Understanding hospital transfers from care homes in England: An ethnographic study of care home staff decision-making

Background: When deciding whether or not to transfer a resident to hospital, a careful consideration of the potential benefits and risks is required. International research suggests that transfer decisions are complex and influenced by both clinical and non-clinical factors, yet this has not been widely studied within the context of care homes in England.

Aim: To develop an in-depth understanding of hospital transfers from care homes in England and produce a conceptual model to describe the decision-making processes of care home staff.

Methods: Data collection occurred in two phases: the first consisted of 28 semi-structured interviews with 30 members of staff across six care homes; the second consisted of 113 hours of ethnographic observations, documentary analysis and informal conversations (with staff, residents, family carers and visiting healthcare professionals) at three of the care homes that had taken part in phase one.

Findings: In the context of care homes in England, hospital transfers can be conceptualised as a series of escalations in which staff make multifactorial decisions about potential benefits and risks. This can include risks to: residents, staff (as decision-makers) and their social relationships, care homes (as organisations), and wider health and social care systems. In order to assess the likely benefits and risks of each transfer, care home staff placed importance on ‘knowing’ residents but also drew upon advance care plans, structured clinical observations, and interactions with others (residents, family carers, colleagues within the care home and visiting healthcare professionals). The involvement of others in decision-making could provide a way for staff to minimise risk (particularly for themselves as an individual), but disagreements about the most appropriate course of action were challenging.

Conclusion: Staff make complex, risk-based decisions about potential transfers, often as a series of escalations. Understanding this can help to inform further research, policy and practice.