This change was directly
attributed to their participation in the forums.
The importance of personal contact in a collaborative
context
The findings demonstrated the positive effects associated with
‘regular face-to-face’ meetings between an ACAT assessor and
ward staff. The ACAT co-researcher reported to her col-
leagues in the larger research team on the effects of assessors’
relative anonymity on the wards, in part related to the ACATs
focus on meeting their core business targets of number of
assessments and the time between referral and assessments. It
became apparent that this focus undermined their ability to
work together to facilitate discharge planning. She reported:
…anonymity came up (as an issue) on the wards… (the nurses found
it) difficult to access the assessor because they would come in, and not
attempt to develop a rapport with (them… rather, they would) do the
assessment, write the recommendations and then head off again. (A2)
In response the ACAT co-researcher changed her practice.
She reported that now ‘I keep in touch (with ward staff) as a
matter of course’ (A2) and that this regular ‘face-to-face’
contact facilitated her ability to work effectively with them.
She argued that this was important because:
They want the contact because when you turn up there (on the ward)
they often troubleshoot with you. They often sit you down and things
will come up, whereas they probably wouldn’t have bothered to
phone, …even if it’s just to debrief…. They know you’re there when a
crisis arises… but they also need to know there is support there as
well. (A2)
This change in practice was oriented at establishing an
ongoing dialogue with the nurses that facilitated discharge
planning and a collective ability to resolve difficult patient
care issues. The RN networking evaluation supported this
finding. For example, one of the nurses commented that,
‘(I) Feel much more comfortable ringing ACAT now I can
put faces to names’ (RN4), while another wrote that
participation in the interactive forums ‘familiarizes ACAT
and nursing staff so that we feel more comfortable in
dealing with each other’ (RN8). The nature of this changed
relationship and its effects were in part captured by the
comments of one participant who noted: ‘They (ACAT)
have become allies and co-workers instead of an outside
dominating force’ (RN3).
Participation in the project also provided the nurses with
an opportunity to make ‘face-to-face’ contact with other
service providers. One nurse wrote ‘it’s good to know whom
you are talking to especially on the phone’ (RN5), while
another suggested, ‘it’s easier to contact a familiar face and
name’ (RN12). It was also apparent that these meetings were
equally beneficial for the providers themselves, as the ACAT
co-researcher argued when she said:
Community organizations are also working in isolation. For them,
coming into a hospital system is daunting. They’re often too afraid to
do it so they don’t… it’s like the nurses making contact with the aged
care system…. It’s just too difficult…. (A2)
These findings suggest that bringing the parties together was
a highly effective mechanism for promoting networks and the
development of linkages between services in aged care. They
also suggest that the members of a multi-disciplinary team
who work across the interface of health and community care,
like ACAT, are strategically positioned to facilitate this
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492 � 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 486–496
process to bring different groups together and break down
their isolation.
The effectiveness of the first nurse networking cycle was
evidenced in the nurses’ response to the evaluation questions,
‘Do you think the networking meetings have been useful?’
and ‘Did you gain useful information from these regular
presentations?’ One hundred per cent of the nurses responded
in the affirmative to both questions. Indeed, the nurses’
interest was evident in that over 70 comments were written
on the evaluation forms, many of which have been included
in the above text. The success of the project was also evident
in the feedback that nurses on other wards in the hospitals
wanted to participate in any future programmes. As the
ACAT co-researcher noted:
It was interesting. I went to one of the hospitals on Monday and a
CN of a new ward came and said, ‘Can we be targeted next year….
Can we be the first ones next year? (A2)
Discussion and implications for nursing practice
The findings of this study provide insights into the issues that
confront nurses in the process of assisting older people make
the transition from hospital to home. That nurses need
assistance is evident in the findings of this study, which
illustrate their minimal knowledge and understanding of the
aged care system, or its function. This finding is indicative of
the relative isolation of ward nurses from community provid-
ers, outlined in the literature (Armitage & Kavanagh, 1996). It
also suggests a relative lack of importance associated with
discharge planning and the coordination of patient care, as
well as problems with keeping abreast of the comprehensive
and continuous changes in the aged care sector.
Historically ward nurses, other than those in senior posi-
tions, have minimal if any involvement in case conference
discussions where members of the multi-disciplinary team
make decisions about the discharge of older patients. In many
circumstances they are subsequently given responsibility for
implementing these decisions without the benefit of involve-
ment in their formulation. Alternatively when decisions are
implemented by a third party, such as a ward charge nurse who
is not directly responsible for the provision of patient care,
critical information relating the patients needs and require-
ments is often overlooked (Hill, 1999). Ward nurses need
direct involvement in the discharge process given their role in
providing ongoing patient care, over time (Anthony &
Hudson-Barr, 1998). However, to fulfil their potential they
need assistance in developing their knowledge of services
available to support older people in the community following
discharge.
The findings of this study indicate that providing nurses
with an opportunity to attend interactive forums assisted in
developing their knowledge of services. Moreover, relating
the discussions from these forums to specific patients,
through the use of case scenarios was a successful strategy
to address such knowledge deficits of ward nurses. This
enabled the nurses to make a direct link between a particular
aged care service and the needs of their patients. Further-
more, it was apparent that their lack of knowledge of services
fed the nurses’ reluctance to participate in discharge plan-
ning. By their own reports, having knowledge of services
empowered them to become more involved in such processes.
Critical to this was the support and involvement of the ward
charge nurse. This finding supports those of similar studies
that highlight the importance of effective leadership in
changing organizational arrangements to improve coordina-
tion (Legge et al., 1996; Fine et al., 1998).
The sharing of information about aged care services, a key
focus of this cycle, provoked what Lincoln (2001) might
suggest was a ‘redistribution of power’ (p. 125). This was
important because, as the study findings illustrate, the
involved ward nurses struggled to understand the operation
of the aged care system or how to gain access to them. In
these circumstances an increased knowledge of services
opened up opportunities to collaborate with the ACAT in
previously unimagined ways. Likewise, the insights gained by
the assessors helped them to develop new understandings of
these knowledge deficits and their implications for the
provision of services. In this way a reconfiguration of power
was critical to improve coordination as new knowledge was
central to develop more effective practice and organizational
arrangements.
The reported problems that nurses experienced with the
ACAT documentation, specifically the referral form, and
the ACAT’s lack of awareness of this issue, demonstrated the
effects of habitual practices in undermining coordination.
These findings illustrate the propensity for multi-disciplinary
community-based groups like ACAT to become captive to the
‘dictates of tradition, habit and bureaucratic systematization
of individual experience’ (Kemmis, 1988, p. 36). In this case,
habitual use of the referral form had, in the words of
Foucault (1988), ‘become part of… (the ACATs) most
familiar landscape’ (p. 10), such that they could not ‘perceive
it any more’ (p. 10). In turn this acted as key impediment to
effective referral processes because the ACAT’s familiarity
with the form masked problems with its use.
Such findings bring to the foreground the importance of
community groups like ACAT collaborating with ward
nurses in a process of ‘mobilizing different understandings
Care of older people Networking between acute care nurses and an ACAT
� 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 486–496 493
to produce a broader story’ (Legge et al., 1996, p. 114) of the
problems they mutually confront. As the literature suggests
(Maclure, 1990; Stoecker & Bonacich, 1992), such encoun-
ters created opportunities for participants in critical research
processes, like the ACAT members and ward nurses, to
develop theoretical analyses of their situation, which inform
possibilities for change. It was this process that the nurses’
use of the referral form appeared to improve. Similar changes
also emerged in relation to new arrangements negotiated
between the ACAT assessor and the ward nurses. These
witnessed the emergence of a partnership where the assessor
was situated as collaborator in the process of enacting the
client’s care plan.
Such findings suggest that meeting together in the inter-
active discussion forums, enabled the members of different
institutional cultures (ACAT & ward nurses) to flesh out
issues, concerns and mutual interests. In this way they were
able to negotiate new practices, which took account of the
varying perspectives of the situation and develop a new
appreciation of each other’s role and responsibilities, which
as the literature highlights, is central to achieving effective
collaboration (Humphries, 1997; Keks et al., 1997; Fine
et al., 1998).
Likewise, it was apparent that participation in the inter-
active discussion forums with the nurses was of significant
importance. Here the project findings confirm those of the
literature, which suggest the importance of face-to-face
contact in the development of collaborative networks (Noh-
ria & Eccles, 1992) and the inter-personal dimensions of
networking (Larson, 1992) – a situation also apparent in the
nurses’ encounters with community providers involved in the
networking forums.
From the findings of this project it is clear that, to ensure
the effective discharge of older people, it is imperative that
nurses prioritize this aspect of care. To facilitate effective
discharge planning, in contexts with ever decreasing lengths
of stay, there is an increasing need for ward nurses to
collaborate with community providers, specialist discharge
planners and/or multi-disciplinary referral and assessment
services. It is clearly important to establish a professional
relationship based on trust and openness that acknowledges
the roles and responsibilities of different service providers in
the discharge process. However, at the same time, these
findings illustrate that much of what constitutes networking
is structured as informal interaction, such as a brief discus-
sion on the ward. Indeed, as the literature notes, collaborative
networks are often facilitated through informal arrangements
at a local level (Walker, 1992) and that personal history,
individual friendships and ‘reputational knowledge’ (Larson,
1992, p. 99) are critical to their development. For ward
nurses it is important not to underestimate their role in this
process and to make time to discuss patients with other
service providers involved in the planning of discharge.
Table 1 outlines considerations for effective ward nurse/
community networking to facilitate this process.
Finally, the overall findings of the study indicated that the
effectiveness of the one-off ACAT assessment process was
improved once the networks with the ward nurses and other
practitioners improved. This was achieved through partici-
pation in the various action research cycles. Further, despite
the time demands associated with their involvement in the
networking project, the time lapse between receipt of the
referral and the conduct of an assessment by the ACAT team
decreased. The data on team activity indicated that this
decrease was due to the improved networks and the associ-
ated increase in efficiencies such as a decrease in the number
of inappropriate referrals sent to the ACAT team. Con-
sequently, older people in the region waited a shorter time to
have their needs assessed. In turn, this hastened the prospect
of their receiving appropriate support. Furthermore, the new
collaborative networks established between the ACAT and
the ward nurses, also meant that older people had access to a
greater array of options post-assessment. This was because
the ACAT were able to more effectively support the nurses in
the discharge planning process.
Table 1 Considerations for effective ward nurse/community net-
working
Time
Discharge planning for older people needs to be a priority for all
nurses and not just the charge nurse or discharger planner
Regular ‘face-to-face’ opportunities for formal and informal
information sharing between ward nurses, assessment teams,
discharge planners and community services is essential
Case discussions need to be conducted at times and a venue when
all relevant nursing staff can participate
Education
All ward nurses need to be provided with regular updates on
changes to the aged care system, the processes of referral to
community services and relevant referral documentation
Education sessions on effective discharge planning should be
interactive and focused on meeting the specific information
needs of ward nurses as well as providing a forum to share
their concerns
Negotiation
Changes to practice need to be negotiated between ward nurses
and community staff to improve the practice and integration
of various service providers in the discharge process
Research
Ward nurses need to be given the opportunities to engage in
practitioner research processes directed at assisting them to
understand and improve their practice
A Robinson and A Street
494 � 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 486–496
Acknowledgements
We would like to acknowledge the members of the ACAT
and the ward nurses who participated in this project. Their
support and enthusiasm ensured its success. We also thank
both the Schools of Nursing and Faculty of Health Sciences at
the University of Tasmania and La Trobe University for their
generous funding in support the project.
Contributions
Study design: AR, AS; data analysis: AR, AS; manuscript
preparation and literature review: AR, AS.
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