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Suboptimal care of acutely unwell ward patients is of growing concern internationally. As empirical study of the problem is underdeveloped this thesis explores factors affecting suboptimal care of acutely unwell ward patients. In order to bring a theoretical understanding to this area, a concept analysis of the term suboptimal care was undertaken. The results of this concept analysis were then used to inform the design and analysis of this multiple case study. The cases for this study were two general surgical and two general medical wards located in two hospitals in the North Island of New Zealand. Interviews and focus groups with nurses, doctors, and managerial staff were undertaken using a semi structured interview approach informed by the concept analysis. Organisational and ward documentation was also reviewed. Using categorical aggregation and pattern matching, an analytical framework emerged from the data. This framework was then used to conduct within, cross case, and hospital analyses. Key findings of this research reveal that workload, teamwork, communication, leadership, skills and knowledge deficit, and organisational systems and processes are significant factors affecting care of acutely unwell ward patients and that these factors are not unique to specific contexts. Polarised views about workload were expressed by those who manage organisations and those who deliver care at ward level. Current approaches to improving care of the acutely unwell ward patient have involved the introduction of service initiatives. However, this study demonstrates that service initiatives alone are insufficient to improve care for acutely unwell ward patients. Recommendations from this study are that strategies should be put in place to support and develop clinical shift leaders and that staffing resources should be reviewed in the context of contemporary acute care settings. These must be informed by the views of organisational managers and ward staff leading to an integrated hospital-wide understanding of factors affecting care of the acutely unwell ward patient.

Factors Affecting the Care of Acutely Unwell Ward Patients: A Multiple Case Study