|Nurse Satisfaction and Creation of an Admission, Discharge, and Teaching Nurse Position
|Betty S. Lane PhD, RN
Joanne Jackson MSN, RN, ONC
Sue E. Odom DNS, RN
Kathleen A. S. Cannella PhD, RN, CNS-BC
Laura Hinshaw ADN, RN
|Journal of Nursing Care Quality
Volume 24 Number 2
Pages 148 - 152
The goal of this study was to evaluate the effect of a newly developed nurse admission, discharge, and teaching position on nurse satisfaction and the quality of the admission and discharge process. A pretest-posttest design was used to collect data on nurse satisfaction, workload, and medication reconciliation. Study results supported the use of an admission, discharge, and teaching nurse to improve nurse satisfaction and the quality of the admission and discharge process.
AQUALITY ADMISSION and discharge process is essential for safe and comprehensive patient care. Delays in admission of patients into the health system can delay problem identification and implementation of treatments, and affect hospital costs. How rapidly a patient is admitted or discharged is heavily influenced by the availability of nurses to effectively assess, plan, and coordinate care. While nurses are admitting and discharging patients, they must continue to meet the ongoing needs of other patients and interface with families, physicians, and other departments. This can result in constant disruption of nursing care delivery and fragmentation of patient care. These rapidly changing dynamics on patient care units also may contribute to nursing stress, dissatisfaction, and attrition.1
Recognizing that admission and discharge activities are time intensive, some hospitals have intermittently implemented admission and discharge nurse positions to improve the efficiency and quality of admission and discharge process.2,3 The job responsibilities of these nurses are often quite varied across health facilities. Unfortunately, the effectiveness of these job positions on nurse satisfaction and patient outcomes is unknown because the literature on the topic is primarily anecdotal or descriptive in nature.
Currently, there is a scarcity of evidence-based information on how admission and discharge models affect the nursing unit environment and patient outcomes. Admissions and discharges may create stress for nurses and disjointed delivery of care. Information on this job stress is important because characteristics of the work environment are linked to the attrition and retention of nurses. This study fills a void in the literature by providing quantifiable information on how an admission, discharge, and teaching (ADT) nurse can affect nurse satisfaction, workload, the quality of the admission process, and medication reconciliation.
ADMISSION AND DISCHARGE PROCESS
A search of CINAHL and Health Source within the last 5 years revealed a shortage of evidence-based articles on the use of specialized admission and discharge nurses. The few articles that were found were primarily anecdotal. Hlipala et al2 described how a hospital revised its admission process and created an admission nurse position, saving time for nurses and decreasing overtime. Lopuszynski3 described her satisfaction as an admission nurse, how her role evolved, and related job functions. The role of the admission nurse was seen as a key factor in decreasing RN workload and improving the efficiency of the admissions process. Managers in several hospitals have described how an admission nurse or team has been used to minimize the admission workload.4 The admission nurse role has also been viewed as a way to improve bed placement.5
Evidence-based studies on discharge planning and patient teaching are also limited in the nursing literature. Discharge planning and patient teaching are important for quality patient care.6 Discharge delays can occur when there is lack of coordination and may result in readmissions. A study in an emergency short-stay unit examined whether patients had received sufficient discharge instruction. Although the majority of patients believed they had received sufficient discharge instruction, 29% had to seek medical advice outside of scheduled appointments and 9% were readmitted with the same diagnosis.7
A few studies have identified aspects of admission and discharge as factors in nurse satisfaction. Kalisch,8 in a qualitative study, found that patient teaching and discharge planning were identified by nurses as nursing care items that were frequently overlooked on medical-surgical units. Work stress and inability to adequately meet the needs of patients have been identified as nurse dissatisfiers and can affect the attrition and retention of nurses.1,9
The nursing unit in which this evaluation study took place was a bone, joint, and neuro unit located in an acute care hospital in the southeast United States. The 37-bed unit receives a large overflow of patients with a variety of medical-surgical diagnoses. This results in a rapid turnover of patients due to admissions, in-house transfers, and discharges. The unit council, to decrease nursing stress and improve the discharge process, developed and piloted an ADT nurse position.
The goal of this project was to evaluate the impact of a newly created ADT nurse position on nurse satisfaction, workload, the quality of the admission and discharge process, and medication reconciliation. The research questions for the study were as follows: (1) Will the nurse satisfaction indicators of job enjoyment and work context as measured on the National Database of Nursing Quality Indicators (NDNQI) RN Survey with Job Satisfaction show improvement following implementation of the ADT nurse position? (2) Will nurse workloads related to unit admissions and discharges decrease as evidenced by work logs? (3) Will nurse satisfaction with admission and discharge process increase as measured on the ADT Process Survey? and (4) Will medication reconciliation rates improve for discharged patients as evidenced by a random retrospective medical record audit?
The design for the study was a pretest-posttest design. Approval for the study was obtained from the Professional Development Council of the Department of Nursing. Nurse participation in the survey was voluntary and confidential. Self-report survey data were gathered from the NDNQI 2006 and 2007 RN Survey with Job Satisfaction Scales—Short Form,10 unit admission and discharge logs, ADT Process Survey, and a retrospective medical record audit.
The NDNQI RN Survey with Job Satisfaction Scales—Short Form examines the nursing quality indicators of job enjoyment and work context. The Job Enjoyment scale has 7 questions related to how nurses perceive their coworkers' job satisfaction. The Work Context scale contains 12 categories related to intent to stay and the quality of the work environment. Hospitals participate in the NDNQI RN Survey as part of the Magnet application process to identify levels of performance in relationship to nurse-sensitive indicators that may affect patient outcomes. Hospitals can compare their performance on nurse-sensitive indicator benchmarks to the national norms of similar hospitals participating in the NDNQI RN Survey. These data can be used by hospitals to set goals, develop interventions, and improve patient outcomes. The NDNQI RN Survey was completed by 18 unit nurses.
Information on the number of admissions and discharges was obtained through examination of work logs. This was done over a 3-month period pre- and postimplementation of the ADT nurse position.
Data on nurse satisfaction with the quality of the admission and discharge process were obtained with the ADT Process Survey.11 This pre- and postsurvey instrument was developed by the clinical nurse researcher and the clinical nurse specialist in conjunction with the unit council. There were no reliabilities established on the survey instrument. Content validity was obtained through development and examination of the survey questions by experienced nurses who participated in the admission and discharge process on the unit.
The nurse self-report survey asked 11 questions related to the admission and discharge process. These questions addressed issues related to (1) time for documentation, (2) incomplete paper work, (3) interruptions, (4) time spent on follow-up phone calls, (5) adequate time with patients, (6) adequate preparation of patients for discharge, (7) quality of assessment and history data, (8) confidence in admission nurse data, (9) contribution of the admission process to patient care, (10) awareness of admission and discharge needs of patients, and (11) overall satisfaction with the admission process. Nurses used a Likert-type scale to rate their satisfaction to questions such as the following: “I am frequently interrupted by admissions and transfers” and “I am aware of the admission/discharge needs of my patient.” The scale contained answer choices of “never, almost never, sometimes, often, and always.” Ten nurses completed the ADT Process Survey. Nurses were eligible for this aspect of the study if they had worked on the unit pre- and postimplementation of the ADT nurse and worked full-time. Ages ranged from 29 to 39 years (some did not indicate their age). Eight nurses worked the day shift and 2 the night shift. Their educational backgrounds varied: 2 had bachelor of science degrees in nursing, 5 had associate degrees in nursing, 1 had a diploma in nursing, and 2 were licensed practical nurses.
Medication reconciliation information was obtained from a random retrospective medical record audit (n = 10). Medication reconciliation at discharge involves comparing the patient's list of admission medications with his or her medications at discharge to prevent omissions and duplications.12
The Statistical Package for the Social Sciences13 software was used to examine the pre- and posttest scores from the ADT Process Survey to obtain information on nurse satisfaction with the quality of the admission process. Percentage differences were calculated for the NDNQI data. Statistical tests were not performed on the NDNQI data because the researchers did not have access to the raw data.
NDNQI RN Survey comparison data (2006–2007) indicated a 25% increase in job enjoyment, under work context; the variable “had enough time with patients” increased by 38%. The number of nurses who said inadequate staffing did not affect unit admissions increased by 100%, and RN plans to remain on the unit increased by 25%. Examination of admission and discharge logs over 3 months revealed that 297 admissions and 119 discharges were conducted by the ADT nurse. This reduced each unit nurse's workload by 1 hour 12 minutes per day (based on an average of 1.5 hours for admissions and 0.5 hours for discharges).
Overall, satisfaction with the admission process post-ADT increased dramatically. A paired samples t test was used to examine differences in the survey means. The mean nurse satisfaction score before implementing the ADT position was 29.10 (SD = 4.97); after implementing the role, it increased to 44.70 (SD = 3.16) (t = 6.308, P < .001). The retrospective medical chart audit (n = 10) indicated that the medication reconciliation rate increased from 18% pre-ADT to 100% post-ADT.
Study findings support the use of the ADT nurse position to improve NDNQI RN Survey overall nurse satisfaction, workload, satisfaction with the admission process, and medication reconciliation. Overall nurse satisfaction on the nursing unit was improved as evidenced by the NDNQI RN Survey comparison data from 2006 to 2007. Nurses in the current study reported they had less desire to leave their position. This may have been related to their perceptions of organizational support for nursing practice. Organizational support for nursing practice has been negatively associated with nurse-reported adverse events and desire to leave and has been positively associated with nurse perceptions regarding quality of care and happiness with their job.14 Conflicts between the values of the nurse and hospital organization can result in ethical conflict that affects satisfaction with the work environment.15,16
Results from the study support those of Hlipala et al,2 who found that the use of an admission nurse can save a nurse up to 1 hour of time per admission. The peak time of admissions in the current study was earlier than was noted by Hlipala et al. Comparisons with the study of Hlipala et al about the number of admissions could not be made because there was no information on bed size and the number of units involved. The ADT nurse position significantly increased the satisfaction levels of the nursing staff with the quality of the admission and discharge process, and patient outcomes were potentially enhanced through greater improvement in medication compliance.
Additional studies are needed to verify the impact of the ADT nurse on comparable types of nursing units and with larger groups of nurses. Three factors may have contributed to the success of the ADT nurse position in this study: (1) the characteristics of the ADT nurse, (2) the permanency of the position, and (3) staff involvement. The individual selected for the ADT position was an experienced nurse with excellent assessment, interpersonal, and organizational skills. Because the staff knew the ADT nurse, trust had been established previously in relationship to her clinical capabilities. The ADT nurse did not have a patient load and could not be “pulled” to another unit. Unit staff were involved in the design of the ADT position and in the hiring of the ADT nurse.
An additional secondary benefit to the development of the ADT nurse position is the opportunity to retain older experienced nurses within the workforce. Older nurses may feel they physically can no longer meet the demands of a staff nurse position. However, their experience and skills are still very much needed to support less experienced staff and improve patient outcomes. The ADT nurse provides a way to retain nurses in the workforce as we face future nursing shortages as a result of increasing numbers of nurse retirements.
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