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A Clinical Pathway for Treating Pneumonia in the Nursing Home: Part I: The Nursing Perspective
ORIGINAL STUDIES
A Clinical Pathway for Treating Pneumonia in the Nursing Home: Part I: The Nursing Perspective Soo Chan Carusone, MSc, Mark Loeb, MD, MSc, and Lynne Lohfeld, PhD Objectives: This paper examines nursing staff’s perspectives on the utility and sustainability of a clinical pathway for treating nursing home residents with pneumonia. Design: A qualitative (case study) design was used. Setting: Data were collected from 6 nursing homes in Southern Ontario (5 from metro regions and 1 from a nonmetro region). Nursing homes were drawn from a larger randomized controlled trial of a clinical pathway for nursing home–acquired pneumonia conducted between 2001 and 2005. The clinical pathway was designed to assist in the identification, diagnosis, and management of pneumonia, including a decision tool for determining the appropriate location of treatment (hospital versus nursing home). Participants: A total of 7 focus groups and 1 one-onone interview were conducted between February 2003 and May 2004. Interview data were analyzed using the template style, described by Miller and Crabtree, to identify key themes.
Pneumonia and other lower respiratory tract infections (LRIs) are a major cause of morbidity, mortality, and hospitalization among nursing home residents. Currently, nearly one third of all nursing home residents with pneumonia are Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada (S.C.C., M.L., L.L.); Department of Pathology and Molecular Medicine, McMaster University (M.L.); Program for Educational Research and Development, McMaster University (L.L.). This research study was funded as part of a Canadian Institutes of Health Research (CIHR) Interdisciplinary Health Research Team (IHRT) grant. S.C.C. is the recipient of a CIHR Canada Graduate Scholarship Doctoral Award. Address correspondence to Lynne Lohfeld, PhD, McMaster University, Michael DeGroote Centre for Learning, Room 3521, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada.E-mail: [email protected]
Copyright ©2006 American Medical Directors Association DOI: 10.1016/j.jamda.2005.11.004 ORIGINAL STUDIES
Findings: Nurses strongly supported the idea of the clinical pathway and believed that providing pneumonia care in the nursing home was better for the resident. As a result of using the clinical pathway, nurses felt that pneumonia was being identified, diagnosed, and treated earlier, resulting in fewer hospitalizations. In addition to the benefits to resident care, the nurses felt that their skills and knowledge also improved. Nurses generally supported the implementation of the pathway although some concern was expressed about the additional responsibility and resources that would entail. Conclusions: The implementation of a clinical pathway for treating pneumonia in nursing homes and quick access to a backup clinician are desired by nurses who also believe it will result in better care and fewer hospitalizations of residents. (J Am Med Dir Assoc 2006; 7: 271–278)
Keywords: Qualitative research; nursing home; nursing; pneumonia care; clinical pathway
hospitalized.1 However, recent research suggests that residents with pneumonia who are at a low- to medium-level mortality risk may be managed safely in a nursing home at less cost.2,3 A clinical pathway was designed by an interdisciplinary team of researchers to assist in the recognition, diagnosis, and management of pneumonia in the nursing home (Figure 1). This pathway is being evaluated in a cluster-randomized controlled clinical trial to determine its effect on hospitalization and clinical outcomes. The successful implementation of this pathway would require cooperation of nursing home administrators, medical directors and attending physicians, staff, and residents and their family members. In Part I of this article, we examine the nurse perspective on the utility and sustainability of a clinical pathway for treating pneumonia in the nursing home. Part II is a report of the views of nursing home administrators and how they compare with those of nursing staff. Carusone et al. 271
pneumonia or other lower respiratory tract infections. This case study examined nursing staff views on the pathway and its use in 6 of the 10 clinical pathway homes (5 from metro regions, with a population of greater than 250 000 people, and 1 from a nonmetro region, with a population between 20 000 and 50 000 people). The researcher (S.C.C.) contacted the administrator directing nursing staff in the participating homes who then invited nurses involved in the care of residents with pneumonia during the study period to take part in an interview. Interviews were conducted between February 2003 and May 2004, at the end of which approximately 300 residents (from all 10 nursing homes) had been managed with the clinical pathway.
LTCF Resident with > 2 Symptoms/Signs: 1. 2. 3. 4. 5.
New or increased cough New or increased sputum production Fever (≥38ºC) Pleuritic chest pain New or increased findings on chest examination
Order Mobile Chest X-Ray (For Diagnosis of Pneumonia)
LTCF Management Criteria* • Resident is able to eat and drink? • Pulse < 100? • Respiratory Rate < 30 min? • BP > 90 systolic (decrease 20 mm Hg†)? • Oxygenation > 92% (>90% for COPD)?
Management on site in LTCF • Levofloxacin 500‡ mg/d orally X 10d • Fluid status assessed by research nurse • Rehydration using hypodermocylysis • Transfer to hospital if management criteria are no longer met
Data Collection NO
YES
Transfer to hospital •Levofloxacin 500‡ mg/d orally X 10d • List of indications outpatient investigation provided • Discharge back to LTCF when LTCF criteria met
*Used to evaluate residents throughout follow-up (in LTCFs and hospital). † For residents with baseline BP < 100. ‡
Adjusted for individuals with decreased renal function.
Fig. 1. Clinical pathway.
METHODS Study Design A single case study design was used to provide a holistic and in-depth exploration of the process of using a clinical pathway for pneumonia (defined here as the case).4 Data were collected from sub-cases (individual homes) until saturation was approached on the major themes of the analysis. Participants This study was part of a multicentered randomized controlled clinical trial involving 20 nursing homes in southern Ontario. The facilities were matched by size and then one of the paired facilities was randomly allocated to use the clinical pathway (Figure 1). The other facility provided normal care, where management decisions were left up to the resident’s physician. Before the initiation of the clinical trial in each of the nursing homes, the study nurses conducted informational sessions about the study that all nurses were encouraged to attend. During the clinical trial, study nurses made regular calls and visits to all participating nursing homes. The nursing staff at the participating nursing homes helped identify potentially eligible residents and provided this information to the study nurse. The study nurse, in collaboration with the facility staff, was then responsible for implementing the clinical pathway (Figure 1) for the management of residents with 272 Carusone et al.
Interview data were collected from nurses by the researcher (S.C.C.) in one-time, individual, and group semistructured interviews. S.C.C. is a trained researcher and was not involved in any clinical care during the study. All interviews were performed in the nursing homes, lasted 45 to 90 minutes, and were tape recorded and transcribed verbatim for accuracy. The interviews focused on 3 major themes: how should pneumonia in the nursing home be managed; how useful is the pneumonia clinical pathway; and what would be needed to continue implementing the pathway in the nursing home. Rigor and Credibility Numerous steps were taken to ensure that the findings were rigorous and faithfully represented participants’ views. Following the recommendations of Miller and Crabtree,5 the researcher made reflective journal entries throughout the study to ensure that decisions made during the study were thoroughly documented. To achieve investigator triangulation, L.L. and S.C.C. collected the interview data at 1 site, and independently coded transcripts. Two additional researchers with extensive clinical and qualitative experience were consulted throughout the study (peer review). A draft report of the findings was reviewed by several nurses (member checking) to ensure a fair representation of participants’ views. An audit trail, consisting of data collection instruments, raw data, and the analysis products, was carefully maintained.6 Ethical Considerations Informed consent was received in writing from all participants prior to conducting any interviews. Individuals were assured that all data would be stored safely and that findings would be presented in an anonymous fashion. None of the researchers worked for a nursing home enrolled in the study. This study was approved by the research ethics board at St Joseph’s Hospital in Hamilton, Ontario, Canada. Data Analysis After audiotapes of interviews were transcribed into verbatim written accounts (transcripts) by a professional typist, the researcher compared the written and audiotaped versions of each interview to correct transcription errors. Following standard procedures used in qualitative research, data from earlier transcripts were analyzed concurrently with ongoing data colJAMDA – June 2006
Table 1. Description of Sub-Cases Site
Size, No. Beds
Funding
Case Mix Index
Occupancy, %
Number of Nurses Interviewed
Time in Study,* mo
A B C D E F
100–150 100–150 ⬎150 ⬍100 ⬎150 ⬎150
Private Charitable Government Private Private Government
⬎105 ⬍95 95–105 95–105 ⬎105 ⬎105
100 100 99 78 96 96
5 1 6 4 3 5
26 30 27 30 24 24
* Number of months using the clinical pathway in the clinical trial at the time of the interviews.
lection.7,8 We used a 5-phase process7 to analyze the data. In phase 1 (description), S.C.C. read each transcript in its entirety before coding data and referred to her reflexive journal to ensure she had a deep understanding of the data. In phases 2 and 3 (organizing and connecting data), she coded passages to identify themes using a modifiable code book (template coding) based on a preliminary codebook created from the interview guide. The template was updated as more data were coded. This was followed by pattern coding9 in which relationships among themes were identified. In phase 4 (corroborating/legitimating), S.C.C. and L.L. individually coded transcripts and compared their findings to reach consensus about disconfirming evidence and alternative explanations. In phase 5 (representing the account), S.C.C. prepared a report in which she highlighted results with supporting quotes, interpreted the findings, and incorporated information from relevant literature. Presenting Results To support the interpretations drawn by the researchers, short exemplars or typical statements (quotes from participants) have been included in the text. Additional quotes are presented in tables to provide a deeper understanding of the case, and to enable readers to consider alternative interpretations.10 Quotes are presented in italics, and their sources identified with a letter corresponding to the sub-case (facility) and the number “1” or “2” when 2 focus groups were conducted at the same facility. Minimal editing was done to preserve authenticity while ensuring readability.11 Ellipses (. . .) were used where irrelevant information was deleted from a quote. Where necessary, clarifying information was added to a participant’s words and they are found nonitalicized in square brackets ([ ]). FINDINGS Setting and Participants In the Province of Ontario, long-term care facilities provide care and services to more than 70 000 persons whose needs cannot be met in the community: 70% are 80 years of age or older; 86% have some degree of incontinence; and 39% require “constant, complete, or total help with eating.”12 The provincial government licenses and regulates 3 types of longterm care facilities, most strongly distinguished by their ownership and management: nursing homes are privately owned ORIGINAL STUDIES
and operated for-profit; municipal homes for the aged are government owned and operated not-for-profit; and charitable homes for the aged are not-for-profit homes owned by charitable organizations. These 3 types of facilities are often referred to collectively as nursing homes, offering their residents 24-hour on-site nursing and personal care as well as access to physicians and other health care professionals, medication administration, room and board, laundry services, and recreational programs. The participants of this study included 24 nurses from 6 different nursing homes. The facilities, summarized in Table 1, had 90 to 250 beds (3 with ⬎ 150 beds). The nursing homes were privately funded (n ⫽ 3), government funded (n ⫽ 2), and charitable organizations (n ⫽ 1). The facilities’ Case Mix Index, an aggregate measure of the personal and nursing care requirements of their residents, ranged from 95 to 105 (n ⫽ 3) to over 105 (n ⫽ 3) (100 represents the provincial average). Occupancy rates were high, which have implications for staffing workloads. One facility had a rate of 78%, and all others were at 96% or above. Data were collected in 7 focus groups and 1 individual interview. All participants were female and either licensed practical nurses or registered nurses. The clinical pathway, summarized in Figure 1, directed staff to request an x-ray for all residents, which in most homes was not standard practice (none of the study homes had on-site x-ray equipment). Chest radiographs were performed in the nursing home, from Monday to Friday, by 1 of 2 companies using mobile units (no prior authorization was necessary and all costs were covered by the province). The pathway also used oxygen saturation values for management of residents. Most participants had either not used an oximeter before or had limited experience with these devices. The choice of antibiotic for the pathway was a respiratory fluoroquinolone (levofloxacin). Several participants referred to single daily doses of the antibiotic as a significant advantage. As one nurse said, “the once-a-day antibiotic is wonderful. It’s a real bonus. And because it’s standardized, we’re more tuned into it, too.” (B). As implemented in the study, the pathway also directed much more rigorous follow-up of residents. How Important Is Pneumonia? Pneumonia was noted by all to be an important problem in nursing homes. Although the high incidence of pneumonia Carusone et al. 273
Table 2. Where should residents with pneumonia be managed? The nursing home is better for the resident “Our clientele is a lot more confused. By shipping them off to the hospital, you’re changing their surroundings. They’re not well, and then you’re adding that on top of the confusion. It really does not help at all.” (A1) “I think they’re more comfortable here.” “This is their home. We’re trying to keep them here. That’s important.” (A1) “Because they’re in a familiar surrounding it’s so much easier. You can make them stay in their room and give them their meals, and they’re quite OK with that. But when they’re in a hospital bed and often in with other people, it’s a whole different issue.” (B) “Any resident with any dementia, they are so confused when they’re into a new setting. It is so hard on them. It’s so hard on the families, because they have to go and stay there 24 hours a day. Otherwise they are climbing out of bed or trying to get home, or [are] very frightened.” (C1) “. . . the staff knowing them and being able to know the little tricks to get them to cooperate, to drink. Even just to drink. There’s a lady I know right now off the top of my head, if you give her orange she’ll never drink. She has to have either ginger ale or apple. And I know that. That’s the idea.” (A1) Problems with the hospital “. . . Now when they go to hospital they have to wait so long. Waiting and waiting, I think is very stressful.” (A1) “. . . in the hospital right away they get a catheter because they have no time for diapers there.” “Sometimes they end up with UTIs. And bedsores.” (C1) “They come back [from the hospital] MRSA positive. And other complications.” (C2) “. . .hospitals are really busy. You send them, by the time they see the resident it’s what? How many hours? In the middle of the night and then they’re just going to order Levaquin and send them back again. It’s too much for the resident.” (D) “Even if they do go on to the hospital and have testing done there, like chest x-rays. . . you get them back from hospital with a 2-liner at the bottom of the record.” “no diagnosis. No results come back with them.” “no x-rays” (F)
was mentioned by some participants, the more prominent issues revolved around disease severity (“it is very, very important. It seems to be the major cause of death” [C1]). Several participants reported that pneumonia develops very quickly in nursing home residents and often leads to hospitalization and other complications. Where Should Residents With Pneumonia Receive Care? There was a strong consensus among nurses in each of the facilities that it would be better if residents with pneumonia were cared for in a nursing home rather than in a hospital. The main reason for this view was that the nursing home was familiar to residents (“They are happier [in the nursing home]. This is their home.” [A1]). It was believed that the familiarity of both the resident to the staff and the staff to the resident was important in achieving cooperation and a positive response to treatment. As one nurse explained, “[In the nursing home] they’re more relaxed and eat better, more likely to respond better to taking medications without resisting. They’re more likely to drink better as well, without having the [need for] IV for fluids” (E). Familiarity of the surroundings was thought to be particularly important for cognitively impaired residents (“They’re used to their surroundings. They’re used to us” [D]). Nurses were also concerned about the impact that moving residents into crowded hospitals has on their care in hospital and their condition once returned to the nursing home (“You talk to families that go into hospital. . . they don’t even see a doctor. They can’t find a nurse. And, they [the residents] come back with pressure sores.” [F]). However, some nurses felt that they did not have the confidence or the resources to either follow the clinical pathway or care for residents with pneumonia in the nursing home without additional support. Nurses most often 274 Carusone et al.
wanted additional registered staff and better access to clinicians capable of diagnosing and prescribing. Not all nursing homes had pulse oximeters, and 1 nursing home complained of poor access to medications from an external pharmacy. In addition, nurses also acknowledged that families have the ultimate decision regarding the location of care and, in a small proportion of cases, request hospitalization regardless of staff recommendations. As one nurse explained, “Family is a big issue here because some families, as soon as the doctor diagnoses their mom [with] pneumonia, they just panic and they want her sent out.” (C2) (see Table 2 for additional quotes). Advantages of Using the Clinical Pathway The nurses were very positive about their experience with the clinical pathway. They noted that it served as a reminder, providing them with information and giving them confidence to take action (“For a lot of people they need hints. . . if you have a guideline sometimes it routes you in the right direction and you feel more sure that ‘yeah, this is what I’m dealing with’” [B]). It also helped standardize pneumonia care in the nursing home so that “everyone is following the same thing” and “everyone is on board” (A2). Another benefit mentioned by the nurses was that the residents were being diagnosed earlier and because there was an easily accessible study nurse who could assess the residents, treatment was initiated earlier. Nurses reported that as a result, in many cases the pathway prevented the hospitalization of residents. As one participant noted, “Early diagnosis and early treatment [leads to] less trauma for the resident” (E). Perhaps the most frequently mentioned benefit of using the clinical pathway was having the study nurse as an accessible “backup” for the nurses in the long-term care facilities. As one JAMDA – June 2006
Table 3. Advantages of Using the Clinical Pathway It’s better for the resident “I found [the study] to be very effective. It was easy to reach somebody to get medication started right away. And the continual follow-up was really, really good.” (B) “I think we learned to recognize it quicker because of the study. It made us much more aware of what we were looking for. That’s a definite benefit. It saved us sending people to the hospital very much so.” (B) “Its likely prevented a lot of deaths since we’ve been on the study, just because it gets caught earlier.” (C1) “I know some of the residents downstairs would get sick a lot you know, but you’re right on it, so actually they lived longer. They did.” (A1) Improved access to clinician “[Pneumonia] seems to pop up quite regularly and when we do have it we can’t always get a hold of the doctor, so [the pathway] saves us shipping people out to the hospital.” (B) “Fast action! Because right away you started [treatment]. When we have to go to the doctor, we always miss a day. . . if it is the weekend, it is more.” (D) “It’s nice to have a second opinion, right? You could compare notes. . . because my assessment could be wrong.” (C2) “Say you had someone with a new cough that day and some other symptoms, so [the research nurse] would go down immediately and assess them. And that is a big difference. You get onto it earlier. . .” “Before we had to wait for the doctor or you would call the doctor, maybe.” (A1) Improved knowledge and skills “I learned a lot from [the study nurse], from the study.” “Yeah, things I had never used before. I learned some things about. . . coumadin levels and antibiotics. Just different things about oxygen.” “I learned a lot.” (A1) “Assessment skills is the number one [thing that I gained]. . . Because you know when you’re listening to the lungs of a resident you could hear crackles, you could hear a wheeze—there were different sounds. Before I couldn’t even differentiate one from the other.” (C2) “The oxygen saturation. We have now become aware of how important this is and the fact that there’s a machine. . .” (C1) “I’m just personally more aware of watching out for the symptoms.” (C1)
nurse said, “I think the staff feels comfortable that somebody actually checked [the resident] . . . whereas [before] we just describe the symptoms to the doctor, and the doctor isn’t there” (D). Not only did this make the nurses feel more comfortable when providing care, but it also reduced the amount of time between diagnosis and treatment. Several nurses described how this prevented hospitalizations: Before the study started we ended up sending a lot of residents to the hospital with congestion, high fever. When the study started, we were able to call in the [study] nurse . . . to come, diagnose, give the order, get the chest x-ray, and get the resident started on antibiotics as soon as possible. We were able to keep the pneumonia here and not send them out to hospital. (E)
In addition to the clear benefits for residents, most of the nurses also noted that using the pathway and interacting with the study nurse improved their clinical skills and knowledge about pneumonia in older adults. This, in turn, led to more confidence when dealing with pneumonia (“I learned a lot from [the study nurse and] from the study” [A1]) (see Table 3 for additional quotes). Concerns With the Pathway Although very few suggestions were made about how to improve the clinical pathway, some nurses were worried about certain aspects of diagnosis and care directed by the pathway. Staff in one nursing home were concerned about the validity of the chest x-rays (“The chest x-ray poses a bit of a problem. . .. You order it one day and they’ll come sometime the next day. So maybe the antibiotic is already working and clearing things. . . so ORIGINAL STUDIES
then the x-ray wouldn’t be too accurate” [C1]). Another nurse in the same facility suggested that mobile x-rays used in nursing homes may be less accurate because they are taken from only one direction. Nursing homes differed greatly in their approach to hypodermoclysis. Some homes used it regularly even before the study whereas others did not. One nurse felt that it should be “a last ditch kind of effort [because] the ones that are confused are not going to be very cooperative with that. So I would rather just slowly but surely get them the fluids orally” (B). Other nurses felt that individuals who need hydration “should go to the hospital because you know what, we don’t have enough staff!” (D). A number of nurses also mentioned adverse reactions to the antibiotic as a concern (“I’ve had a few bad incidents of really bad side effects, diarrhea” [A1]). Implementation of the Pathway To successfully adopt the clinical pathway, most of the nurses felt that additional training on chest assessments would be required (“We need to stress that we need training” [D]). The study nurse would also need to be replaced with an in-house staff person who could serve as a backup for nurses on the units. Participants strongly believed that having an accessible backup person to assist in the diagnosis and facilitate the treatment of residents was essential to achieving the benefits of the pathway (“[Having the study nurse available] took away a lot of the fear of pneumonia. Well, ‘fear’ might be a bit strong, but there was always someone that you could call if you just weren’t sure. . .” [A2]). Most nurses felt that a single individual, such as a nurse Carusone et al. 275
Table 4. Barriers to Implementing the Pneumonia Clinical Pathway Further training “Confidence. Being able to make your own judgements. And skill. You have to have a certain amount of skill to be able to make the judgment. That’s something they’d have to have some education and upgrades.” (B) “I’d want a bit more training listening to chests.” (C1) “I think it’s more the comfort level of the staff pertaining to the assessment or auscultation skills. You want to rule out that it’s not something else, because the onus is going to be on us. For it to be implemented it has to be in a policy and we have to be trained.” (D) “We need, I think, to stress it that we need training. Some of the nurses here worked in a hospital so they’re very good at doing this. Some haven’t. We just need to be on the same page so that we’re going to be able to do a good job at it.” (D) More responsibility and work “We’ll try and do a lot of that but it’s the workload I guess. . . we are so busy.” (A1) “. . . I would rather send the resident to the hospital. If nobody was going to check, and it will be depending on us—ok, this is it. We can’t. . . We want a back up.” (D) “There should be someone that is in charge, to take the responsibility.” (E) “Most of the time we have an agency [nurse]. . . It’s kind of hard. It’s scary. To me, it’s scary. I’d rather send the resident to the hospital.” (D) “[we want] somebody we could fall back on. . .We won’t abuse the resource! We won’t call her [all the time]! It’s [just] nice that you know there is someone you could call if you’re really in a bind.” (D) “I really like this idea [of using the pathway with a “middle person”], I think we should have someone like the nurse practitioner that knows, that needs to be responsible. Because if we identify the symptoms, we can call them and tell them what is going on [and] the order can be started immediately.” (E) “If we had a nurse practitioner available to us when we needed her— that would be helpful.” (F) “If we are questioning somebody and we are just not too sure is it pneumonia or, isn’t it?’—and that goes [for] any shift: days, evening or nights – it would help to have ANY second opinion!” (F)
practitioner or infectious disease practitioner, should be responsible for initiating treatment in-house. However, some nurses felt that a team of trained people could also fill that role. There was no agreement about whether those individuals should receive additional time or pay for these responsibilities. Although most of the study participants strongly supported the implementation of the pathway, some nurses were concerned about the additional responsibility that would entail if fewer residents were hospitalized. In one facility, a registered nurse (RN) expressed concern that without a backup person she would have more work to do (“I am the only RN. I cannot manage everybody else’s load because I have my [own] problems. . .”). She then went on to state, “there should be somebody [other than me] that is responsible” (E). Barriers to continued use of the clinical pathway for pneumonia included the costs and time associated with upgrading nurses’ clinical skills and ensuring easy access to the oximeter and portable x-ray equipment. Other barriers included more general personnel and financial pressures facing nursing homes, particularly when there are disease outbreaks. At the individual level, fear of change and a lack of confidence could also be problematic. As one nurse said, “I know some of the RPNs have been here for 25 years and all these changes are not easy for them” (B) (see Table 4 for additional quotes). DISCUSSION The interviews we conducted with nursing staff at 6 nursing homes revealed that nurses strongly supported the idea of providing pneumonia care in the nursing home. Overall they believed that avoiding hospitalization, when possible, was better for residents who would be more comfortable and less confused if cared for in the familiar surroundings of the 276 Carusone et al.
nursing home. The nurses were also concerned about the amount of time spent waiting for care and the potential for complications that are associated with sending residents to hospital. They also indicated that on-site care is consistent with the preferences of residents and most family members. According to Longo et al,13 identifying and managing acute illnesses in nursing homes involves 4 stages or types of activities: symptom recognition, illness identification, clinician notification, and treatment. Our findings suggest that a clinical pathway may facilitate the process at each stage. The pathway provides nurses with information on symptoms with which to identify cases of pneumonia, and then guides them through the stages of diagnosis and management of cases, resulting in more timely treatment. This was confirmed in our interviews with nurses. In addition to directly benefiting residents, nurses also felt that their knowledge, clinical skills, and confidence had increased as a consequence of using the pneumonia pathway. These factors are positively associated with nurses’ autonomy,14,15 suggesting that the pathway may also contribute to job satisfaction and nurse retention.16 –18 We believe that an important outcome of using the pathway is to facilitate communication among nursing home staff and between nurses and physicians. Effective communication is critical to providing high-quality care in any health care setting. However, for several reasons, this may be more difficult to achieve in the nursing home setting. First, physicians are usually not on-site and so much of the nurse-physician communication must occur in the absence of personal contact. In one study, nurses reported that poor communication was the leading reason for providing less-than-optimal care in nursing homes.19 In acute care settings, numerous studies have found a posJAMDA – June 2006
itive correlation between nurse-physician communication and outcomes such as quality of care, mortality, length of stay, nurse retention, and perception of good-quality care.20 –22 However, few studies have examined the role of nurse-physician communication in the nursing home. One such study found that communication is an important barrier to providing timely care for acute infections in nursing homes.13 Another study demonstrated a positive association between the quality of nurse-physician communication and the degree of concurrence between drug use and recommended drug selection and polymedicine practices in nursing homes.23 Reasons for poor nurse-physician communication include physician distrust of nurses’ assessments.13,24 In part, this may be due to the difference in diagnostic cues: physicians are guided more by specific signs and symptoms, whereas nurses tend to focus more on resident response to illness when diagnosing or treating health problems.24 The use of this clinical pathway may facilitate nurse-physician communication by providing nurses with a list of signs, symptoms, and vital statistics that are more consistent with physician expectations of diagnostic cues to use when contacting physicians about suspected pneumonia cases in nursing homes. It may also facilitate communication among nursing home staff by identifying a consistent set of important signs, symptoms, and vital signs to be monitored and charted. The identification and management of pneumonia cases may also be enhanced by using a “middle-person,” such as a nurse practitioner or an identified staff person, to serve as a liaison between nurses and physicians. Our study participants believed that having quick access to the study nurse during the trial facilitated early diagnosis and treatment, and also prevented unnecessary hospitalization of residents for pneumonia. Research has identified several benefits from employing nurse practitioners in nursing homes, including reduced emergency department and acute care costs, and lower hospitalization rates.25–27 One recent study demonstrated that nursing home residents under the care of both nurse practitioners and physicians received more acute care visits and received more treatments for eye, ear, nose and throat, and dermatologic problems than residents only under the care of a physician.28 In our study, in addition to the above-mentioned benefits to the residents, the nurses believed that the personal contact with the study nurse improved their knowledge and clinical skills, which has far-reaching implications for improving the quality of care of all nursing home residents. Although most participants were in favor of adopting the clinical pathway in their facility, a number of concerns were raised. The most important one, expressed by some of the participants, was a reluctance to take on more responsibility for decisions involved in identifying and managing pneumonia. By providing additional training and improved communication via a “middle-person,” some of these concerns were addressed. It may be important to further explore these issues and how to deal with them in individual facilities. We acknowledge that this study has several limitations. First, this cross-sectional study explored the nurses’ experience with a pneumonia clinical pathway in the context of a clinical trial in which additional personnel and material reORIGINAL STUDIES
sources were provided. This experience may differ significantly when the pathway is implemented as part of “normal care” by nursing homes, and may also change with the time of exposure to the pathway. Second, because nurses conceptually supported the pathway, they might have been more hesitant to express concerns about its use and implementation. A longer term examination of the perceived benefits and problems associated with using this clinical pathway could help answer more detailed questions about its implementation as part of standard operating procedures rather than part of a clinical trial. CONCLUSION These findings suggest that nurses are in favor of using a clinical pathway for treating nursing home–acquired pneumonia. The implementation of the pathway, in conjunction with easy access to a backup clinician, may result in better care and decreased rate of hospitalization of residents, as well as to improved knowledge, confidence, and skills for nursing home nurses. REFERENCES 1. Loeb M, McGeer A, McArthur M, et al. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. Arch Intern Med 1999;159:2058 –2064. 2. Fried TR, Gillick MR, Lipsitz LA. Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients with pneumonia, J Gen Intern Med 1995;10:246 –250. 3. Kruse RL, Mehr DR, Boles KE, et al. Does hospitalization impact survival after lower respiratory infection in nursing home residents? Med Care 2004;42:860 – 870. 4. Yin RK. Case Study Research: Design and Methods. 3rd ed. Thousand Oaks, CA: SAGE Publications Inc., 2003. 5. Miller WL, Crabtree BF. Depth interviewing. In: Crabtree BF, Miller WL, eds. Doing Qualitative Research. 2nd ed. Thousand Oaks, CA: SAGE Publications Inc., 1999:89 –107. 6. Sandelowski M. The problem of rigor in qualitative research. Adv Nurs Sci 1986;8:27–37. 7. Miller WL, Crabtree BF. The dance of interpretation. In: Crabtree BF, Miller WL, eds. Doing Qualitative Research. 2nd ed. Thousand Oaks, CA: SAGE Publications Inc., 1999:127–143. 8. Patton MQ. Qualitative Research and Evaluation Methods. 3rd ed. Thousand Oaks, CA: SAGE Publications Inc., 2002. 9. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. Thousand Oaks, CA: SAGE Publications, Inc., 1994. 10. Stake RE. The Art of Case Study Research. Thousand Oaks, CA: SAGE Publications Inc., 1995. 11. Krueger RA. Analyzing and Reporting Focus Group Results. Volume 6, The Focus Group Kit (Morgan D.L. & Krueger R.A.). Thousand Oaks, CA: SAGE Publications, Inc., 1997. 12. Smith M. Commitment to care: A plan for long-term care in Ontario (a report for the Ministry of Health, Long-Term Care Division). Ottawa: Ministry of Health and Long-Term Care. Report 7610-2241610. Available at: www.health.gov.on.ca/english/public/pub/ministry_reports/ ltc_04/mophltc.report04.pdf. Accessed January 13, 2006. 13. Longo DR, Young J, Mehr D, et al. Barriers to timely care of acute infections in nursing homes: A preliminary qualitative study. J Am Med Dir Assoc 2004;5:S5–S10. 14. Mrayyan MT. Nurses’ autonomy: Influence of nurse managers’ actions. J Adv Nurs 2004;45:326 –336. 15. Wade GH. Professional nurse autonomy: Concept analysis and application to nursing education. J Adv Nurs 1999;30:310 –318. 16. Chaboyer W, Najman J, Dunn S. Factors influencing job valuation: A comparative study of critical care and non-critical care nurses. Int J Nurs Stud 2001;38:153–161. Carusone et al. 277
17. Cowin L. The effects of nurses’ job satisfaction on retention: An Australian perspective. J Nurs Adm 2002;32:283–291. 18. Finn CP. Autonomy: An important component for nurses’ job satisfaction. Int J Nurs Stud 2001;38:349 –357. 19. Scott-Cawiezell J, Schenkman M, Moore L, et al. Exploring nursing home staff’s perceptions of communication and leadership to facilitate quality improvement. J Nurs Care Qual 2004;19:242–252. 20. Rafferty AM, Ball J, Aiken LH. Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Qual Health Care 2001;10:32–37. 21. Shortell SM, Zimmerman JE, Rousseau DM, et al. The performance of intensive care units: Does good management make a difference? Med Care 1994;32:508 –525. 22. Zimmerman JE, Shortell SM, Rousseau DM, et al. Improving intensive care: Observations based on organizational case studies in nine intensive care units: A prospective, multicenter study. Crit Care Med 1993;21: 1443–1451.
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23. Schmidt I, Svarstad BL. Nurse-physician communication and quality of drug use in Swedish nursing homes. Soc Sci Med 2002;54:1767–1777. 24. Cadogan MP, Franzi C, Osterweil D, Hill T. Barriers to effective communication in skilled nursing facilities: Differences in perception between nurses and physicians. J Am Geriatr Soc 1999;47:71–75. 25. Burl JB, Bonner A, Khan AM. Geriatric nurse practitioners in long-term care: Demonstration of effectiveness in managed care. J Am Geriatr Soc 1998;46:506 –510. 26. Garrard J, Kane RL, Radosevich DM, et al. Impact of geriatric nurse practitioners on nursing-home residents’ functional status, satisfaction, and discharge outcomes. Med Care 1990;28:271–283. 27. Intrator O, Castle NG, Mor V. Facility characteristics associated with hospitalization of nursing home residents: Results of a national study. Med Care 1999;37:228 –237. 28. Aigner MJ, Drew S, Phipps J. A comparative study of nursing home resident outcomes between care provided by nurse practitioners/physicians versus physicians only. J Am Med Dir Assoc 2004; 5:16 –23.
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A Clinical Pathway for Treating Pneumonia in the Nursing Home: Part I: The Nursing Perspective Soo Chan Carusone, MSc, Mark Loeb, MD, MSc, and Lynne Lohfeld, PhD Objectives: This paper examines nursing staff’s perspectives on the utility and sustainability of a clinical pathway for treating nursing home residents with pneumonia. Design: A qualitative (case study) design was used. Setting: Data were collected from 6 nursing homes in Southern Ontario (5 from metro regions and 1 from a nonmetro region). Nursing homes were drawn from a larger randomized controlled trial of a clinical pathway for nursing home–acquired pneumonia conducted between 2001 and 2005. The clinical pathway was designed to assist in the identification, diagnosis, and management of pneumonia, including a decision tool for determining the appropriate location of treatment (hospital versus nursing home). Participants: A total of 7 focus groups and 1 one-onone interview were conducted between February 2003 and May 2004. Interview data were analyzed using the template style, described by Miller and Crabtree, to identify key themes.
Pneumonia and other lower respiratory tract infections (LRIs) are a major cause of morbidity, mortality, and hospitalization among nursing home residents. Currently, nearly one third of all nursing home residents with pneumonia are Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada (S.C.C., M.L., L.L.); Department of Pathology and Molecular Medicine, McMaster University (M.L.); Program for Educational Research and Development, McMaster University (L.L.). This research study was funded as part of a Canadian Institutes of Health Research (CIHR) Interdisciplinary Health Research Team (IHRT) grant. S.C.C. is the recipient of a CIHR Canada Graduate Scholarship Doctoral Award. Address correspondence to Lynne Lohfeld, PhD, McMaster University, Michael DeGroote Centre for Learning, Room 3521, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada.E-mail: [email protected]
Copyright ©2006 American Medical Directors Association DOI: 10.1016/j.jamda.2005.11.004 ORIGINAL STUDIES
Findings: Nurses strongly supported the idea of the clinical pathway and believed that providing pneumonia care in the nursing home was better for the resident. As a result of using the clinical pathway, nurses felt that pneumonia was being identified, diagnosed, and treated earlier, resulting in fewer hospitalizations. In addition to the benefits to resident care, the nurses felt that their skills and knowledge also improved. Nurses generally supported the implementation of the pathway although some concern was expressed about the additional responsibility and resources that would entail. Conclusions: The implementation of a clinical pathway for treating pneumonia in nursing homes and quick access to a backup clinician are desired by nurses who also believe it will result in better care and fewer hospitalizations of residents. (J Am Med Dir Assoc 2006; 7: 271–278)
Keywords: Qualitative research; nursing home; nursing; pneumonia care; clinical pathway
hospitalized.1 However, recent research suggests that residents with pneumonia who are at a low- to medium-level mortality risk may be managed safely in a nursing home at less cost.2,3 A clinical pathway was designed by an interdisciplinary team of researchers to assist in the recognition, diagnosis, and management of pneumonia in the nursing home (Figure 1). This pathway is being evaluated in a cluster-randomized controlled clinical trial to determine its effect on hospitalization and clinical outcomes. The successful implementation of this pathway would require cooperation of nursing home administrators, medical directors and attending physicians, staff, and residents and their family members. In Part I of this article, we examine the nurse perspective on the utility and sustainability of a clinical pathway for treating pneumonia in the nursing home. Part II is a report of the views of nursing home administrators and how they compare with those of nursing staff. Carusone et al. 271
pneumonia or other lower respiratory tract infections. This case study examined nursing staff views on the pathway and its use in 6 of the 10 clinical pathway homes (5 from metro regions, with a population of greater than 250 000 people, and 1 from a nonmetro region, with a population between 20 000 and 50 000 people). The researcher (S.C.C.) contacted the administrator directing nursing staff in the participating homes who then invited nurses involved in the care of residents with pneumonia during the study period to take part in an interview. Interviews were conducted between February 2003 and May 2004, at the end of which approximately 300 residents (from all 10 nursing homes) had been managed with the clinical pathway.
LTCF Resident with > 2 Symptoms/Signs: 1. 2. 3. 4. 5.
New or increased cough New or increased sputum production Fever (≥38ºC) Pleuritic chest pain New or increased findings on chest examination
Order Mobile Chest X-Ray (For Diagnosis of Pneumonia)
LTCF Management Criteria* • Resident is able to eat and drink? • Pulse < 100? • Respiratory Rate < 30 min? • BP > 90 systolic (decrease 20 mm Hg†)? • Oxygenation > 92% (>90% for COPD)?
Management on site in LTCF • Levofloxacin 500‡ mg/d orally X 10d • Fluid status assessed by research nurse • Rehydration using hypodermocylysis • Transfer to hospital if management criteria are no longer met
Data Collection NO
YES
Transfer to hospital •Levofloxacin 500‡ mg/d orally X 10d • List of indications outpatient investigation provided • Discharge back to LTCF when LTCF criteria met
*Used to evaluate residents throughout follow-up (in LTCFs and hospital). † For residents with baseline BP < 100. ‡
Adjusted for individuals with decreased renal function.
Fig. 1. Clinical pathway.
METHODS Study Design A single case study design was used to provide a holistic and in-depth exploration of the process of using a clinical pathway for pneumonia (defined here as the case).4 Data were collected from sub-cases (individual homes) until saturation was approached on the major themes of the analysis. Participants This study was part of a multicentered randomized controlled clinical trial involving 20 nursing homes in southern Ontario. The facilities were matched by size and then one of the paired facilities was randomly allocated to use the clinical pathway (Figure 1). The other facility provided normal care, where management decisions were left up to the resident’s physician. Before the initiation of the clinical trial in each of the nursing homes, the study nurses conducted informational sessions about the study that all nurses were encouraged to attend. During the clinical trial, study nurses made regular calls and visits to all participating nursing homes. The nursing staff at the participating nursing homes helped identify potentially eligible residents and provided this information to the study nurse. The study nurse, in collaboration with the facility staff, was then responsible for implementing the clinical pathway (Figure 1) for the management of residents with 272 Carusone et al.
Interview data were collected from nurses by the researcher (S.C.C.) in one-time, individual, and group semistructured interviews. S.C.C. is a trained researcher and was not involved in any clinical care during the study. All interviews were performed in the nursing homes, lasted 45 to 90 minutes, and were tape recorded and transcribed verbatim for accuracy. The interviews focused on 3 major themes: how should pneumonia in the nursing home be managed; how useful is the pneumonia clinical pathway; and what would be needed to continue implementing the pathway in the nursing home. Rigor and Credibility Numerous steps were taken to ensure that the findings were rigorous and faithfully represented participants’ views. Following the recommendations of Miller and Crabtree,5 the researcher made reflective journal entries throughout the study to ensure that decisions made during the study were thoroughly documented. To achieve investigator triangulation, L.L. and S.C.C. collected the interview data at 1 site, and independently coded transcripts. Two additional researchers with extensive clinical and qualitative experience were consulted throughout the study (peer review). A draft report of the findings was reviewed by several nurses (member checking) to ensure a fair representation of participants’ views. An audit trail, consisting of data collection instruments, raw data, and the analysis products, was carefully maintained.6 Ethical Considerations Informed consent was received in writing from all participants prior to conducting any interviews. Individuals were assured that all data would be stored safely and that findings would be presented in an anonymous fashion. None of the researchers worked for a nursing home enrolled in the study. This study was approved by the research ethics board at St Joseph’s Hospital in Hamilton, Ontario, Canada. Data Analysis After audiotapes of interviews were transcribed into verbatim written accounts (transcripts) by a professional typist, the researcher compared the written and audiotaped versions of each interview to correct transcription errors. Following standard procedures used in qualitative research, data from earlier transcripts were analyzed concurrently with ongoing data colJAMDA – June 2006
Table 1. Description of Sub-Cases Site
Size, No. Beds
Funding
Case Mix Index
Occupancy, %
Number of Nurses Interviewed
Time in Study,* mo
A B C D E F
100–150 100–150 ⬎150 ⬍100 ⬎150 ⬎150
Private Charitable Government Private Private Government
⬎105 ⬍95 95–105 95–105 ⬎105 ⬎105
100 100 99 78 96 96
5 1 6 4 3 5
26 30 27 30 24 24
* Number of months using the clinical pathway in the clinical trial at the time of the interviews.
lection.7,8 We used a 5-phase process7 to analyze the data. In phase 1 (description), S.C.C. read each transcript in its entirety before coding data and referred to her reflexive journal to ensure she had a deep understanding of the data. In phases 2 and 3 (organizing and connecting data), she coded passages to identify themes using a modifiable code book (template coding) based on a preliminary codebook created from the interview guide. The template was updated as more data were coded. This was followed by pattern coding9 in which relationships among themes were identified. In phase 4 (corroborating/legitimating), S.C.C. and L.L. individually coded transcripts and compared their findings to reach consensus about disconfirming evidence and alternative explanations. In phase 5 (representing the account), S.C.C. prepared a report in which she highlighted results with supporting quotes, interpreted the findings, and incorporated information from relevant literature. Presenting Results To support the interpretations drawn by the researchers, short exemplars or typical statements (quotes from participants) have been included in the text. Additional quotes are presented in tables to provide a deeper understanding of the case, and to enable readers to consider alternative interpretations.10 Quotes are presented in italics, and their sources identified with a letter corresponding to the sub-case (facility) and the number “1” or “2” when 2 focus groups were conducted at the same facility. Minimal editing was done to preserve authenticity while ensuring readability.11 Ellipses (. . .) were used where irrelevant information was deleted from a quote. Where necessary, clarifying information was added to a participant’s words and they are found nonitalicized in square brackets ([ ]). FINDINGS Setting and Participants In the Province of Ontario, long-term care facilities provide care and services to more than 70 000 persons whose needs cannot be met in the community: 70% are 80 years of age or older; 86% have some degree of incontinence; and 39% require “constant, complete, or total help with eating.”12 The provincial government licenses and regulates 3 types of longterm care facilities, most strongly distinguished by their ownership and management: nursing homes are privately owned ORIGINAL STUDIES
and operated for-profit; municipal homes for the aged are government owned and operated not-for-profit; and charitable homes for the aged are not-for-profit homes owned by charitable organizations. These 3 types of facilities are often referred to collectively as nursing homes, offering their residents 24-hour on-site nursing and personal care as well as access to physicians and other health care professionals, medication administration, room and board, laundry services, and recreational programs. The participants of this study included 24 nurses from 6 different nursing homes. The facilities, summarized in Table 1, had 90 to 250 beds (3 with ⬎ 150 beds). The nursing homes were privately funded (n ⫽ 3), government funded (n ⫽ 2), and charitable organizations (n ⫽ 1). The facilities’ Case Mix Index, an aggregate measure of the personal and nursing care requirements of their residents, ranged from 95 to 105 (n ⫽ 3) to over 105 (n ⫽ 3) (100 represents the provincial average). Occupancy rates were high, which have implications for staffing workloads. One facility had a rate of 78%, and all others were at 96% or above. Data were collected in 7 focus groups and 1 individual interview. All participants were female and either licensed practical nurses or registered nurses. The clinical pathway, summarized in Figure 1, directed staff to request an x-ray for all residents, which in most homes was not standard practice (none of the study homes had on-site x-ray equipment). Chest radiographs were performed in the nursing home, from Monday to Friday, by 1 of 2 companies using mobile units (no prior authorization was necessary and all costs were covered by the province). The pathway also used oxygen saturation values for management of residents. Most participants had either not used an oximeter before or had limited experience with these devices. The choice of antibiotic for the pathway was a respiratory fluoroquinolone (levofloxacin). Several participants referred to single daily doses of the antibiotic as a significant advantage. As one nurse said, “the once-a-day antibiotic is wonderful. It’s a real bonus. And because it’s standardized, we’re more tuned into it, too.” (B). As implemented in the study, the pathway also directed much more rigorous follow-up of residents. How Important Is Pneumonia? Pneumonia was noted by all to be an important problem in nursing homes. Although the high incidence of pneumonia Carusone et al. 273
Table 2. Where should residents with pneumonia be managed? The nursing home is better for the resident “Our clientele is a lot more confused. By shipping them off to the hospital, you’re changing their surroundings. They’re not well, and then you’re adding that on top of the confusion. It really does not help at all.” (A1) “I think they’re more comfortable here.” “This is their home. We’re trying to keep them here. That’s important.” (A1) “Because they’re in a familiar surrounding it’s so much easier. You can make them stay in their room and give them their meals, and they’re quite OK with that. But when they’re in a hospital bed and often in with other people, it’s a whole different issue.” (B) “Any resident with any dementia, they are so confused when they’re into a new setting. It is so hard on them. It’s so hard on the families, because they have to go and stay there 24 hours a day. Otherwise they are climbing out of bed or trying to get home, or [are] very frightened.” (C1) “. . . the staff knowing them and being able to know the little tricks to get them to cooperate, to drink. Even just to drink. There’s a lady I know right now off the top of my head, if you give her orange she’ll never drink. She has to have either ginger ale or apple. And I know that. That’s the idea.” (A1) Problems with the hospital “. . . Now when they go to hospital they have to wait so long. Waiting and waiting, I think is very stressful.” (A1) “. . . in the hospital right away they get a catheter because they have no time for diapers there.” “Sometimes they end up with UTIs. And bedsores.” (C1) “They come back [from the hospital] MRSA positive. And other complications.” (C2) “. . .hospitals are really busy. You send them, by the time they see the resident it’s what? How many hours? In the middle of the night and then they’re just going to order Levaquin and send them back again. It’s too much for the resident.” (D) “Even if they do go on to the hospital and have testing done there, like chest x-rays. . . you get them back from hospital with a 2-liner at the bottom of the record.” “no diagnosis. No results come back with them.” “no x-rays” (F)
was mentioned by some participants, the more prominent issues revolved around disease severity (“it is very, very important. It seems to be the major cause of death” [C1]). Several participants reported that pneumonia develops very quickly in nursing home residents and often leads to hospitalization and other complications. Where Should Residents With Pneumonia Receive Care? There was a strong consensus among nurses in each of the facilities that it would be better if residents with pneumonia were cared for in a nursing home rather than in a hospital. The main reason for this view was that the nursing home was familiar to residents (“They are happier [in the nursing home]. This is their home.” [A1]). It was believed that the familiarity of both the resident to the staff and the staff to the resident was important in achieving cooperation and a positive response to treatment. As one nurse explained, “[In the nursing home] they’re more relaxed and eat better, more likely to respond better to taking medications without resisting. They’re more likely to drink better as well, without having the [need for] IV for fluids” (E). Familiarity of the surroundings was thought to be particularly important for cognitively impaired residents (“They’re used to their surroundings. They’re used to us” [D]). Nurses were also concerned about the impact that moving residents into crowded hospitals has on their care in hospital and their condition once returned to the nursing home (“You talk to families that go into hospital. . . they don’t even see a doctor. They can’t find a nurse. And, they [the residents] come back with pressure sores.” [F]). However, some nurses felt that they did not have the confidence or the resources to either follow the clinical pathway or care for residents with pneumonia in the nursing home without additional support. Nurses most often 274 Carusone et al.
wanted additional registered staff and better access to clinicians capable of diagnosing and prescribing. Not all nursing homes had pulse oximeters, and 1 nursing home complained of poor access to medications from an external pharmacy. In addition, nurses also acknowledged that families have the ultimate decision regarding the location of care and, in a small proportion of cases, request hospitalization regardless of staff recommendations. As one nurse explained, “Family is a big issue here because some families, as soon as the doctor diagnoses their mom [with] pneumonia, they just panic and they want her sent out.” (C2) (see Table 2 for additional quotes). Advantages of Using the Clinical Pathway The nurses were very positive about their experience with the clinical pathway. They noted that it served as a reminder, providing them with information and giving them confidence to take action (“For a lot of people they need hints. . . if you have a guideline sometimes it routes you in the right direction and you feel more sure that ‘yeah, this is what I’m dealing with’” [B]). It also helped standardize pneumonia care in the nursing home so that “everyone is following the same thing” and “everyone is on board” (A2). Another benefit mentioned by the nurses was that the residents were being diagnosed earlier and because there was an easily accessible study nurse who could assess the residents, treatment was initiated earlier. Nurses reported that as a result, in many cases the pathway prevented the hospitalization of residents. As one participant noted, “Early diagnosis and early treatment [leads to] less trauma for the resident” (E). Perhaps the most frequently mentioned benefit of using the clinical pathway was having the study nurse as an accessible “backup” for the nurses in the long-term care facilities. As one JAMDA – June 2006
Table 3. Advantages of Using the Clinical Pathway It’s better for the resident “I found [the study] to be very effective. It was easy to reach somebody to get medication started right away. And the continual follow-up was really, really good.” (B) “I think we learned to recognize it quicker because of the study. It made us much more aware of what we were looking for. That’s a definite benefit. It saved us sending people to the hospital very much so.” (B) “Its likely prevented a lot of deaths since we’ve been on the study, just because it gets caught earlier.” (C1) “I know some of the residents downstairs would get sick a lot you know, but you’re right on it, so actually they lived longer. They did.” (A1) Improved access to clinician “[Pneumonia] seems to pop up quite regularly and when we do have it we can’t always get a hold of the doctor, so [the pathway] saves us shipping people out to the hospital.” (B) “Fast action! Because right away you started [treatment]. When we have to go to the doctor, we always miss a day. . . if it is the weekend, it is more.” (D) “It’s nice to have a second opinion, right? You could compare notes. . . because my assessment could be wrong.” (C2) “Say you had someone with a new cough that day and some other symptoms, so [the research nurse] would go down immediately and assess them. And that is a big difference. You get onto it earlier. . .” “Before we had to wait for the doctor or you would call the doctor, maybe.” (A1) Improved knowledge and skills “I learned a lot from [the study nurse], from the study.” “Yeah, things I had never used before. I learned some things about. . . coumadin levels and antibiotics. Just different things about oxygen.” “I learned a lot.” (A1) “Assessment skills is the number one [thing that I gained]. . . Because you know when you’re listening to the lungs of a resident you could hear crackles, you could hear a wheeze—there were different sounds. Before I couldn’t even differentiate one from the other.” (C2) “The oxygen saturation. We have now become aware of how important this is and the fact that there’s a machine. . .” (C1) “I’m just personally more aware of watching out for the symptoms.” (C1)
nurse said, “I think the staff feels comfortable that somebody actually checked [the resident] . . . whereas [before] we just describe the symptoms to the doctor, and the doctor isn’t there” (D). Not only did this make the nurses feel more comfortable when providing care, but it also reduced the amount of time between diagnosis and treatment. Several nurses described how this prevented hospitalizations: Before the study started we ended up sending a lot of residents to the hospital with congestion, high fever. When the study started, we were able to call in the [study] nurse . . . to come, diagnose, give the order, get the chest x-ray, and get the resident started on antibiotics as soon as possible. We were able to keep the pneumonia here and not send them out to hospital. (E)
In addition to the clear benefits for residents, most of the nurses also noted that using the pathway and interacting with the study nurse improved their clinical skills and knowledge about pneumonia in older adults. This, in turn, led to more confidence when dealing with pneumonia (“I learned a lot from [the study nurse and] from the study” [A1]) (see Table 3 for additional quotes). Concerns With the Pathway Although very few suggestions were made about how to improve the clinical pathway, some nurses were worried about certain aspects of diagnosis and care directed by the pathway. Staff in one nursing home were concerned about the validity of the chest x-rays (“The chest x-ray poses a bit of a problem. . .. You order it one day and they’ll come sometime the next day. So maybe the antibiotic is already working and clearing things. . . so ORIGINAL STUDIES
then the x-ray wouldn’t be too accurate” [C1]). Another nurse in the same facility suggested that mobile x-rays used in nursing homes may be less accurate because they are taken from only one direction. Nursing homes differed greatly in their approach to hypodermoclysis. Some homes used it regularly even before the study whereas others did not. One nurse felt that it should be “a last ditch kind of effort [because] the ones that are confused are not going to be very cooperative with that. So I would rather just slowly but surely get them the fluids orally” (B). Other nurses felt that individuals who need hydration “should go to the hospital because you know what, we don’t have enough staff!” (D). A number of nurses also mentioned adverse reactions to the antibiotic as a concern (“I’ve had a few bad incidents of really bad side effects, diarrhea” [A1]). Implementation of the Pathway To successfully adopt the clinical pathway, most of the nurses felt that additional training on chest assessments would be required (“We need to stress that we need training” [D]). The study nurse would also need to be replaced with an in-house staff person who could serve as a backup for nurses on the units. Participants strongly believed that having an accessible backup person to assist in the diagnosis and facilitate the treatment of residents was essential to achieving the benefits of the pathway (“[Having the study nurse available] took away a lot of the fear of pneumonia. Well, ‘fear’ might be a bit strong, but there was always someone that you could call if you just weren’t sure. . .” [A2]). Most nurses felt that a single individual, such as a nurse Carusone et al. 275
Table 4. Barriers to Implementing the Pneumonia Clinical Pathway Further training “Confidence. Being able to make your own judgements. And skill. You have to have a certain amount of skill to be able to make the judgment. That’s something they’d have to have some education and upgrades.” (B) “I’d want a bit more training listening to chests.” (C1) “I think it’s more the comfort level of the staff pertaining to the assessment or auscultation skills. You want to rule out that it’s not something else, because the onus is going to be on us. For it to be implemented it has to be in a policy and we have to be trained.” (D) “We need, I think, to stress it that we need training. Some of the nurses here worked in a hospital so they’re very good at doing this. Some haven’t. We just need to be on the same page so that we’re going to be able to do a good job at it.” (D) More responsibility and work “We’ll try and do a lot of that but it’s the workload I guess. . . we are so busy.” (A1) “. . . I would rather send the resident to the hospital. If nobody was going to check, and it will be depending on us—ok, this is it. We can’t. . . We want a back up.” (D) “There should be someone that is in charge, to take the responsibility.” (E) “Most of the time we have an agency [nurse]. . . It’s kind of hard. It’s scary. To me, it’s scary. I’d rather send the resident to the hospital.” (D) “[we want] somebody we could fall back on. . .We won’t abuse the resource! We won’t call her [all the time]! It’s [just] nice that you know there is someone you could call if you’re really in a bind.” (D) “I really like this idea [of using the pathway with a “middle person”], I think we should have someone like the nurse practitioner that knows, that needs to be responsible. Because if we identify the symptoms, we can call them and tell them what is going on [and] the order can be started immediately.” (E) “If we had a nurse practitioner available to us when we needed her— that would be helpful.” (F) “If we are questioning somebody and we are just not too sure is it pneumonia or, isn’t it?’—and that goes [for] any shift: days, evening or nights – it would help to have ANY second opinion!” (F)
practitioner or infectious disease practitioner, should be responsible for initiating treatment in-house. However, some nurses felt that a team of trained people could also fill that role. There was no agreement about whether those individuals should receive additional time or pay for these responsibilities. Although most of the study participants strongly supported the implementation of the pathway, some nurses were concerned about the additional responsibility that would entail if fewer residents were hospitalized. In one facility, a registered nurse (RN) expressed concern that without a backup person she would have more work to do (“I am the only RN. I cannot manage everybody else’s load because I have my [own] problems. . .”). She then went on to state, “there should be somebody [other than me] that is responsible” (E). Barriers to continued use of the clinical pathway for pneumonia included the costs and time associated with upgrading nurses’ clinical skills and ensuring easy access to the oximeter and portable x-ray equipment. Other barriers included more general personnel and financial pressures facing nursing homes, particularly when there are disease outbreaks. At the individual level, fear of change and a lack of confidence could also be problematic. As one nurse said, “I know some of the RPNs have been here for 25 years and all these changes are not easy for them” (B) (see Table 4 for additional quotes). DISCUSSION The interviews we conducted with nursing staff at 6 nursing homes revealed that nurses strongly supported the idea of providing pneumonia care in the nursing home. Overall they believed that avoiding hospitalization, when possible, was better for residents who would be more comfortable and less confused if cared for in the familiar surroundings of the 276 Carusone et al.
nursing home. The nurses were also concerned about the amount of time spent waiting for care and the potential for complications that are associated with sending residents to hospital. They also indicated that on-site care is consistent with the preferences of residents and most family members. According to Longo et al,13 identifying and managing acute illnesses in nursing homes involves 4 stages or types of activities: symptom recognition, illness identification, clinician notification, and treatment. Our findings suggest that a clinical pathway may facilitate the process at each stage. The pathway provides nurses with information on symptoms with which to identify cases of pneumonia, and then guides them through the stages of diagnosis and management of cases, resulting in more timely treatment. This was confirmed in our interviews with nurses. In addition to directly benefiting residents, nurses also felt that their knowledge, clinical skills, and confidence had increased as a consequence of using the pneumonia pathway. These factors are positively associated with nurses’ autonomy,14,15 suggesting that the pathway may also contribute to job satisfaction and nurse retention.16 –18 We believe that an important outcome of using the pathway is to facilitate communication among nursing home staff and between nurses and physicians. Effective communication is critical to providing high-quality care in any health care setting. However, for several reasons, this may be more difficult to achieve in the nursing home setting. First, physicians are usually not on-site and so much of the nurse-physician communication must occur in the absence of personal contact. In one study, nurses reported that poor communication was the leading reason for providing less-than-optimal care in nursing homes.19 In acute care settings, numerous studies have found a posJAMDA – June 2006
itive correlation between nurse-physician communication and outcomes such as quality of care, mortality, length of stay, nurse retention, and perception of good-quality care.20 –22 However, few studies have examined the role of nurse-physician communication in the nursing home. One such study found that communication is an important barrier to providing timely care for acute infections in nursing homes.13 Another study demonstrated a positive association between the quality of nurse-physician communication and the degree of concurrence between drug use and recommended drug selection and polymedicine practices in nursing homes.23 Reasons for poor nurse-physician communication include physician distrust of nurses’ assessments.13,24 In part, this may be due to the difference in diagnostic cues: physicians are guided more by specific signs and symptoms, whereas nurses tend to focus more on resident response to illness when diagnosing or treating health problems.24 The use of this clinical pathway may facilitate nurse-physician communication by providing nurses with a list of signs, symptoms, and vital statistics that are more consistent with physician expectations of diagnostic cues to use when contacting physicians about suspected pneumonia cases in nursing homes. It may also facilitate communication among nursing home staff by identifying a consistent set of important signs, symptoms, and vital signs to be monitored and charted. The identification and management of pneumonia cases may also be enhanced by using a “middle-person,” such as a nurse practitioner or an identified staff person, to serve as a liaison between nurses and physicians. Our study participants believed that having quick access to the study nurse during the trial facilitated early diagnosis and treatment, and also prevented unnecessary hospitalization of residents for pneumonia. Research has identified several benefits from employing nurse practitioners in nursing homes, including reduced emergency department and acute care costs, and lower hospitalization rates.25–27 One recent study demonstrated that nursing home residents under the care of both nurse practitioners and physicians received more acute care visits and received more treatments for eye, ear, nose and throat, and dermatologic problems than residents only under the care of a physician.28 In our study, in addition to the above-mentioned benefits to the residents, the nurses believed that the personal contact with the study nurse improved their knowledge and clinical skills, which has far-reaching implications for improving the quality of care of all nursing home residents. Although most participants were in favor of adopting the clinical pathway in their facility, a number of concerns were raised. The most important one, expressed by some of the participants, was a reluctance to take on more responsibility for decisions involved in identifying and managing pneumonia. By providing additional training and improved communication via a “middle-person,” some of these concerns were addressed. It may be important to further explore these issues and how to deal with them in individual facilities. We acknowledge that this study has several limitations. First, this cross-sectional study explored the nurses’ experience with a pneumonia clinical pathway in the context of a clinical trial in which additional personnel and material reORIGINAL STUDIES
sources were provided. This experience may differ significantly when the pathway is implemented as part of “normal care” by nursing homes, and may also change with the time of exposure to the pathway. Second, because nurses conceptually supported the pathway, they might have been more hesitant to express concerns about its use and implementation. A longer term examination of the perceived benefits and problems associated with using this clinical pathway could help answer more detailed questions about its implementation as part of standard operating procedures rather than part of a clinical trial. CONCLUSION These findings suggest that nurses are in favor of using a clinical pathway for treating nursing home–acquired pneumonia. The implementation of the pathway, in conjunction with easy access to a backup clinician, may result in better care and decreased rate of hospitalization of residents, as well as to improved knowledge, confidence, and skills for nursing home nurses. REFERENCES 1. Loeb M, McGeer A, McArthur M, et al. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. Arch Intern Med 1999;159:2058 –2064. 2. Fried TR, Gillick MR, Lipsitz LA. Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients with pneumonia, J Gen Intern Med 1995;10:246 –250. 3. Kruse RL, Mehr DR, Boles KE, et al. Does hospitalization impact survival after lower respiratory infection in nursing home residents? Med Care 2004;42:860 – 870. 4. Yin RK. Case Study Research: Design and Methods. 3rd ed. Thousand Oaks, CA: SAGE Publications Inc., 2003. 5. Miller WL, Crabtree BF. Depth interviewing. In: Crabtree BF, Miller WL, eds. Doing Qualitative Research. 2nd ed. Thousand Oaks, CA: SAGE Publications Inc., 1999:89 –107. 6. Sandelowski M. The problem of rigor in qualitative research. Adv Nurs Sci 1986;8:27–37. 7. Miller WL, Crabtree BF. The dance of interpretation. In: Crabtree BF, Miller WL, eds. Doing Qualitative Research. 2nd ed. Thousand Oaks, CA: SAGE Publications Inc., 1999:127–143. 8. Patton MQ. Qualitative Research and Evaluation Methods. 3rd ed. Thousand Oaks, CA: SAGE Publications Inc., 2002. 9. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. Thousand Oaks, CA: SAGE Publications, Inc., 1994. 10. Stake RE. The Art of Case Study Research. Thousand Oaks, CA: SAGE Publications Inc., 1995. 11. Krueger RA. Analyzing and Reporting Focus Group Results. Volume 6, The Focus Group Kit (Morgan D.L. & Krueger R.A.). Thousand Oaks, CA: SAGE Publications, Inc., 1997. 12. Smith M. Commitment to care: A plan for long-term care in Ontario (a report for the Ministry of Health, Long-Term Care Division). Ottawa: Ministry of Health and Long-Term Care. Report 7610-2241610. Available at: www.health.gov.on.ca/english/public/pub/ministry_reports/ ltc_04/mophltc.report04.pdf. Accessed January 13, 2006. 13. Longo DR, Young J, Mehr D, et al. Barriers to timely care of acute infections in nursing homes: A preliminary qualitative study. J Am Med Dir Assoc 2004;5:S5–S10. 14. Mrayyan MT. Nurses’ autonomy: Influence of nurse managers’ actions. J Adv Nurs 2004;45:326 –336. 15. Wade GH. Professional nurse autonomy: Concept analysis and application to nursing education. J Adv Nurs 1999;30:310 –318. 16. Chaboyer W, Najman J, Dunn S. Factors influencing job valuation: A comparative study of critical care and non-critical care nurses. Int J Nurs Stud 2001;38:153–161. Carusone et al. 277
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23. Schmidt I, Svarstad BL. Nurse-physician communication and quality of drug use in Swedish nursing homes. Soc Sci Med 2002;54:1767–1777. 24. Cadogan MP, Franzi C, Osterweil D, Hill T. Barriers to effective communication in skilled nursing facilities: Differences in perception between nurses and physicians. J Am Geriatr Soc 1999;47:71–75. 25. Burl JB, Bonner A, Khan AM. Geriatric nurse practitioners in long-term care: Demonstration of effectiveness in managed care. J Am Geriatr Soc 1998;46:506 –510. 26. Garrard J, Kane RL, Radosevich DM, et al. Impact of geriatric nurse practitioners on nursing-home residents’ functional status, satisfaction, and discharge outcomes. Med Care 1990;28:271–283. 27. Intrator O, Castle NG, Mor V. Facility characteristics associated with hospitalization of nursing home residents: Results of a national study. Med Care 1999;37:228 –237. 28. Aigner MJ, Drew S, Phipps J. A comparative study of nursing home resident outcomes between care provided by nurse practitioners/physicians versus physicians only. J Am Med Dir Assoc 2004; 5:16 –23.
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