Referrals to Emergency Departments— The Processes and Factors That Influence Decision-Making among Community Nurses


The aim of the study was to describe the basis on which municipal care registered nurses (RN) make decisions and their experiences when referring older persons from nursing homes to emergency departments (EDs). RNs in the community are to ensure that older adults receive good care quality in nursing home. This study used a descriptive design with a qualitative content analysis. The analysis of the data from the 13 interviews revealed one theme “Shared responsibilities in the best interests of the older person reduce feelings of insufficiency”. The content was formulated, which revealed the RNs’ feelings, reasoning and factors influencing them and their actions in the decision-making situation, before the patients were referred to an emergency department. Complex illnesses, non-adapted organizations, considerations about what was good and right in order to meet the older person’s needs, taking account of her/his life-world, health, well-being and best interests were reported. Co-worker competencies and open dialogues in the “inner circle” were crucial for the nurses’ confidence in the decision. Hesitation to refer was associated with previous negative reactions from ED professionals. The RN sometimes express that they lacked medical knowledge and were uncertain how to judge the acute illness or changes. Access to the “outer circle”, i.e. physicians and hospital colleagues, was necessary to counteract feelings of insecurity about referrals. When difficult decisions have to be made, not only medical facts but also relationships are of importance. To strengthen the RNs’ and staff members’ competence by means of education seems to be important for avoiding unnecessary referrals. Guidelines and work routine need to be more transparent and referrals due to the lack of resources are not only wasteful but can worsen the older persons’ health.

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Kihlgren, A. , Sunvisson, H. , Ziegert, K. and Mamhidir, A. (2014) Referrals to Emergency Departments— The Processes and Factors That Influence Decision-Making among Community Nurses. Open Journal of Nursing, 4, 366-374. doi: 10.4236/ojn.2014.45042.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Bakalis, N., Bowman, G.S. and Porock, D. (2003) Decision Making in Greek and English Registered Nurses in Coronary Care Units. International Journal of Nursing Studies, 4, 749-760.
[2] Bucknall, T. and Thomas, S. (1997) Nurses’ Reflections on Problems Associated with Decision-Making in Critical Care Settings. Journal of Advanced Nursing, 25, 229-237.
[3] Austin, M.J. and Claassen, J. (2008) Implementing Evidence-Based Practice in Human Service Organizations: Preliminary Lessons from the Frontlines. Journal of Evidence-based Social Work, 5, 271-293.
[4] Carter, M.W., Datti, B. and Winters, J.M. (2006) ED Visits by Older Adults for Ambulatory Care-Sensitive and Supply-Sensitive Conditions. The American Journal of Emergency Medicine, 24, 428-434.
[5] Finn, J.C., Flicker, L., Mackenzie, E., Jacobs, I.G., Fatovich, D.M., Drummond, S., Harris, M., Holman, D.C. and Sprivulis, P. (2006) Interface between Residential Aged Care Facilities and a Teaching Hospital Emergency Department in Western Australia. The Medical Journal of Australia, 184, 432-435.
[6] Carter, L., Skinner, J. and Robinson, S. (2009) Patients from Care Homes Who Attend the Emergency Department: Could They Be Managed Differently. Emergency Medicine Journal, 26, 259-262.
[7] Jablonski, R.A., Utz, S.W., Steeves, R. and Gray, D.P. (2007) Decisions about Transfer from Nursing Home to Emergency Department. Journal of Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honor Society of Nursing/Sigma Theta Tau, 39, 266-272.
[8] McCloskey, R.M. (2011) A Qualitative Study on the Transfer of Residents between a Nursing Home and an Emergency Department. Journal of the American Geriatrics Society, 59, 717-724.
[9] Radwin, L.E. (1998) Empirically Generated Attributes of Experience in Nursing. Journal of Advanced Nursing, 27, 590-595.
[10] Carpenter, B.D., Van Haitsma, K., Ruckdeschel, K. and Lawton, M.P. (2000) The Psychosocial Preferences of Older Adults: A Pilot Examination of Content and Structure. The Gerontologist, 40, 335-348.
[11] Luker, K.A., Austin, L., Caress, A. and Hallett, C.E. (2000) The Importance of “Knowing the Patient”: Community Nurses’ Constructions of Quality in Providing Palliative Care. Journal of Advanced Nursing, 31, 775-782.
[12] Fagerberg, I. (2004) Registered Nurses’ Work Experiences: Personal Accounts Integrated with Professional Identity. Journal of Advanced Nursing, 46, 284-291.
[13] The National Board of Health and Welfare (2005) Quality Management and Patient Safety in Health Care. Lednings-system för kvalitet och patientsäkerhet i hälsooch sjukvården. SOSFS 2005:12 (M) Socialstyrelsen, Stockholm. (In Swedish)
[14] The National Board of Health and Welfare (2001) National Board of Health Regulations on Competence Requirements for Nurses in Prescribing Medicines. Socialstyrelsens föreskrifter om kompetenskrav för sjuksköterskor vid förskrivning av läkemedel. SOSFS 2001:16 Socialstyrelsen, Stockholm. (In Swedish)
[15] Kihlgren, A.L., Fagerberg, I., Skovdahl, K. and Kihlgren, M. (2003) Referrals from Home Care to Emergency Hospital Care: Basis for Decisions. Journal of Clinical Nursing, 12, 28-36.
[16] Netting, F. and O’Connor, M. (2008) Recognizing the Need for Evidence-Based Macro Practices in Organizational and Community Settings. Journal of Evidence Based Social Work, 5, 473-496.
[17] Nyström, M., Dahlberg, K. and Carlsson, G. (2003) Non-Caring Encounters at an Emergency Care Unit—A Life-World Hermeneutic Analysis of an Efficiency-Driven Organization. International Journal of Nursing Studies, 40, 761-769.
[18] McCloskey, R.M. and van den Hoonaard, D. (2007) Nursing Home Residents in Emergency Departments: A Foucauldian Analysis. Journal of Advanced Nursing, 59, 186-194.
[19] Turjamaa, R., Hartkainen, S. and Pietilä, A.-M. (2013) Forgotten Resources of Older Home Care Clients: Focus Group Study in Finland. Nursing and Health Sciences, 15, 333-339.
[20] Berland, A., Gundersen, D. and Bentsen, S.-B. (2012) Patient Safety and Falls: A Qualitative Study of Home Care Nurses in Norway. Nursing and Health Sciences, 14, 452-457.
[21] Kihlgren, A.L., Wimo, A. and Mamhidir, A.-G. (2013) Older Patients Referred by Community Nurses to Emergency Departments—A Descriptive Cross-Sectional Follow-Up Study in a Swedish Context. Scandinavian Journal of Caring Sciences, 28, 97-103.
[22] Graneheim, U.H. and Lundman, B. (2004) Qualitative Content Analysis in Nursing Research: Concepts, Procedures and Measures to Achieve Trustworthiness. Nurse Education Today, 24, 105-112.
[23] Sandelowski, M. (1998) Writing a Good Read: Strategies for Re-Presenting Qualitative Data. Research in Nursing & Health, 21, 375-382.<375::AID-NUR9>3.0.CO;2-C
[24] Gillespie, S.M., Gleason, L.J., Karuza, J. and Shah, M.N. (2010) Health Care Providers’ Opinions on Communication between Nursing Homes and Emergency Departments. Journal of the American Medical Directors Association, 11, 204-210.
[25] Sarvimaki, A. and Benko, S.S. (2001) Values and Evaluation in Health Care. Journal of Nursing Management, 9, 129-137.
[26] Kihlgren, A.L., Nilsson, M. and Sorlie, V. (2005) Caring for Older Patients at an Emergency Department—Emergency Nurses’ Reasoning. Journal of Clinical Nursing, 14, 601-608.
[27] Saliba, D., Kington, R., Buchanan, J., Bell, R., Wang, M., Lee, M., Herbst, M., Lee, D., Sur, D. and Rubenstein, L. (2000) Appropriateness of the Decision to Transfer Nursing Facility Residents to the Hospital. Journal of the American Geriatrics Society, 48, 154-163.
[28] Cohen-Mansfield, J. and Lipson, S. (2002) Medical Decisions for Troubled Breathing in Nursing Home Residents. International Journal of Nursing Studies, 39, 557-561.
[29] Purdy, W. (2002) Nursing Home to Emergency Room? The Troubling Last Transfer. The Hastings Center Report, 32, 46-48.
[30] Nortvedt, P., Pedersen, R., Grothe, K.H., Nordhaug, M., Kirkevold, M., Slettebo, A., Brinchmann, B.S. and Andersen, B. (2008) Clinical Prioritisations of Healthcare for the Aged—Professional Roles. Journal of Medical Ethics, 34, 332-335.
[31] Social Service Act (2001) The Social Service Act of Sweden.
[32] Westin, L., &OUMLhrn, I. and Danielson, E. (2012) Residents’ Experiences of Encounters with Relatives and Significant Persons: A Hermeneutic Study. Nursing and Health Sciences, 14, 495-500.
[33] Coleman, P.G., Carare, R.O. and Petrov, I. (2011) Spiritual Belief, Social Support, Physical Functioning and Depression among Older People in Bulgaria and Romania. Aging & Mental Health, 15, 327-333.
[34] Sandelowski, M. (1995) Sample Size in Qualitative Research. Research in Nursing & Health, 18, 179-183.
[35] Leininger, M. (1991) Transcultural Care Principles, Human Rights, and Ethical Considerations. Journal of Transcultural Nursing, 3, 21-23.
[36] Kvale, S. (1997) The Qualitative Research Interview. Den kvalitativa forskningsintervjun. Studentlitteratur, Lund. (in Swedish)
[37] Mishler, E.G. (1986) Research Interviewing: Context and Narrative. Harvard University Press, Cambridge, 53-59.
[38] Mantzoukas, S. (2007) The Evidence-Based Practice Ideologies. Nursing Philosophy: An International Journal for Healthcare Professionals, 8, 244-255.
[39] Sunvisson, H., Habermann, B., Weiss, S. and Benner, P. (2009) Augmenting the Cartesian Medical Discourse with an Understanding of the Person’s Lifeworld, Lived Body, Life Story and Social Identity. Nursing Philosophy: An International Journal for Healthcare Professionals, 10, 241-252.

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