Cause And Effect On Lengthy Hospital Stay Nursing Essay

1. Introduction

The proportion of population aged 65 and over has increased from 9.8% in 1995 to 13.1% in 2010, it is projected that by 2033, the proportion of population aged 65 and over will increase to 26.8% (HKCSD, 2010). In view of aging population rapid increasing in Hong Kong, its healthcare services will face a greater demand and challenge. To face these challenges, traditional management in healthcare system is not enough in this field. In today’s health care system worldwide, increased attention is being focused on human resources management (HRM). The World Health Report 2000 by WHO stated that human resources are one of three principle health system inputs, with the other two major inputs being physical capital and consumables. Stefane et al. (2006) argue that the practices of HRM must be developed in order to find the appropriate balance of manpower and the ability of employees to work effectively and efficiently. The most important of the health system inputs, the performance and the benefits the system can deliver based on the strong knowledge, adequate skills and high motivation of those individuals responsible for delivering healthcare services (WHO, 2000).

2. Background

2.1 Challenge

In 2010, elderly people 65 years and above make up 13% of Hong Kong population but account for around 50% of patient days in HA hospitals, it is projected that by 2017, the proportion of elderly people will increase to 15.6% while their share of HA patient days will rise to around 60% (HA Strategic Service Plan 2012-2017). In view of population ageing and the elderly accounted for hospital beds occupied is on the rise, healthcare services are facing greater challenge and pressure, high clinical workload leaded high turnover of clinical staffs in HA hospitals. To face the high demanding of healthcare services and manpower shortage of the clinical staffs, HA Strategic Service Plan 2012-17 recommends to allaying staff shortage and high turnover, better managing growing service demand, ensuring service quality and safety, enhancing partnerships with patients and community, ensuring adequate resources to meet service needs, and enhancing corporate governance.

2.2 Clinical Issue

In my area, a geriatric setting ward, our clients are the elderly group those 65 years or older peoples. We are face to a high demanding of hospital inpatient care services, the average of length of stay(ALOS) for our elderly clients is 10.8 days, it’s higher than the 9.7 days for an elderly patient and 5.3 days for a non-elderly patient on average in HA hospitals. The long ALOS lead hospital beds crowding, high workload of the frontline staffs, and increase conflicts with the patients and their families on handling discharge process by staffs, decrease quality of care, front line staffs frustrated and poor morale.

3. Analysis

3.1 Current Problems

Guralnick, La Croix, & Everett (1989) mentioned that about 50%-70% of those 65 or older have at least two or more chronic conditions that frequently limit the functional independence of older people and increase hospitalization. In many developed health systems, unnecessary in-hospital services are a large problem, the rate of inappropriate bed use by older people may be approximately 20% of all be days (McDonagh et al., 2000; Celik et al., 2001 & Panis et al., 2002). The health care system of Hong Kong is similar to those developed countries, put another way, one day in every five that older people spend in hospital is probably unnecessary.

Medical or non medical reasons may delay a patient’s discharge from hospital. It has been estimated that 30% of all hospital discharges are delayed for non-medical reasons (Selker et al., 1989). Remain causes of delayed discharge from hospital are (Dept of Health 2003):

1. Inadequate assessment of the patient by health care professionals resulting in, for example, a poor knowledge of the patient’s social backgrounds.

2. Poor organization, for example late booking of transport preventing timely discharge from hospital.

3. Poor communication between the hospital and providers of services in the community.

Similar issues are presenting in my unit regard to decreased patient satisfaction and quality of care with the discharge process. Prolonged hospitalization not only increases cost, it is also associated with other complications like nonsocomial infections, immobility, pressure sores, deep vein thrombosis and de-conditioning. It’s well documented that shorter lengths of stay lead to lower infection risk and improved cost efficiency, disproving the notion that longer stays mean better care (Haley, 1998; Plowman et al., 2001). Better care for patients is one of the core values for all healthcare professionals, Hager (2010) said that patient satisfaction could potentially be extrapolated to staff satisfaction because improved patient satisfaction can emphasize a job well done.

3.2 The Cause and Effect Analysis

As we motioned before, a long ALOS of the elderly is the issue in my unit that caused lower patients satisfaction, lower staff’s jobs well-being, affected the quality of care, and lower cost effectiveness. To create an intention of change in our staffs, we are firstly to analysis the cause and effect used a fishbone diagram as below:

Figure 1, Cause and effect on lengthy hospital stay

3.3 SWOT Analysis on Current Services

SWOT analysis is a strategic planning tool that is exceedingly valuable, it involves identifying strengths, weaknesses, opportunities and threats. Fine (2009) stated that the use of SWOT Analysis allows organizations to maximize their strengths, minimize their weakness, take advantage of their opportunities and overcome their weaknesses. Use SWOT analysis on our issue as bellow.

INTERNAL

Strengths

Weaknesses

Staffs wishes to provide good quality of care for the elderly

Multidisciplinary care for the patients

High rate of unnecessary hospitalization

High workload of frontline staffs

Front staffs frustration to deal with discharge

Patients and their families frustration

EXTERNAL

Opportunities

Treats

Standardize and efficiency the discharge process

Increase staff’s job satisfaction to retain manpower

Increase interdisciplinary communication

Recent researches raised up the avoidable hospitalization

High demanding on healthcare services in Hong Kong

Clinical staffs shortage in HA hospitals

Table 1, SWOT Analysis on Current Services

3.4 PEST Analysis on the needs of change

Mullins (2005) stated that leadership performance and effectiveness depends on successful opportunities, challenges and risk presented by changes in external environment. PESTEL analyzing tool can influences in the general environment, using a PESTEL tool to analyzing the general factors as bellow.

Political:

– HA Strategic Service Plan 2012-17 recommends to allaying staff shortage and high turnover, better managing growing service demand, ensuring service quality and safety, enhancing partnerships with patients and community, ensuring adequate resources to meet service needs, and enhancing corporate governance.

Economic:

– Benefit to budget control by hospital

– Increased cost effective

– Increased staff satisfaction to reducing the cost of high staff turnover rate

Sociological:

– Ageing population

– Elderly in low social class family with limited family support

Technological:

– Increased interdisciplinary communication

– Standardized and efficiency the discharge process

Table 2, Strategic analysis ‘PEST’ (Adapted form Lynch 2003 cited in Mullins 2005)

4. Discussion

4.1 General Systems Theory

As Boxall et al (2007) defined that HRM is: “The management of work and people towards desired ends.” Susan (1995) defined that an open system is dependent on the environment for inputs, which are transformed during throughput to produce outputs that are exchanged in the environment. Open systems models less concerned organizations only, as Wright & Snell (1991) argued that the view of HRM has been developed further in open systems, skills and abilities are treated as inputs from the environment; employee behaviors are treated as throughput; and employee satisfaction and performance are treated as outputs. Wright & Snell (1991) also said that Open systems is used to describe a competence management model of organizations. In this model, the HRM subsystem functions to obtain, use, maintain, and transfer competencies. HRM as a control system is based in open systems theory (Snell’s, 1992). In a more narrow discussion, Kozlowski & Salas (1994) describe that is a multilevel organizational systems approach to understanding training, implementation and transfer. Many methods, models and theories are used to understand HRM in Context assume that organizations well functioning. Theoretical perspectives based in sociology, economics, management, and psychology focus on different aspects of the domain of HRM in Context (Wright & McMahan 1992). Let’s go to discuss how these methods, models and theories can apply in my area to change.

4.2 Leadership Styles

Two types of leadership were first identified by Burns in 1978 as transactional and transformational leadership. Our discussion will revolve around these two types of leadership patterns. Weber (cited in Turner, 1998) who raised that transactional leadership is based on knowledge and hierarchical control, transactional leader’s aim to negotiate and bargain for higher efficiency. Transformation leaders is a charismatic personality who seeks to change or transform the peoples with their qualities by using the new thinking for change within the Organization. Outhwaite (2003) also state that the transactional leadership involves the skills required in the effective daily operation of a team, while transformational leadership involves how to integrate a team works together and the innovativeness of their approach to the work.

Marquis & Huston (2008) suggested that a composite of the two different types of leaders is shown in bellows table:

Transactional Leadership

Transformational Leadership

Focuses on management tasks

Is a caretaker

Uses trade-offs to meet goals

Dose not identify shared values

Examines causes

Uses contingency reward

Identifies common values

Is committed

Inspires others with vision

Has long-term vision

Looks at effects

Empowers others

Table 4, Transactional & Transformational Leader (Marquis & Huston, 2008)

Transactional leadership is most concerned with managing predictability and order (Faugier & Woolnough, 2002). According to Marquis & Huston(2008),the characteristics of transactional leadership may increase working stress of nursing staffs, reduce morale and reduce working satisfaction, it’s not suitable apply in my unit to solve the issues mentioned, it also adverse to the HA strategic plan.For our issues, in current management, line manager should not only concerned the outcome data of ALOS, it should be have a good analysis and classification where does the problem occur, to organize colleagues to identify the where the problems are, and arranged for some of the related training or education for colleagues. By the way, a transformational leader can allow and empower individuals to lead certain aspects of a project such as an early screen of discharge planning program (See Appendix 1) based on their areas of expertise. Transformational leader can work together with team members, to identify the various internal and external factors, they has a long- term of vision to finding solutions in team. A line manager should explore the barriers and to identify conflicts when they occur, and then work collaboration in the team to resolve to these problems (Outhwaite, 2003). In addition, leaders should remain a part of the team, though working with the team and cooperation with team members to understand the view points of the employees (Outhwaite, 2003). Transformational leadership focused on leadership and interpersonal process between leaders and followers, team member was encouraged by empowerment (Hyett 2003). Empowerment will be able the front staffs to trust their own ability to create and adapt to change. Team approach is important to set boundaries, goals, accountability, and make sure have enough supports to team members (Hyett 2003). Cook (2004) using five attributes identified to explain the issue of transformational leadership are Creativity, Highlighting, Influencing, Respecting, and Supporting. A transformational leadership is more appropriate then the transactional leadership in view of current nursing professional in HA hospital. Reflect to our issues, a transformational leader can work together with team members, though cooperation relationship to understand the view points of employee’s. Leader has a different vision to thinking that what the problems on, such as whether a shortage of manpower, inadequate assessment and insufficient knowledge of the front staffs. Employees are empowered by line manager to using their own strengths to solve the problem, and line manager act as a co-coordinator, for example, assume the role of education to facilitate employee to learning. Seek for some resources to facilitate staffs learning, for example, arrange discharge planning related course for frontline staffs. Bennis and Nanus (1985), also to state that a transformational leader has the ability to commit people to action-that is, can help followers to covert into leaders and to assist new leaders to become viable agents of organization change.

4.3 Managing Change

As for leading organizational to change, Kotter J, the Harvard University Professor, suggested that an organization can change rapidly if they will go through the following eight stages. To help the organization to change in effective and completely, Kotter(1996) summarizes the steps in his model include the following:

Establish a sense of urgency

Form a powerful guiding coalition

Create a vision

Communication the vision

Empower others to act on the vision

Plan for a create short-term wins

Consolidate improvements and sustain the momentum for change

Institutionalize the new approaches

Kotter & Cohen (2002) organizes each of these steps into 3 distinct phases. The first phase is called ”creating a climate for change” and includes steps 1, 2, and 3. The second phase, ”engaging and enabling the whole organization,” consists of steps 4, 5, and 6. The final phase, ”implementing and sustaining the change,” encompasses steps 7 and 8. Kotter & Cohen (2002) believes that organizational change can be managed using a dynamic, nonlinear approach on the eight stages.

Change is a complex process; it may involve some procedures and multi-discipline, change is not easy, Marquis and Huston (2008) raise that all major change brings feeling of achievement and pride as well as loss and stress. Robert et al (2007) suggested utilizing a change model can help guide the change process and help to reduce obstacles which may be encountered. Lewin (cited in Michele & LeAnn 2009) identified three stages “unfreezing-change-refreezing” to categorize the complex human processes, attitudes, and thoughts that affect a change process. Diane (2006) described unfreezing is when disequilibrium is recognized into the system to disrupt the status quo, change is the process of a new status changing, and refreezing is when the change becomes the new status quo and a new behaviors are frozen. It will then go on to analyze the issue how to maintain high quality of nursing care using the three-stage process of change as Lewin described.

Unfreezing, this stage can be described as a “thawing” stage on the system and creating the motivation or readiness for change. “An awareness of the need for change occurs” (Diane 2006, p: 811), this stage is cognitive exposure to the change idea, identified the problem, and work to generate alternative solutions. When a change idea occurs, a change agent such as a leader or a frontline nurse needs trust, respect, and rapport to unfreezing individuals and groups effectively suggested by Diane (2006). In this stage change agent need purpose how to change, why change and benefits of change. These show that things have to change in a way that everyone can understand. For the issue of long ALOS, Why we need change? It is to reduce the ALOS of elderly patients (change idea). How to change? A transformational leader may lead followers to work together, though well organized to find out the real problem lies, then there is consensus that the needs to be change(for example to increase staff level on elderly patient assessment and discharge planning). Obviously, the benefits of change are improve the quality of service and enhanced the confidence and ability of nurses.

Change, this stage is a process of a new level behavior changing, which implies that the actual visible change occurs. After the unfreeze stage, the change stage is where people begin to resolve their uncertainty and look for new ways to do things. People start to believe and act in ways that support the new direction. Diane (2006) described when the staffs involved collect enough information to clarify and identify the issue; they can be planned and initiated to make a change. In this stage, when the needs of change has to be consensus that the leader to be develop the plan of change with team members and begin to change. Change should be implemented only for good reasons (Marquis and Huston 2008).

Refreezing, in this stage new behavior after change are integrated and stabilized. Marquis and Huston (2008) stated that change needs at least 3 to 6 months before it will be accepted as part of the system, if the refreezing stage is incomplete the change will be ineffective and the pre-change behaviors will be resumed.

Diane (2006) raises reinforcement and rewards the changes of behaviors are important as individuals integrate the change into their own value system. In this stage leader may celebrate the success of the change, thanks all staffs whom involved in the changes for enduring a change process, and helps them believe that future change will be successful.

Lewin (1951, cited in Swage 2004) also developed a framework of ‘force field analysis’ is used to develop goals and initiate change in organizations. Apply on the our issues, the framework of ‘force field analysis’ (see figure 2 below).

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Figure 2, Force Field Analysis (Lewin 1951)

To identify the goals of change, a SMART standard statement was identified to reduce staffs turnover and improve patient outcomes as below:

“By the end of April/2014, the average length of stay reduces 20% or above and clinical staffs turnover rate under then 5%”

S (Specific)

There will be significant reduce the length of stay of patients in ward.

M (Measurable)

Through statistics to assess the effectiveness of the standard.

A (Achievable)

The standard is achievable in the time and percentage indicated.

R (Relevant)

Reduce the length of stay rate 20% or more of patients, and clinical staff’s turnover rate under then 5% in Geriatric Unit.

T (Time-framed)

By the end of April/2014.

Table 3, SMART standard statement to reduce LOS

4.4 Learning Organization

Learning Organization is a management concept proposed by Peter Senge (Peter M. Senge) in “The Fifth Discipline”. The five disciplines of learning organization are systems thinking, personal mastery, mental models, shared vision, and team learning (Senge, 1990). To face the daily changes more dramatically in the world, organizations worldwide now require that learning be delivered with greater speed, at less cost, and more effectively to workplaces and mobile workforces. Continuous learning and knowledge provide the key raw materials for wealth creation and have become the fountainhead of organizational and personal power (Michael J. Marquardt 2011). Knowledge management is one of the most important to building a learning organization. Work and learning are more becoming the same thing, leaning is at the heart of the productive activity, it’s the new form of labor (Zuboff, 1998, P395). It’s often to improve value through new ideas and information rather than material products. Kline & Saundars (2010) argued that with all these challenges and potential benefits to the organization, it was just a matter of time before the new species of learning organization arrived.

Learning organization does not just a single model; it is an attitude or philosophy of the concept and the role of employees on the organization, with the thinking of a new way of the organization, everyone should be involved in identifying and resolving problems, and enables organizations to constantly try to improve and enhance its capacity. The characteristics of a learning organization can be expressed in the following figures.

Figure 3, Systems of Learning Organization Model (Marquardt, 2011)

Figure 4, Learning Subsystem (Marquardt, 2011)

Learning is the key element improve patient’s outcome, reduce the ALOS and increase the frontline staff’s jobs well-being on my clinical issue. Merister & Willyerd (2010) said that learning is becoming participatory, social, fun, engaging, and, most important, integrated with work. Though the continuous learning, staffs may increase their clinical and management knowledge to critical assess the elderly patient’s needs, identified and agreeing the organization’s needs, well planning in patient’s discharge, and increase their job satisfaction.

5. Recommendation

To deal with this issue and maintain a good quality of medical care, recent trends include reducing the lengths of stay for inpatient care; reducing the number of long stay beds; shifting care into the community; providing high levels of acute care at home (hospital at home), and implement a effective discharge planning. By the way, the lack of care coordination, insufficiency patient’s assessment and tailoring to patient needs, as well as lack of knowledge of staffs on discharge planning resulted in prolongs hospital stay. Townsend et al. (1988) suggested that discharge planning may influence both the length of hospital stay and the pattern of care within the community by bridging the gap between hospital and home. Providing a comprehensive and effective discharge planning for each hospitalized elderly patient is necessary to reduce the length of hospital stay, increase patient outcomes and increase frontline staff’s job satisfactions in my unit.

As the analysis section stated, we sort out manpower shortage, lack of organization and poor staffs levels are cause a high ALOS of elderly in my unit, that often haunt us, because this is directly affects the quality of our services and lower staff morale. Make organization changes are necessary to deal these problems, which include creating learning culture and build up a good leadership modeling. Developing nursing leadership is one of the greatest challenges in the nursing profession (Mahoney, 2001). Hospital Authority Strategic Service Plan 2012-2017 stated that front line staffs will be support to expand their knowledge and skills to keep pace and enhance their job satisfaction in three areas: leadership skills, management skills, and clinical competence.

Reducing unnecessary in-hospital stay, reducing post-discharge adverse events as well as improving patient satisfaction are relevant measures of a successful discharge process, nurses bring a unique perspective of caring to this process. Yilmaz & Emiroglu (2005) cited that nurse is an important part of the multidisciplinary team’s discharge planning. Hester (1996) & Naylor (1994) raise that nurses acknowledged the importance of a nursing leadership role in providing continuity of care throughout the discharge planning process. To increase quality of care and patient’s satisfaction will raise clinical staff’s morale and reduce staffs turnover rate, several studies have looked at nursing staff turnover to quantify an estimated cost of replacing nursing staff, making nursing satisfaction has a significant benefit to the organization (O’Brien-Pallas et al., 2006; Hall, 1981; Contino, 2002; Bland Jones & Gates, 2009; Bland Jones, 2004). As a line manager, an early screen discharge planning program (See Appendix 1) is recommended to achieve the desired outcomes. In this program, a case manager should be empowered by line manager to organize the program; he/she is act as a bridge to coordinate the front nurse, doctor and other displinenary to enhance patient’s discharge planning. Good leadership styles are most important in both line manager and case manager; by the way, we are also suggested to promote the learning organization environment in our unit, as Senge (1990) finds that team learning are the fundamental learning unit in modern organizations. Good communication among the members of the team by line managers, which results in stretching the ability of the organization to grow and develop.

6. Conclusion

HRM is most important of the health system inputs to enhance staff’s knowledge and skills, and to motivate individuals to delivering high quality of healthcare services (WHO, 2000). The purpose of the Early Screen for Discharge Planning (ESDP) was to determine the effectiveness of the interdisciplinary team to develop improved discharge teaching and processes with inclusion of early provision of discharge goals, identification of barriers, and subsequent teaching and problem-solving of the barriers to impact patient and their family’s perception of the discharge process. HRM is the one of important element to lead success to implement this purpose, as we noted before, HRM must be developed in order to find the appropriate balance of manpower and the ability of employees to work effectively and efficiently (Stefane et al., 2006).This project hoped to shed new light on the development of measurable outcomes for successful discharge to increase frontline staff’s job satisfactions and retain the clinical manpower, to improve quality of care for patients as well as to reduce the hospital costs.

Dear Ngai

After page 14 I lost my patience with the blatant plagiarism in this work. You have not read a number of the books that you have put in this work however you have found a number of sources which quote the references you have used. You have taken these paragraphs and presented them as your own work. If you do this in your final submission then you will fail the module.

Aside from this major problem, your work does not identify a new service or major process that you are going to look at. It is a great shame that you did not send in an Outline as you could have saved yourself a lot of work by identifying this earlier.

Most of the work presented here does not address the assignment requirements. Please read the assignment guidelines in the Introduction of the LSM and on the Day 1 and Day 2 PowerPoint slides which you can find on the VLE.

You have a lot of work to do to turn this around and rewrite it.

Regards

Gus