Why was this research project needed?

Care home residents are more likely to be transferred and admitted to hospital in unplanned, emergency situations. Although some transfers and admissions can be potentially life-saving, others may lead to residents becoming distressed, disoriented and more unwell.

As a result, a range of interventions have been introduced in recent years which aim to reduce transfers from care homes. This includes; recognise and respond to deteriorations in residents’ health; and ensuring, where appropriate, residents have advanced care plans in place that provide recommendations about the care they would (and would not) like to receive.

Despite these strategies being put in place, evaluations of whether such strategies reduce the number of residents going to hospital have produced unclear results. One potential reason why these interventions might not be working as intended is that at present, the work that care home staff do in-house (i.e. inside the care home) when deciding whether to transfer residents to hospital may not be fully understood by people outside of the immediate care home team.

Although researchers in other countries, such as USA and Australia have studied staff decision-making, it is not clear whether research conducted in other countries would be useful for thinking about care homes in England. To this end, we aimed to better understand the decisions that care home staff in England make when faced with residents who might need to be transferred to hospital.

What did we do?

Step 1: Interviewed 30 care home staff

We interviewed 30 members of staff working across six care homes in the East and West Midlands of England about their experiences of being involved in transfer decisions. We spoke to staff working in a variety of roles, working across a diverse range of care homes. In total, we spoke to seven managers, three deputy managers, seven nurses, seven senior carers and six carers.

Step 2: Fieldwork in three care homes

We then returned to three of the homes, spending over 100 hours observing the work staff did to keep residents well and the work staff did when residents became unwell. We listened to conversations staff had about hospital transfers (with colleagues, residents, families and healthcare professionals) and we looked at policies and documents that staff used in their roles.

We combined the information and looked for recurring themes to develop a better picture of the decisions that care home staff make when faced with residents who may need to go to hospital.

What did we find?

Although there were circumstances when staff felt they would immediately initiate a transfer to hospital – for example if a resident had a head injury, possible fracture or life-threatening symptoms – more often than not, transfers occurred after a series of decisions had been made.

Upon noticing a resident was unwell, staff often sought advice from a colleague or chose to escalate to a senior staff member. Eventually, if the situation was unresolved amongst the team, staff might escalate to an emergency service, by calling 999, or a non-emergency service, by calling a GP or 111.

When deciding whether to escalate staff felt responsible for weighing-up a range of different risks. This included:

Risks to residents

Staff were concerned that care provided in hospital may not meet residents’ needs but they also felt that there were occasions when residents needed tests and treatments that were not available in the care home.

Risks to staff as decision makers

Staff wanted to feel like they had ‘done enough’ for the resident but also felt there was a need to ensure they were ‘covered’ and able to ‘justify’ their actions.

Risks to social relationships

Staff felt the decision to transfer a residents (or not) could damage their relationships with residents, family carers, colleagues and healthcare professionals, particularly if they made a decisions which others did not agree with.

Risks to the care homes in which staff worked

Staff were concerned that their decisions might have repercussions for the care home in which they worked, for example by influencing other people’s views of the home.

Risks to wider health and social care organisation

Staff described healthcare services as “under stress” and wanted to ensure they only requested support when necessary. They also discussed the potential for their decisions to influence broader perceptions of care homes, the social care sector and staff working within it.

Oftentimes, staff felt they would have preferred to care for the resident in the care home but also felt that to do so would create new risks – for example to their employment, reputation and financial stability.

Our take home messages

Our findings shed light on complex and multifaceted decisions that care home staff make prior to calling external healthcare services for support. Based on our findings, we suggest that acknowledging risk is an important first step in identifying ways to reduce risks for staff during transfer decisions. For example:

• Care home managers could support staff by encouraging staff to have open conversations about the risks that concern them when deciding whether to transfer a resident to hospital. This could be as part of every transfer decision, or after the event, for example in a debriefing or reflection session.
• Researchers and health and social care professionals who work alongside care home staff can support care home staff by identifying and evaluating different ways to reduce the risks that staff perceive during decision-making.