What to write
Usefulness of the work
Sustainability
Potential for spread to other contexts
Implications for practice and for further study in the field
Suggested next steps
Explanation
The conclusion of a healthcare improvement paper should address the overall usefulness of the work, including its potential for dissemination and implications for the field, both in terms of practice and policy. It may be included as a separate section in or after the discussion section, or these components may be incorporated within a single overall discussion section.
The authors of this report highlight the usefulness of their research with reference to ‘the national(US) emphasis on reduction of readmission by payers’. They also refer throughout the paper to the debates and research around appropriate nurse staffing levels, and the impact of nurse staffing levels on the sustainability of quality improvement initiatives in general, with reference to the key role of nurses in improving care and evidence that nursing staff levels are associated with delivery of high quality care. Although the authors don’t refer directly to potential for spread to other contexts, the generalisability of their findings is discussed in a separate section of the discussion (not included here).
In this example, the authors refer to ‘implications for hospital administrators’ because their findings ‘suggest that hospitals might also achieve reduction in readmissions by focusing on the number of patients assigned to nurses’. They also observe that these findings speak to ‘the validity of the California minimum staffing ratio for paediatric care’. Perhaps they could have suggested more in terms of implications for policy, for example what their findings might mean for the potential of payer organisations to influence nurse staffing levels through their contracts, or for broader government legislation on nurse-patient ratios. However, in their discussion they also recognise the limitations of a single study to inform policy decisions.
The need for further study is emphasised in the wider discussion section. The authors note that ‘more research is needed to better understand the reasons for children’s readmissions and thus identify which ones are potentially preventable’, calling for ‘additional research on both paediatric readmission measures and the relationship between nursing care delivery, nurse staffing levels and readmissions’. In writing about healthcare improvement, it is important that the authors’ conclusions are appropriately related to their findings, reflecting their validity and generalisability, and their potential to inform practice. In this case, direct recommendations to change practice are appropriately withheld given the need for further research.
Example
We have found that average paediatric nurse staffing ratios are significantly associated with hospital readmission for children with common medical and surgical conditions. To our knowledge, this study is the first to explicitly examine and find an association between staffing ratios and hospital readmission in paediatrics… Our findings have implications for hospital administrators given the national emphasis on reduction of readmissions by payers. The role of nursing care in reducing readmissions has traditionally focused on nurse-led discharge planning programmes in the inpatient setting and nurse-directed home care for patients with complex or chronic conditions.
While these nurse-oriented interventions have been shown to significantly reduce readmissions, our findings suggest that hospitals might also achieve reductions in readmission by focusing on the number of patients assigned to nurses. In paediatrics, limiting nurses’ workloads to four or fewer patients appears to have benefits in reducing readmissions.
Further, hospitals are earnestly examining their discharge processes and implementing quality improvement programmes aimed at preparing patients and families to manage health condition(s) beyond the hospital. Quality improvement initiatives to improve inpatient care delivery often depend upon the sustained efforts of front-line workers, particularly nurses. Prior research shows that hospitals with better nurse staffing ratios deliver Joint Commission-recommended care for key conditions more reliably, highlighting the inter-relationship of nurse staffing levels and quality improvement success.
The sustainability of quality improvement initiatives related to paediatric readmission may ultimately depend on nurses’ ability to direct meaningful time and attention to such efforts.1
Training
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