Improving networks between acute care nurses and an aged care assessment team

CARE OF OLDER PEOPLE

Improving networks between acute care nurses and an aged care

assessment team

Andrew Robinson PhD, RN

Senior Lecturer, Tasmanian School of Nursing, University of Tasmania, Hobart, Tasmania, Australia

Annette Street PhD

Professor of Cancer and Palliative Care Studies, Director, LTU/A & RMC Nursing Clinical School, La Trobe University,

Bundoora, Australia

Submitted for publication: 20 January 2003

Accepted for publication: 22 July 2003

Correspondence:

Andrew Robinson

Senior Lecturer

Tasmanian School of Nursing

University of Tasmania

Private Bag 121, Hobart

Tasmania 7000

Australia

Telephone: 03 6226 4735

E-mail: [email protected]

ROBINSON A & STREET A (2004)ROBINSON A & STREET A (2004) Journal of Clinical Nursing 13, 486–496

Improving networks between acute care nurses and an aged care assessment team

Background. Acute care nurses have an important role in the discharge planning of

older people from hospital to home. However, few nurses understand the changing

aged care system or the consequences of poor referral on the lives of older people

postdischarge.

Aims and objectives. This paper reports the findings of a research project, which

aimed to investigate the possibilities for facilitating the transition of older people

from hospital to home through improving the working relationship between nurses

and members of a multidisciplinary aged care assessment team (ACAT).

Design and methods. The paper reports one action research cycle from a larger

project. Action research was chosen because its focus on knowledge development

and action leads to practical solutions to clinical problems. The research approach

included interactive forums designed to facilitate effective collaboration between the

nurses and ACAT in the discharge planning of older people. Data collection strat-

egies included audiotapes of ACAT research discussions, field notes, policy docu-

ments, referral forms and an evaluation tool.

Results and conclusions. The findings illustrate that ward nurses have, at best, a

limited knowledge and understanding of the aged care system, its function, or how

to access services. They need assistance to develop their knowledge of services

available to support older people following discharge. The conduct of interactive

forums, which utilize a case study approach, facilitated such knowledge develop-

ment and empowered the nurses to become more involved in discharge planning.

Participation in the forums also facilitated new collaborative partnerships between

the nurses and ACAT, which enhanced effective discharge planning.

Relevance to clinical practice. The paper outlines practical strategies to support

collaboration between ward nurses and community providers and/or multi disci-

plinary assessment services. It provides a list of key considerations for the devel-

opment of effective ward/community networks to facilitate the discharge of older

people.

Key words: acute nursing, aged care, aged care assessment teams, discharge planning,

elderly

486 � 2004 Blackwell Publishing Ltd

Introduction

The percentage of older people in the population of countries

in the Western world is rapidly increasing. In Australia 12%

of the population was aged 65 years and over in 1996, an

increase from 9% in 1976. By 2016 it is projected that the

aged population will represent 16% of Australia’s total

population (AIHW, 2002a). The association between age and

morbidity means that older people are high users of hospital

services. Moreover, many older people experience acute and

chronic illnesses concurrently so often require both acute and

long-term care at the same time (Leutz et al., 1994; Macko

et al., 1995). Over the last decade in Australia, as in other

countries, inter-sectoral borders, for example have become

much less self-contained (according to Howe, 1996) as the

management of care has increasingly required the coordina-

ted use of services across sectors. This is evident in the

‘growing tension at the boundaries between what were once

relatively discrete systems’ (p. 1).

This has occurred at a time when acute care services have

been subject to a process of deinstitutionalization to

improve efficiencies and contain spending. Inevitably, this

has resulted in shorter lengths of hospital stay (Baulder-

stone, 1997; AIHW, 2002b). Faster turnover increases the

importance of effective discharge planning and places a

growing burden on community and residential care agencies

responsible for providing services to older people in the

postdischarge period. As in many other countries, problems

with the coordination of care between acute, community

and residential care services are endemic. This is reflective

of a growing demand to improve the level of service

integration (Swerissen, 2002).

In Australia, a key group involved in determining the

discharge needs of older people is the aged care assessment

team (ACAT). An ACAT is a multi-disciplinary group

consisting primarily of nurses and paramedical staff. ACAT’s

functions are formalized in their operational guidelines

(Commonwealth Department of Health and Family Services,

1996), which outline their roles and responsibilities. How-

ever, the function of teams is not specified absolutely. Rather,

the guidelines acknowledge the need for teams to be ‘flexible’

in their operation to account for ‘local circumstances’

(Commonwealth Department of Community Services, 1987,

p. 1).

ACAT’s responsibilities include:

1 assessing the medical, psychological, social and functional

status of older clients and making recommendations for

services;

2 determining eligibility for entry to residential care (AIHW,

2002a);

3 networking with other providers to facilitate the coordi-

nation of care for older clients, to facilitate their access to

services;

4 participate in discharge planning with hospital staff

(Commonwealth Department of Health and Family Servi-

ces, 1996).

Developing networks is deemed essential if ACATs are to

establish cooperative relations with service providers, receive

referrals and ensure clients receive appropriate services

without delay (Commonwealth Department of Health and

Family Services, 1996). Indeed, this is acknowledged as a key

strategy of the aged care assessment programme (Gibson &

Means, 1997).

ACATs function as a separate entity (Commonwealth

Department of Health and Family Services, 1996) and are

usually co-located in acute hospitals or with community

service providers. They are funded by Commonwealth and

State Governments, and are required to report to both. They

have a responsibility to provide assessment services to a

defined geographical area. In Australia, this means there are

121 ACATs servicing the population of people over 70

(AIHW, 2002a) and since its inception the number of clients

assessed through the Aged Care Assessment Program has

increased each year (Butler, 1997). It is worth noting that the

largest group of clients fall into the 80–84 age group (Lincoln

Gerontology Centre – Aged Care Group, 1996).

ACATs provide an assessment service to older people

located in multiple contexts, including acute, community and

residential care. This means they work across the interface of

acute and community-based care, which places them in an

ideal position to mediate the transition of older clients

between hospitals and the aged care system in the community

(McCallum, 1994). It also means ACATs are strategically

positioned to develop networks and linkages between other

service providers in aged care (Fine, 1997) including ward

nurses in acute hospitals.

Ward nurses play a central role in discharge planning

(Jackson, 1994; Lowenstein & Hoff, 1994), a key mechanism

in the transition of older people from hospital to home and a

‘vital link’ in facilitating continuity of care (Bull & Roberts,

2001). Shorter hospital stays add to the complexity of the

discharge process (Bendz et al., 2002). Effective discharge

planning is important because patients and their carers must

learn new information, skills and strategies for immediate

self-care within a short period of time (Cimprich, 1992).

Nurses are credited as being the most appropriate people to

coordinate these activities (Williams, 1991), given their role

in providing ongoing patient care, over time (Anthony &

Hudson-Barr, 1998). At the same time, pressures for early

discharge have given added impetus for nurses to refer to

Care of older people Networking between acute care nurses and an ACAT

� 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 486–496 487

ACATs (Howe, 1996). This is especially important for older

people, as they are most likely to have the greatest needs

following discharge (Dansky et al., 1996).

Significant issues have an impact on the effectiveness of the

nurses’ role in discharge planning. In part this relates to

philosophical interests that divide acute and community-

based health care providers (Kearney, 1994; Legge et al.,

1996; Fine et al., 1998) as well as ‘professional territoriality’

and a ‘lack of mutual trust and respect’, representing

significant barriers to cooperation (South Australian Com-

munity Health Research Unit, 1994, p. 43). Armitage &

Kavanagh (1997) report that ‘busy nurses often give dis-

charge planning a low priority… underrate the value of

discharge preparation for patients welfare,’ and are more

concerned with ‘the immediate demands of patient care and

the mechanics of discharge from hospital than with care in

the community’ (pp. 17–18). Reflecting its relative lack of

status, discharge planning is often reduced to an ad hoc

process and the discharge of many patients from hospital is

often precipitous (Fine et al., 1996).

Given these concerns it is hardly surprising to find that

discharge planning is described as a complex process (Walz

& Hakim, 2002) that is ‘fragile and vulnerable to break-

down’ (Jewell, 1993, p. 1294). For example, evidence reveals

that many nurses struggle to conduct assessments that

acknowledge the care needs of older patients (Armitage

et al., 1995; Clare & Hofmeyer, 1998), or to estimate their

coping abilities following discharge (Nixon et al., 1998).

Nurses receive little if any feedback on the effectiveness of

their discharge planning, have a poor knowledge of commu-

nity-based services, and experience difficulties accessing them

(Lowenstein & Hoff, 1994; Armitage & Kavanagh, 1996).

This is a cause for concern because, if nurses’ assessment of

patient’s needs is limited, then important information will go

unrecognized in the discharge process. Adding to these

problems is evidence that early discharge has negative

implications for referral processes from ward nurses to

community agencies (Worth et al., 1994).

After concerns were raised about the effectiveness of the

relationship between ACAT and ward nurses in facilitating

the discharge of older patients from a number of Australian

hospitals, it was decided to conduct a study to address this

issue. In this study, the focus was on the practice of the

involved health professionals. There was a deliberate decision

not to involve older people in the research directly and nor

was this appropriate. In general, older people were involved

in a one-off assessment by the ACAT and in the vast majority

of cases there was no ongoing relationship or continuity with

the Team. This reflected the fact that as an organization

ACAT did not provide an ongoing assessment service to a

specific group of older people over time, but rather a one-off

assessment to large aged care population within a defined

geographical area. The intention in the study was therefore to

develop strategies to ensure this one-off assessment encounter

was effective. As such, in the first instance, the focus of the

research was on identifying the issues and implementing

strategies. To this end, after careful deliberation, action

research was chosen as the most appropriate method to

analyse and improve the capacity of ACAT and ward nurses

to network effectively in the discharge planning process. As

will be seen below in the findings, utilizing this process

actually meant that the effect of the change in practice on the

older people was documented.

Method: action research

Action research is a label that is loosely applied to a range of

research methods and processes that share a common interest

in the relationship between knowledge and action; that values

the participation of all stakeholders in the conduct and

decision making of the research; as well as addressing

practical problems to improve a situation (Street, 2002). In

this study a critical action research method was employed

with members of an ACAT to improve inter-sectoral

networks. This approach is marked by an emancipatory

interest and a particular concern with the concurrent devel-

opment of theory and practice, promoting collaboration

between researcher and participants, and collective con-

sciousness raising through the process of critical reflective

discussions (dialogue/narrative). In this sense, as Kemmis

(2001) notes, emancipatory action research ‘aims not only at

improving outcomes, and improving the self-understanding

of practitioners, but also at assisting practitioners to arrive at

a critique of their… work and work settings’ (p. 92). The

interest of critical action research is fuelled by a desire to

disrupt dominant power relations in an effort to recreate new

and just social situations in a ‘project of possibility’ (Simon,

1988, p. 1), to provoke a ‘transformative’ endeavour in a

‘partisan struggle for a better world’ (Kincheloe & McLaren,

1994, p. 140). Such a project affirms the place of practice and

opens an opportunity for practitioners, like the members of

the ACAT involved in this study, to address injustice through

developing networks that improve the coordination of care

and outcomes for their older clients.

The outcomes of action research in health care are context-

specific and may be focused on a clinical problem (Koch

et al., 2000) or take a wider approach to changing health care

culture (Jirapaet, 2000). Reflective of the critical intent of this

study the aim was to develop a cultural change in the

professional relationships that existed between members of

A Robinson and A Street

488 � 2004 Blackwell Publishing Ltd, Journal of Clinical Nursing, 13, 486–496

the ACAT and nurses in acute settings. To do this, the study

was structured around an action research process following

the work of Street and Robinson (Street, 1995; Street &

Robinson, 1995).

Unlike linear research designs, action research uses a

circular or spiral design to depict the process. After a

preliminary investigation has been undertaken to explore

the literature and the health care context, strategic action is

planned, implemented and monitored. Analysis of the

findings is followed by collaborative reflection on the success

of the plan or the need to modify it and begin another cycle of

planning, implementation, data collection, analysis and

reflection. This cyclical process continues until the situation

has improved. In this instance the study comprised six action

cycles and a series of subcycles. This paper reports the

findings of one action cycle (the first nurses networking cycle)

as illustrated in Fig. 1. However, a short overview of the

larger project on ACAT developing linkages with service

providers is offered below to explain the context for this

cycle.

Short overview of ACAT linkages project

The ACAT linkages project began after an ACAT member

contacted the first author to discuss her concerns around poor

relationships between ACAT and various service providers.

Both authors then met with the ACAT Manager and the

Director of Aged Care services in the Health Department and

agreement was reached to establish an action research project

to address this concern. A number of key stakeholders were

invited to become members of a project steering group.

Meetings were held with the ACAT members and the first

author outlined the proposed project and the action research

process. Seven members of ACAT volunteered to join the

research as co-researchers. The Human Research Ethics

Committee of the Faculty of Health Sciences at La Trobe

University approved the study (no. FHEC 95/072). All ethical

guidelines adhering to confidentiality, anonymity and

informed consent were observed.

The ACAT co-researchers met on 30 occasions over a

period of 20 months and participated in planning, imple-

mentation, data collection, individual interviews and colla-

borative reflection. During these meetings an array of

concerns emerged regarding the professional working rela-

tionships between ACAT staff and service providers, primar-

ily general practitioners and nurses in acute hospitals. These

concerns were addressed in the planning for three cycles of

the action research process (see Fig. 1). The team collected

data both continuously as each cycle progressed and at their

conclusion. Data collection strategies for the cycles included

audiotapes of ACAT research and reflection discussions.

These were developed into case notes by the first author and

circulated to the co-researchers and reported to the steering

committee. The co-researchers also kept field notes of their

Figure 1 Represents the complete

sequence of action research cycles involved

in the larger project. The dark shaded areas

represent the ‘First Nurse Networking

Cycle’, which is the subject of this paper.



implementation strategies and participated in interviews.

Policy documents, guidelines and referral forms were also

analysed. An evaluation tool was administered to all partici-

pants to ascertain their feedback on the success of the

strategic action.

The paper does not report the whole story of the research.

It represents a report of the first of three action cycles, which

had a focus on developing the ACAT’s networks with

hospital nurses and general practitioners. In total, 56 nurses

from five wards at three hospitals participated in two

sequential networking cycles, with a further 16 general

practitioners involved in the third action research cycle. As

outlined above, the subject of this paper is the first nurses

networking cycle.

The nurses networking cycle

Objective

This first nurses networking cycle was designed to improve

the working relationship between nurses in two small

hospitals and members of ACAT to facilitate more effective

collaboration in assessment, referral and discharge planning.

Rationale

The rationale for this cycle emerged during the preliminary

investigation of an earlier cycle (see Fig. 1), sometimes called

a reconnaissance stage. A series of meetings had been

conducted where it became plain that ACAT members were

troubled about the impact of their poor relationship with

nursing staff in acute hospitals concerning the transition of

older clients from hospital to the community. Evidence

collected during this process indicated that the ward nurses

had, at best, limited knowledge of, or involvement in, the

assessment process. This was apparent in the limited number

of referrals to the team from hospitals, as well as the late and

inappropriate referrals received by the ACAT. Further, team

members perceived that hospital staff members were often

hostile to the ACAT, symptomatic of what they believed to be

unrealistic expectations of their capacity to link clients to

services, in the context of service shortages. The nurses’ lack

of basic knowledge of the community-based services avail-

able to older people exacerbated the situation; as did their

limited interest in discharge planning and the consequences

for their older clients following a period of hospitalization

Further investigation during this stage revealed that the

processes employed by the team members to develop

networks and linkages with nurses were ineffective because

they utilized a prescriptive and controlling approach.

Effective networks are predicated on developing collaborat-

ive relations based on mutual trust and respect in the context

of a collaborative relationship (Legge et al., 1996). Addi-

tional analysis revealed that the ACAT took no responsibility

for working with or encouraging hospital staff to facilitate

client access to services. Rather their ‘core business’ was

concerned with conducting assessments and making recom-

mendations for services, despite their operational guidelines

(Commonwealth Department of Health and Family Services,

1996) indicating a clear responsibility to work with other

providers to facilitate client access. This preliminary investi-

gation formed the basis for the decision to embark on an

action strategy in acute settings.

Context

Fortuitously, one co-researcher had been assigned as the

ACAT assessor servicing two small hospitals. Consistent with

the team’s preliminary findings she reported that the ward

nurses were ‘extremely negative about ACAT’. Furthermore,

problems with discharge planning and client assessment were

exacerbated because of an expectation that the charge nurse

would assume responsibility for these activities. It was, in her

words, ‘obviously something that was historical, they were

used to doing it’ (A2). In the context of a busy ward it was

apparent that the charge nurses’ primary concerns centred on

overseeing the biomedical care, rather than preparation for

discharge. Additionally, it was evident that a prevailing ethic

existed within each ward that if clients experienced problems

following discharge ‘it would be picked up in the community’

(A2).

Planning action

It was decided that the most effective strategy would be for

this ACAT co-researcher to establish a series of interactive

forums on two wards in the two small hospitals. These

interactive forums were designed to enable the ACAT

members and nurses to explore their concerns with:

• the nurses’ role in discharge planning;

• the operation of the aged care system;

• the interrelationship between aged care services and the

acute care system;

• ways that ACAT assessors could collaborate with nurses to

facilitate the transition of their older clients to community

and residential care contexts.

Consistent with the collaborative intent of this project the

ACAT co-researcher posted a suggestion sheet on each ward

that asked the nurses to identify relevant issues for discussion

at the forums.



Implementation: interactive forums

Following meetings with both charge nurses and informal

discussions with the nurses on each ward, the interactive

forums commenced in the two hospitals with interested

nurses attending. The forums spanned a period of 4 months

and all 27 nurses participated in this cycle. Between 10 and

15 interactive forums were held in each hospital. Attendance

was facilitated by conducting the forums during the double

staff period between day and evening shifts, so that some

nurses provided patient care while others left the ward to

attend sessions. Additionally, the forums were generally

‘short and sweet’, which meant the nurses were more inclined

to leave the ward to attend even on ‘busy days’. However, the

problems associated with fluctuating workloads and rotating

shiftwork meant it was impossible for every nurse to attend

every session.

Despite a planned agenda, the content of forums was

flexible and informed by comments made on the suggestion

sheets posted on each ward. However, as the forums

progressed and other issues arose, they too were addressed.

For example, at the nurses’ request, staff from a number of

agencies, such as the Home and Community Care Program

(key providers of services to older people in the community)

also participated in some sessions. In this way the programme

was responsive to the nurses’ needs.

The structure of the forums also reinforced the colla-

borative approach. In general, they were conducted in an

informal manner and the ACAT co-researcher reported that

the nurses actively participated in the discussions. Impor-

tantly, regular attendance by a few highly motivated

nurses served to encourage participation among their

colleagues.

To promote the nurses’ active participation in the forums

the issues under discussion were related directly to clients

nursed on their ward. This process involved drawing on case

scenarios of particular clients and examining their postdis-

charge needs in relation to particular services. The nurses

were then able to explore how specific services might, or

might not, meet patient needs and how they could facilitate

their patient’s access to these services during the discharge

process. Thus the nurses made direct links between a

particular service and the needs of their patients.

Adopting this strategy was important for several reasons.

Firstly, because the nurses were generally very busy and

worried about ‘getting behind with their work’, the interac-

tive forums had to be of immediate relevance if the nurses

were to make the effort to attend. Secondly, the use of case

scenarios meant that the ACAT co-researcher was able to

demonstrate to the nurses the importance of targeting clients

to refer to the ACAT and her role in the process of matching

client needs to the admission criteria employed by individual

service providers.

Evaluation, analysis and reflection

Effectiveness of case scenarios

Evaluation of the cycle revealed that the use of case scenarios

was highly effective. The ACAT co-researcher reported that

when she drew on case scenarios the nurses were often

astounded when they realized how these criteria were applied

to their patients. However, despite the team’s preliminary

analysis she was shocked by what she found and reported:

I was really surprised at their lack of knowledge. I assumed they had

a greater knowledge than they did and I was continually astounded as

to how ill informed they were! (A2)

Comments made by nurses such as the forums ‘clarified the

services available and how to access them’ (RN3) and ‘the

maze (that is the aged care system) is more familiar now so I

am now aware of services available and how to access them’

(RN6), indicate that participation improved the nurses’

understanding of the aged care system.

Not surprisingly, evaluation indicated that because of their

involvement in the forums the nurses developed an improved

understanding of ACAT’s role and the decision making

processes that informed an ACAT assessment. One partici-

pant commented: ‘It now makes more sense why some

(patients) are able to be placed easier than others’ (RN5).

Changes to the practice of discharge planning

Analysis of the data also revealed that improved understand-

ing of services helped to build the nurses’ confidence to

participate in discharge planning. Written comments such as

‘We are able to advise patients more confidently of services

available’ (RN17), ‘Knowing the services that can be offered

to patients has helped me with discharge planning’ (RN2)

and ‘Information discussed (in the sessions) helps me to

answer questions and give advice to patients’ (RN11),

supported this finding.

The direct involvement of the ward charge nurses in the

forums facilitated this change. Recognizing the benefits

associated with the nurses participating in discharge plan-

ning, as the forums progressed, the charge nurses of both

wards encouraged their staff to take more responsibility in

this area. In the process, hierarchical power relations were

changed as the charge nurses took a more participatory

approach to these activities.



However, the nurses did not take on this new responsibility

in isolation. There was a concurrent increase in the level of

collaboration between the ACAT co-researcher and the ward

staff in discharge planning. She reported re-negotiating her

role in the discharge process, saying that:

I’ve been meeting with them and working out what services they

think the person should need. I’ve been saying what I think they

should need, then (after some discussion) reaching an agreement and

clearly documenting ‘I will refer to family-based care, you will refer

for an OT assessment, I will do this, you will do that’ and it has been

collaborative in that regard. (A2)

Changes to referral patterns

The ACAT co-researcher found that part of the problem with

the limited number and often inappropriate referrals from

ward nurses related to the fact that they were ‘scared’ of filling

out the ACAT referral form incorrectly. At one meeting of the

larger ACAT research team, another ACAT co-researcher

confirmed this. She reported that she had received ‘wonderful

feedback’ on the project when she commented to involved

nurses on the quality of a referral she had received. They spoke

of attending a networking forum that addressed the ACAT

referral form. This co-researcher reported that ‘they were really

thrilled and positive (about the forum) and they said it’s been

really helpful because they really didn’t know how to fill out the

form’ (A4).

The nurses newfound confidence in using the ACAT

referral form became evident when members of the larger

ACAT research team reported that the quality of referrals

sent to ACAT had improved and that the generation of

referrals from the two involved hospitals to a programme

providing postacute care for older people, associated with the

ACAT, increased by 38% (Tasmanian Department of Com-

munity and Health Services, 1996). This change was directly

attributed to their participation in the forums.

The importance of personal contact in a collaborative

context

The findings demonstrated the positive effects associated with

‘regular face-to-face’ meetings between an ACAT assessor and

ward staff. The ACAT co-researcher reported to her col-

leagues in the larger research team on the effects of assessors’

relative anonymity on the wards, in part related to the ACATs

focus on meeting their core business targets of number of

assessments and the time between referral and assessments. It

became apparent that this focus undermined their ability to

work together to facilitate discharge planning. She reported:

…anonymity came up (as an issue) on the wards… (the nurses found

it) difficult to access the assessor because they would come in, and not

attempt to develop a rapport with (them… rather, they would) do the

assessment, write the recommendations and then head off again. (A2)

In response the ACAT co-researcher changed her practice.

She reported that now ‘I keep in touch (with ward staff) as a

matter of course’ (A2) and that this regular ‘face-to-face’

contact facilitated her ability to work effectively with them.

She argued that this was important because:

They want the contact because when you turn up there (on the ward)

they often troubleshoot with you. They often sit you down and things

will come up, whereas they probably wouldn’t have bothered to

phone, …even if it’s just to debrief…. They know you’re there when a

crisis arises… but they also need to know there is support there as

well. (A2)

This change in practice was oriented at establishing an

ongoing dialogue with the nurses that facilitated discharge

planning and a collective ability to resolve difficult patient

care issues. The RN networking evaluation supported this

finding. For example, one of the nurses commented that,

‘(I) Feel much more comfortable ringing ACAT now I can

put faces to names’ (RN4), while another wrote that

participation in the interactive forums ‘familiarizes ACAT

and nursing staff so that we feel more comfortable in

dealing with each other’ (RN8). The nature of this changed

relationship and its effects were in part captured by the

comments of one participant who noted: ‘They (ACAT)

have become allies and co-workers instead of an outside

dominating force’ (RN3).

Participation in the project also provided the nurses with

an opportunity to make ‘face-to-face’ contact with other

service providers. One nurse wrote ‘it’s good to know whom

you are talking to especially on the phone’ (RN5), while

another suggested, ‘it’s easier to contact a familiar face and

name’ (RN12). It was also apparent that these meetings were

equally beneficial for the providers themselves, as the ACAT

co-researcher argued when she said:

Community organizations are also working in isolation. For them,

coming into a hospital system is daunting. They’re often too afraid to

do it so they don’t… it’s like the nurses making contact with the aged

care system…. It’s just too difficult…. (A2)

These findings suggest that bringing the parties together was

a highly effective mechanism for promoting networks and the

development of linkages between services in aged care. They

also suggest that the members of a multi-disciplinary team

who work across the interface of health and community care,

like ACAT, are strategically positioned to facilitate this



process to bring different groups together and break down

their isolation.

The effectiveness of the first nurse networking cycle was

evidenced in the nurses’ response to the evaluation questions,

‘Do you think the networking meetings have been useful?’

and ‘Did you gain useful information from these regular

presentations?’ One hundred per cent of the nurses responded

in the affirmative to both questions. Indeed, the nurses’

interest was evident in that over 70 comments were written

on the evaluation forms, many of which have been included

in the above text. The success of the project was also evident

in the feedback that nurses on other wards in the hospitals

wanted to participate in any future programmes. As the

ACAT co-researcher noted:

It was interesting. I went to one of the hospitals on Monday and a

CN of a new ward came and said, ‘Can we be targeted next year….

Can we be the first ones next year? (A2)

Discussion and implications for nursing practice

The findings of this study provide insights into the issues that

confront nurses in the process of assisting older people make

the transition from hospital to home. That nurses need

assistance is evident in the findings of this study, which

illustrate their minimal knowledge and understanding of the

aged care system, or its function. This finding is indicative of

the relative isolation of ward nurses from community provid-

ers, outlined in the literature (Armitage & Kavanagh, 1996). It

also suggests a relative lack of importance associated with

discharge planning and the coordination of patient care, as

well as problems with keeping abreast of the comprehensive

and continuous changes in the aged care sector.

Historically ward nurses, other than those in senior posi-

tions, have minimal if any involvement in case conference

discussions where members of the multi-disciplinary team

make decisions about the discharge of older patients. In many

circumstances they are subsequently given responsibility for

implementing these decisions without the benefit of involve-

ment in their formulation. Alternatively when decisions are

implemented by a third party, such as a ward charge nurse who

is not directly responsible for the provision of patient care,

critical information relating the patients needs and require-

ments is often overlooked (Hill, 1999). Ward nurses need

direct involvement in the discharge process given their role in

providing ongoing patient care, over time (Anthony &

Hudson-Barr, 1998). However, to fulfil their potential they

need assistance in developing their knowledge of services

available to support older people in the community following

discharge.

The findings of this study indicate that providing nurses

with an opportunity to attend interactive forums assisted in

developing their knowledge of services. Moreover, relating

the discussions from these forums to specific patients,

through the use of case scenarios was a successful strategy

to address such knowledge deficits of ward nurses. This

enabled the nurses to make a direct link between a particular

aged care service and the needs of their patients. Further-

more, it was apparent that their lack of knowledge of services

fed the nurses’ reluctance to participate in discharge plan-

ning. By their own reports, having knowledge of services

empowered them to become more involved in such processes.

Critical to this was the support and involvement of the ward

charge nurse. This finding supports those of similar studies

that highlight the importance of effective leadership in

changing organizational arrangements to improve coordina-

tion (Legge et al., 1996; Fine et al., 1998).

The sharing of information about aged care services, a key

focus of this cycle, provoked what Lincoln (2001) might

suggest was a ‘redistribution of power’ (p. 125). This was

important because, as the study findings illustrate, the

involved ward nurses struggled to understand the operation

of the aged care system or how to gain access to them. In

these circumstances an increased knowledge of services

opened up opportunities to collaborate with the ACAT in

previously unimagined ways. Likewise, the insights gained by

the assessors helped them to develop new understandings of

these knowledge deficits and their implications for the

provision of services. In this way a reconfiguration of power

was critical to improve coordination as new knowledge was

central to develop more effective practice and organizational

arrangements.

The reported problems that nurses experienced with the

ACAT documentation, specifically the referral form, and

the ACAT’s lack of awareness of this issue, demonstrated the

effects of habitual practices in undermining coordination.

These findings illustrate the propensity for multi-disciplinary

community-based groups like ACAT to become captive to the

‘dictates of tradition, habit and bureaucratic systematization

of individual experience’ (Kemmis, 1988, p. 36). In this case,

habitual use of the referral form had, in the words of

Foucault (1988), ‘become part of… (the ACATs) most

familiar landscape’ (p. 10), such that they could not ‘perceive

it any more’ (p. 10). In turn this acted as key impediment to

effective referral processes because the ACAT’s familiarity

with the form masked problems with its use.

Such findings bring to the foreground the importance of

community groups like ACAT collaborating with ward

nurses in a process of ‘mobilizing different understandings



to produce a broader story’ (Legge et al., 1996, p. 114) of the

problems they mutually confront. As the literature suggests

(Maclure, 1990; Stoecker & Bonacich, 1992), such encoun-

ters created opportunities for participants in critical research

processes, like the ACAT members and ward nurses, to

develop theoretical analyses of their situation, which inform

possibilities for change. It was this process that the nurses’

use of the referral form appeared to improve. Similar changes

also emerged in relation to new arrangements negotiated

between the ACAT assessor and the ward nurses. These

witnessed the emergence of a partnership where the assessor

was situated as collaborator in the process of enacting the

client’s care plan.

Such findings suggest that meeting together in the inter-

active discussion forums, enabled the members of different

institutional cultures (ACAT & ward nurses) to flesh out

issues, concerns and mutual interests. In this way they were

able to negotiate new practices, which took account of the

varying perspectives of the situation and develop a new

appreciation of each other’s role and responsibilities, which

as the literature highlights, is central to achieving effective

collaboration (Humphries, 1997; Keks et al., 1997; Fine

et al., 1998).

Likewise, it was apparent that participation in the inter-

active discussion forums with the nurses was of significant

importance. Here the project findings confirm those of the

literature, which suggest the importance of face-to-face

contact in the development of collaborative networks (Noh-

ria & Eccles, 1992) and the inter-personal dimensions of

networking (Larson, 1992) – a situation also apparent in the

nurses’ encounters with community providers involved in the

networking forums.

From the findings of this project it is clear that, to ensure

the effective discharge of older people, it is imperative that

nurses prioritize this aspect of care. To facilitate effective

discharge planning, in contexts with ever decreasing lengths

of stay, there is an increasing need for ward nurses to

collaborate with community providers, specialist discharge

planners and/or multi-disciplinary referral and assessment

services. It is clearly important to establish a professional

relationship based on trust and openness that acknowledges

the roles and responsibilities of different service providers in

the discharge process. However, at the same time, these

findings illustrate that much of what constitutes networking

is structured as informal interaction, such as a brief discus-

sion on the ward. Indeed, as the literature notes, collaborative

networks are often facilitated through informal arrangements

at a local level (Walker, 1992) and that personal history,

individual friendships and ‘reputational knowledge’ (Larson,

1992, p. 99) are critical to their development. For ward

nurses it is important not to underestimate their role in this

process and to make time to discuss patients with other

service providers involved in the planning of discharge.

Table 1 outlines considerations for effective ward nurse/

community networking to facilitate this process.

Finally, the overall findings of the study indicated that the

effectiveness of the one-off ACAT assessment process was

improved once the networks with the ward nurses and other

practitioners improved. This was achieved through partici-

pation in the various action research cycles. Further, despite

the time demands associated with their involvement in the

networking project, the time lapse between receipt of the

referral and the conduct of an assessment by the ACAT team

decreased. The data on team activity indicated that this

decrease was due to the improved networks and the associ-

ated increase in efficiencies such as a decrease in the number

of inappropriate referrals sent to the ACAT team. Con-

sequently, older people in the region waited a shorter time to

have their needs assessed. In turn, this hastened the prospect

of their receiving appropriate support. Furthermore, the new

collaborative networks established between the ACAT and

the ward nurses, also meant that older people had access to a

greater array of options post-assessment. This was because

the ACAT were able to more effectively support the nurses in

the discharge planning process.

Table 1 Considerations for effective ward nurse/community net-

working

Time

Discharge planning for older people needs to be a priority for all

nurses and not just the charge nurse or discharger planner

Regular ‘face-to-face’ opportunities for formal and informal

information sharing between ward nurses, assessment teams,

discharge planners and community services is essential

Case discussions need to be conducted at times and a venue when

all relevant nursing staff can participate

Education

All ward nurses need to be provided with regular updates on

changes to the aged care system, the processes of referral to

community services and relevant referral documentation

Education sessions on effective discharge planning should be

interactive and focused on meeting the specific information

needs of ward nurses as well as providing a forum to share

their concerns

Negotiation

Changes to practice need to be negotiated between ward nurses

and community staff to improve the practice and integration

of various service providers in the discharge process

Research

Ward nurses need to be given the opportunities to engage in

practitioner research processes directed at assisting them to

understand and improve their practice



Acknowledgements

We would like to acknowledge the members of the ACAT

and the ward nurses who participated in this project. Their

support and enthusiasm ensured its success. We also thank

both the Schools of Nursing and Faculty of Health Sciences at

the University of Tasmania and La Trobe University for their

generous funding in support the project.

Contributions

Study design: AR, AS; data analysis: AR, AS; manuscript

preparation and literature review: AR, AS.

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