Definition: Existence of clear lines of responsibility clarifying accountability of staff members and delineating the job role.
At both sites the staff member discharging patients was not necessarily the staff member who had been in charge of caring for the patient that day. This
happened if the charge nurse thought the discharge should happen when the usual staff member was not available. The discharge lounge at Site 1 was managed by a nursing sister and one of a number of nurses – usually the next nurse available – would undertake the discharge when patients’ medicines arrived in the lounge. These staff members had not previously been involved in the patients’ care.
At Site 2, the Ward pharmacist and the nursing teams reported to different departments, however, in terms of explaining medicines to the patients, the level of role co-ordination was not clear. The content of patient discharges often duplicated, rather than complemented, the content of discussions about
medicines with the pharmacist – it was unclear whether this was by design or because the different roles of the ward pharmacist and the nurse were unclear.
Defences
At Site 2, the staff member conducting the discharge was normally, but not always, the nurse in charge of the room on the ward where the patient’s bed was situated. At Site 1, the charge nurse or the ward manager decided if patients were to be transferred to the discharge lounge, where they would wait for their medicines to be delivered. Discharges conducted on the ward were usually the responsibility of the nurse in charge of the patient on the ward that day.
152 4.3.3.2 Staff workload
Definition: Level of activity and pressures on time during a shift.
Staff observed on both wards appeared extremely busy at all times and workloads appeared to influence their prioritisation of tasks, for example staff sometimes appeared too busy to spend a lot of time with their patients talking about medicines, which would limit the detail they would offer. However, it was not always clear whether the limited detail offered was due to staff attitudes (individual factors) or to staff workload. Time with patients seemed hurried if the staff member was due elsewhere, for example back in the dispensary, or if staff members were due to take breaks. Time spent with the patient often varied, for example some staff members would conduct the discharge standing by the patient’s bed reading the medicines from a list, and in one case whilst the patient was also standing with a coat on waiting to leave the ward.
Discharges were observed to be delayed by lunch and performing care
activities for other patients, for instance being asked to help a patient from his chair. Workloads meant that discharge could be conducted by a nurse that the patient did not know because they had not been allocated to that patient’s room.
Discharges were sometimes observed to happen very quickly in order to fit the task in around other duties and breaks.
“The discharge happened quickly. Only one new medicine (isosorbide mononitrate) and slightly more time was taken to discuss this one. The nurse took the leaflet out of the box to discuss the side effects of this medicine with the patient. The patient was standing up, dressed and ready to go home. The nurse was also standing up and tipped the medicines onto the bed. The nurse was about to go on a break. The patient asked for information about exercise but was given a leaflet about diet. The patient had been worried about doing exercise because he enjoys the gym and walking.” (Field notes: Site 2, Ward, 7/1/14)
Once they were underway, discharges could be interrupted by staff members consulting the nurse about problems or asking for help. On more than one occasion this led to the patient’s discharge being suspended whilst the nurse attended to other duties.
153 Defences
No defences were observed in this domain 4.3.3.3 Supervision and Leadership
Definition: The availability and quality of direct and local supervision and leadership.
Nursing line management reinforced that patients should be moved to the discharge lounge at Site 1, which was an internal transfer of care which impacted on the continuity of care that patients experienced.
Defences
At both sites, it was clear each day which team member was in charge of the ward, and activities in the discharge lounge were co-ordinated by a nursing sister.
4.3.3.4 Management of staff and staffing levels
Definition: The appropriate management and allocation of staff to ensure adequate skill mix and staffing levels for the volume of work.
The number of discharges varied from day to day, ranging from none to as many as nine. On days where comparatively large numbers of patients were discharged from wards, there were increased levels of work for staff members involved in preparing patients and their medicines for discharge, yet staffing levels did not appear to be influenced by the number of patients leaving the hospital. This may have impacted on the time available to staff to spend with each patient.
Defences
None were observed in this domain.
4.3.3.5 Equipment and supplies
Definition: Availability and functioning of equipment and supplies.
The availability of medicines appeared to influence how patients were
discharged. Many patients waited a long time for their medicines, either on the ward or in a discharge lounge. In one or two cases staff counselled patients about their medicines without the medicines being present, sometimes describing colours or shapes of tablets. In another case, the medicine
154
prescribed (Valsartan) was not available in the hospital so the pharmacist advised the patient to obtain the medicine from an alternative source, which meant they may not have been able to obtain that medicine.
Patients were rarely given information about how to get further supplies of their medicines once they were back in primary care.
Defences
At Site 2, a ward pharmacist was able to dispense commonly prescribed TTO medicines from a supply on the ward. This meant that for some patients the waiting times for medicines before discharge was reduced, which may have meant they were less fatigued and more able to understand the information they were given.
4.3.4 Latent / organisational factors