Understanding the work and decision-making strategies of bed management nurses: a systematic review
Intended for healthcare professionals
Evidence and practice    

Understanding the work and decision-making strategies of bed management nurses: a systematic review

Ellen Benjamin Nurse, University of Massachusetts Amherst College of Nursing, Amherst MA, US

Why you should read this article:
  • To recognise the crucial role of bed management nurses in effective patient flow processes

  • To enhance your understanding of the issues that bed management nurses commonly experience during decision-making, such as dealing with external pressures and conflicting priorities

  • To consider how nurse managers and hospital leaders could collaborate with bed management nurses and use their knowledge and experience during process improvement initiatives

The need for hospital-wide solutions to improve patient flow is broadly recognised. Bed management nurses are integral to patient flow processes, and recognition of their strengths and skills is crucial in implementing effective solutions, yet there is limited research describing their role.

This article details a systematic review of the literature on bed management nurses. Six themes were identified: complexity in a context of scarcity; dealing with external pressures and conflicting priorities; need for multiple decision-making strategies; uncertainty; need for training; and unrecognised yet important work. The findings could assist nurse managers and hospital leaders to promote communication, teamwork and coordination between hospital staff and bed management nurses.

Nursing Management. doi: 10.7748/nm.2021.e2016

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

efbenjamin@umass.edu

Conflict of interest

None declared

Benjamin E (2021) Understanding the work and decision-making strategies of bed management nurses: a systematic review. Nursing Management. doi: 10.7748/nm.2021.e2016

Published online: 05 October 2021

The management of patient flow is complex and has profound implications for the quality of patient care provided, including its safety, effectiveness, efficiency and equity (McHugh et al 2011). Various healthcare agencies, health think tanks and medical organisations have called for system-wide approaches to improve patient flow (McHugh et al 2011, Karakusevic 2016, Javidan et al 2021). Such approaches require effective teamwork, negotiation and collaboration between healthcare providers, managers and bed management departments, and their success depends on trust and transparency (Boiko et al 2020).

Bed management is one element of patient flow that significantly affects patient care and healthcare costs (Cudney et al 2019). Bed managers deal with patient admissions from emergency departments (EDs), operating rooms, labour and delivery departments, other hospitals and diagnostic services (He et al 2019). However, there is little research on the role and the decision-making strategies involved (Polit and Beck 2003, Landa et al 2018), and an initial search of the literature revealed no systematic reviews of bed management decision-making processes.

This article details a systematic review that was undertaken to clarify the work of bed management nurses, with the aim of supporting effective communication and collaboration between hospital leaders, nurse managers and bed management nurses to ensure the provision of safe patient care.

Key points

  • Bed management nurses are integral to patient flow, and their knowledge and experience are valuable assets in process improvement initiatives

  • Hospital leaders should support and use the expertise of bed management nurses to enhance the quality of care provided

  • Increased clarity and recognition of the role of nurses in bed management could contribute to successful patient flow initiatives

  • Nurse managers need to understand the function and decision-making processes of bed management nurses to improve the hospital-wide communication and teamwork required for effective patient care

Aim

To review literature that examined bed management nurses specifically and to review interdisciplinary literature on patient flow to provide insight into this topic.

Method

A systematic literature review was conducted to identify studies published between 2000 and 2021 in the PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Business Source databases. This broad search strategy was chosen to accommodate the low volume of research and to include interdisciplinary research. Google Scholar, reference lists and authors’ names were used to identify additional sources. The following Medical Subject Headings (MeSH) terminology and reference keywords were used to identify literature: (‘bed placement’ OR ‘bed assignment’ OR ‘bed management’ OR ‘patient assignment’ OR ‘bed capacity’ OR ‘bed occupancy/methods’) AND (‘decision-making’ OR ‘decision support systems’).

The research question was: ‘How does literature written between 2000 and 2021 describe the work and decision-making strategies of bed management nurses compared with other components of patient flow management?’

Qualitative and quantitative studies were included if they discussed bed management strategies, decision-making processes or patient flow practice improvement initiatives. Studies were included if they were written in English between 2000 and 2021. One additional study from 1999 was included because it was cited frequently in the literature and could add substance to the review.

Articles were excluded if they focused on:

  • Bed management for a specific patient population or disease.

  • Managing assignments for a specialty unit.

  • Capacity management during times of mass casualty or during the coronavirus 2019 (COVID-19) pandemic.

  • Discharge planning decisions.

A total of 313 articles were identified through database searching. After removing duplicates, the titles and abstracts of 274 articles were screened, and 208 articles were excluded, either because the title was not relevant or the abstract met exclusion criteria. An additional 16 articles were identified through other sources. The full text of 82 articles was assessed for eligibility, and 68 articles were excluded for various reasons, including if they did not mention the role of nurses, had limited discussion of nurses’ effect on bed management decisions, if the full text was not available or if they were not peer-reviewed research. This left 14 studies that were included in this systematic review.

The full text of each article was reviewed by the author (EB) using narrative synthesis to identify common themes. Relevant data included descriptions of decision-making strategies, challenges, and bed managers’ perspectives and insight into the broader context of their work. The author used bracketing and reflexivity to avoid bias. Analysis was inductive and the final themes were not identified until all the content had been reviewed. The Critical Appraisal Skills Programme (2018) Systematic Reviews checklist was used to measure quality, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) checklist was used to promote rigor (Moher et al 2009).

Findings

Of the 14 studies reviewed, only five examined bed management nurses’ decision-making directly through qualitative data collection methods including observation, semi-structured interviews, focus groups, documentation review and previous research (Boaden et al 1999, Proudlove et al 2003, Allen 2015, Bloomer et al 2016, Rosenberg et al 2018). The remaining nine articles focused on practice improvement initiatives, but also commented on the role or effect of nurses in bed management. Five studies were conducted in the UK (Boaden et al 1999, Harper 2002, Proudlove et al 2003, 2007, Allen 2015). Table 1 provides a summary of the included studies.

Table 1.

Summary of the included studies

nm.2021.e2016_0001_tb1.jpg

Analysis of the 14 studies revealed six themes:

  • Complexity in a context of scarcity.

  • Dealing with external pressures and conflicting priorities.

  • Need for multiple decision-making strategies.

  • Uncertainty.

  • Need for training.

  • Unrecognised yet important work.

Complexity in a context of scarcity

Bed management nurses face high patient volumes and insufficient bed capacity (Boaden et al 1999, Harper 2002, Proudlove et al 2003, Landa et al 2018). In addition to an overall imbalance of supply and demand, there are complex factors that further restrict the number of beds that would be appropriate for each patient.

For example, bed management nurses consider patients’ attributes such as their level of acuity, emergent or elective status, inpatient status, insurance and behaviour (Harper 2002, Lovett et al 2014, Bloomer et al 2016, Rosenberg et al 2018). These attributes need to be matched with the characteristics of the room, for example whether it is private or multiple occupancy or has specialty equipment, its designation as an isolation room for infection control and the capabilities of the unit in which it is situated (Harper 2002, Bloomer et al 2016).

In the context of scarcity, this complexity is reflected by the range of metaphors that were used to describe decision-making, such as ‘juggling competing needs’ (Bloomer et al 2016), a process of ‘match-making’ under intense pressure (Allen 2015), a ‘balancing act’ (Boaden et al 1999) and ‘firefighting’ (Proudlove et al 2003, Jessup et al 2016).

Dealing with external pressures and conflicting priorities

Bed management nurses frequently face external pressures and agendas. For example, Bloomer et al (2016) described pressures from: patients and family members, who may desire a private room rather than a multiple-occupancy room; medical staff, who may prefer patients to be placed close to their offices; and support staff, whose workload may be increased by patient room changes. Patients’ insurance and funding incentives can also influence whether they are placed in single-occupancy or multiple-occupancy rooms, but these considerations must be balanced with hospital capacity (Bloomer et al 2016). Some bed management nurses described feeling pressure from management or administration to optimise bed allocations at the cost of disregarding the requirements of individual patients (Allen 2015).

Landa et al (2018) found that bed management nurses were guided by hospital-defined critical time and critical number parameters, which measure the volume and length of time patients wait for bed assignment, meaning that they had to misallocate patients or delay elective admissions when thresholds were exceeded. Other external pressures included individual units’ priorities and agendas such as reducing workload or a preference for patients with specific diagnoses (Allen 2015, Rosenberg et al 2018). When facing these external pressures, bed management nurses often found it challenging to maintain control and authority over their decision-making process (Bloomer et al 2016, Rosenberg et al 2018).

Need for multiple decision-making strategies

Bed management nurses rely on multiple strategies and perspectives to guide complex decision-making, and several authors noted that these roles were unique among hospital staff because of their holistic and integrative perspectives (Proudlove et al 2003, Allen 2015, Rosenberg et al 2018). The holistic perspective was demonstrated by bed management nurses’ understanding of hospital-wide demands and capacities (Allen 2015). Boaden et al (1999) described the need for a combination of strategic and operational decision-making whereby bed managers attempt to consider system-wide process improvement and manage day-to-day decisions about patient placements.

A recurrent idea that emerged in this review was the need for bed managers to have a clinical background. Having a clinical understanding often enabled bed management nurses to assess patients’ needs more efficiently and match them to an appropriate unit (Proudlove et al 2003, Rosow et al 2003). Allen (2015) characterised the decision-making process of these nurses as ‘grounded in clinical pragmatism’ rather than being based on formal criteria, and described one strategy based on clinical experience as a tendency to ‘typify patients’. For example, some labelled patients as ‘jumpers’ or ‘CIWA [Clinical Institute Withdrawal Assessment for Alcohol] patients’, phrases that quickly communicated a patient’s risk of falls due to their tendency to climb out of bed or their risk of agitation due to alcohol withdrawal (Allen 2015). This strategy aligns with Harper’s (2002) recommendations, which include the importance of classifying patients when developing a model to accurately reflect patient flow processes.

Uncertainty

This review identified that there are high levels of uncertainty in several aspects of the work of bed management nurses. For example, Boaden et al (1999) reported that bed managers gathered information about potential admissions and discharges on a fluctuating ‘piecemeal’ basis and used informal sources, such as past experience or recent trends, to estimate patient volume influx. Several studies found that ED admissions were particularly random and unpredictable because many patients may arrive rapidly in a short period (Harper 2002, Jessup et al 2016, Landa et al 2018), while other studies reported that information about bed capacity and status were uncertain and challenging to confirm (Boaden et al 1999, Proudlove et al 2003). This uncertainty is an important feature of the bed management process and increases the complexity of decision-making.

Many bed managers also experienced uncertainty in relation to their career paths. Landa et al (2018) and Proudlove et al (2007) found that the role was not well-defined systematically or in job descriptions, and that the terminology used and goals set were frequently vague and challenging to measure. Furthermore, bed management nurses often felt frustrated about the lack of evaluative criteria and job objectives, and found it challenging to recognise when they were doing a good job (Boaden et al 1999).

Need for training

Proudlove et al (2007) reported that bed management nurses had little training, with many of them citing this as a significant concern for their profession. The researchers developed a training programme that included inpatient flows, tools and resources to address work challenges and achieve local and national performance measures (Proudlove et al 2007). Following the training, participants reported considerable improvement in their knowledge and confidence, and they also recognised how inadequately prepared they had been for their role before undertaking the programme. This finding is supported by Enriquez et al (2009) and Tortorella et al (2013), who asserted that increased education and training on patient flow is critical for process improvement initiatives.

Unrecognised yet important work

Allen (2015) described bed management as ‘largely invisible work’ and found that nurses were routinely excluded from hospital strategy planning. In other studies, many bed managers reported feeling unappreciated, isolated and unsupported (Boaden et al 1999, Proudlove et al 2007, Jessup et al 2016), while Rosenberg et al (2018) found that physicians and staff nurses were frequently unable to describe the role of bed managers in coordinating transfers.

Although it frequently appears to be unrecognised, the work of bed managers is critical to efficient patient flow, and several process improvement projects have found that the input and involvement of bed management nurses were essential to their success (Enriquez et al 2009, Lovett et al 2014, Landa et al 2018, Rocha et al 2018).

Discussion

Hospital administrators and nurse leaders who are seeking to identify process improvement strategies for patient flow improvement should collaborate with bed management nurses and draw on their strengths and unique perspectives. Bed management nurses are uniquely and closely involved in patient flow decisions across hospital systems and have demonstrated their ability to manage complex decision-making in the context of scarcity, uncertainty and competing priorities. They offer critical thinking from a holistic perspective and have a wealth of knowledge about patients’ needs, hospital equipment and unit capacities. Bed management nurses are adept at integrating strategic, operational and clinical considerations to solve problems, and their experience makes them well-suited for involvement in projects that aim to improve patient flow.

In addition to highlighting the strengths of bed management nurses, this review recommends the following strategies to support and improve their work:

  • Leaders should offer guidance on how to balance the conflicting priorities of patient needs, staff needs and administrative goals.

  • Bed management nurses’ job descriptions, objectives and evaluative criteria should be clarified, since this could improve their performance and job satisfaction.

  • Hospital administrators should assess their training programmes and consider whether their bed managers receive adequate preparation for the role.

  • Management should increase awareness of bed management widely among hospital staff. Greater recognition of the role may enable bed management nurses to feel better supported and could improve teamwork and coordination between employees.

Limitations

Despite significant efforts to identify sources through multiple databases and keywords, it is likely that some relevant studies were not included in this review. In addition, several of the included studies were conducted before 2010, so their findings may not reflect contemporary patient flow. While this is a limitation, it also demonstrates the need for further research on this topic.

The studies involved several redundancies in authorship, for example Proudlove authored three of the five UK studies (Boaden et al 1999, Proudlove et al 2003, 2007), which limits viewpoints and research approaches. Furthermore, the findings may have been influenced by publication bias, which occurs when journals favour publishing studies with significant findings over those with insignificant results. This is particularly relevant for the quality improvement articles included in this review, since these were more likely to have demonstrated successful patient flow management interventions and may have placed higher value on the role of bed management nurses than those that found no significant improvement.

Finally, there was a lack of consistency in the terminology used in relation to bed management and patient flow; for example, the process of assigning a patient to a bed was described in several ways, including ‘bed placement’, ‘bed assignment’, or ‘patient assignment’. Although a broad search strategy with multiple keywords aimed to identify all relevant literature, the lack of consistency in terminology makes it likely that some relevant studies were not included in this review.

Conclusion

The findings of this systematic review highlight bed management nurses’ skills, emphasise the value of their work and offer insight into strategies that should be implemented by hospital leaders to support them. As Allen (2015) noted, input from nurses is often absent from hospital strategy planning, so nurse leaders should be encouraged to strengthen and recognise the voice of the nursing profession in these forums.

Bed management nurses are integral to patient flow and their knowledge and experience are valuable assets in process improvement initiatives, so it is important for hospital leaders to support and use this expertise to enhance the quality of patient care provided. In addition, further research is necessary to increase understanding of the work and decision-making strategies of bed management nurses.

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