Lost in hospital: a qualitative interview study that explores the perceptions of NHS inpatients who spent time on clinically inappropriate hospital wards

Abstract

Background

Prior research suggests that the placement of patients on clinically inappropriate hospital wards may increase the risk of experiencing patient safety issues.

Objective

To explore patients' perspectives of the quality and safety of the care received during their inpatient stay on a clinically inappropriate hospital ward.

Design

Qualitative study using semi‐structured interviews.

Participants and setting

Nineteen patients who had spent time on at least one clinically inappropriate ward during their hospital stay at a large NHS teaching hospital in England.

Results

Patients would prefer to be treated on the correct specialty ward, but it is generally accepted that this may not be possible. When patients are placed on inappropriate wards, they may lack a sense of belonging. Participants commented on potential failings in communication, medical staff availability, nurses' knowledge and the resources available, each of which may contribute to unsafe care.

Conclusions

Patients generally acknowledge the need for placement on inappropriate wards due to demand for inpatient beds, but may report dissatisfaction in terms of preference and belonging. Importantly, patients recount issues resulting from this placement that may compromise their safety. Hospital managers should be encouraged to appreciate this insight and potential threat to safe practice and where possible avoid inappropriate ward transfers and admissions. Where such admissions are unavoidable, staff should take action to address the gaps in safety of care that have been identified.

Background

Research conducted in the UK,1 Spain,2 France3 and New Zealand4, 5 reports that inpatients are often placed on clinically inappropriate hospital wards when there is an excess demand for beds on the correct specialty ward. It is particularly common for medical patients to be placed on surgical wards.2, 6, 7, 8 Patients placed on inappropriate wards are usually referred to as ‘outliers’, ‘boarders’ or ‘sleep‐outs’.9 In the UK, a national survey conducted in May 2003 estimated the prevalence of patients on inappropriate wards to be 7.5%.10

Prior research suggests that hospital staff hold a number of concerns about the quality and safety of care provided for patients placed on clinically inappropriate wards. When patients are cared for within inappropriate clinical areas, competing demands on nurses' time are created due to the diverse needs of different patient groups.9 Furthermore, physicians may spend excess time travelling to visit patients who are located outside of their specialty's bed base.4, 9 Alternatively, medical review may be omitted, leading to a prolonged length of hospital stay.2, 5, 6, 9 Communication barriers are introduced when patients are located outside of their own specialty as medical and nursing staff may not be readily familiar with one another.3, 9, 11 Input from staff with specialist expertise may be reduced; in particular, nursing staff may lack the knowledge to provide optimal care for patients who come from outside of the specialty they work within.9, 12, 13, 14 The ward environment may be unsuitable due to a lack of required equipment and medication.9, 15 Movement to a different ward may disorientate confused or impaired patients and pose a falls risk.9 Furthermore, studies have suggested that patients with upper gastrointestinal haemorrhage,16 stroke17 and asthma18 have better outcomes when they are treated on specialist units.

While it is known that approximately 1 in 10 patients experiences an event in their health care which causes them harm,19, 20 research that investigates the safety issues faced by patients placed on clinically inappropriate wards remains sparse. Furthermore, patient safety researchers are encouraged to include the patient perspective within their research,21, 22, 23, 24 and prior research demonstrates that patients are willing and able to comment on matters relating to the quality and safety of their care.25, 26 However, there is no prior published empirical research that investigates patients' experiences of being placed on a clinically inappropriate ward or their perceptions of the quality and safety issues they may face. This study sought to address this gap in the literature via the following research questions: What are patients' overall feelings about being placed on ‘outlying’ wards? Do patients perceive differences in the nursing or medical care received on correct specialty vs. ‘outlying’ wards? What are patients' thoughts and experiences of the quality and safety of care received?

Methods

Setting

The study took place at a single large NHS teaching hospital in the north of England. NHS ethics and R&D approval was granted for the study.

Participants

A ‘clinically inappropriate ward’ was defined as a ward outside of the correct speciality bed base. For example, a medical patient on a surgical ward met the study inclusion criteria, as did an orthopaedic (surgical) patient on an ear, nose and throat (ENT) (surgical) ward. Nineteen participants who had spent time on at least one clinically inappropriate ward were interviewed between January and April 2011. Eighteen of these participants had also spent time on the correct specialty ward for their illness. Six participants had been inpatients regularly (three or more separate times) during the preceding year. Participants were purposively selected to cover a variety of demographic characteristics, medical conditions and inappropriate ward locations. Potential participants were sampled from five different wards which were known to care for a relatively moderate or relatively high number of ‘outliers’ (two orthopaedic surgery wards, gynaecology, ENT and plastics). During their inpatient stay, potential participants were given information about the study and asked whether they would like to be interviewed about their experiences following discharge. All interviews were conducted in participants' homes within 10 days of discharge from hospital. For the purposes of reporting the results, participants have been allocated a pseudonym which broadly reflects their age, gender and ethnicity. participants' characteristics are summarized in Table 1.

Table 1.

Summary of participant characteristics

Pseudonym	Age group	Specialty of patient	Inappropriate ward specialty
Clare	30–39	Medical	Orthopaedic
Enid	80–89	Geriatric	Gynaecology
Paul	60–69	Medical	ENT
Eileen	60–69	Medical	Orthopaedic
Iris	80–89	Orthopaedic and Geriatric	ENT
Edward	80–89	Geriatric	Orthopaedic
Amy	20–29	ENT, pain management	Plastics
Kash	20–29	Medical	Plastics
Gary	40–49	Surgical	Orthopaedic
Elsie	70–79	Geriatric	Gynaecology, ENT and plastics
Helen	60–69	Medical	Orthopaedic
Carol	50–59	Medical	Orthopaedic and plastics
Rachel	40–49	Medical	Gynaecology
Isobel	40–49	Orthopaedic	Gynaecology
Lynn	50–59	Urology	Plastics
Hazel	70–79	Medical	ENT
Alma	80–89	Geriatric	Plastics
Ivy	80–89	Vascular	Orthopaedic
Sandra	60–69	Orthopaedic	Gynaecology

ENT, ear, nose and throat.

Collection of data

A topic guide was constructed following an extensive literature review (Appendix 1). The aim was to explore participants' experiences of the quality and safety of health care provided on clinically inappropriate wards vs. the correct specialty ward. Participants were asked about the wards they had stayed on and differences between these wards, transfers between wards, the medical and nursing input received and their feelings about being placed on a clinically inappropriate ward. Interviews lasted between 20 and 80 min with the majority of interviews lasting approximately 45 min.

Analysis of data

All interviews were transcribed verbatim by LG. LG and JA undertook coding and all authors contributed to theme development ensure reliability.27 Qualitative data management software ATLAS.ti 5.0 (Scientific Software Development GmbH, Berlin, Germany) was used to facilitate analysis. A thematic approach to data analysis which drew upon the principles of constant comparison was adopted.28 Analysis was begun once the first few interviews had been transcribed to allow for ongoing development of the topic guide. Analysis involved line‐by‐line coding and an iterative process of categorizing data items into key themes and subthemes. Particular attention was paid to divergent cases.

Results

Four key themes were derived as a result of the analysis. These four key themes and their associated subthemes are reported hereafter.

Patient feelings

Divide in overall opinion about being placed on a clinically inappropriate ward

The majority of interviewees accepted their placement on a clinically inappropriate ward. While they might have preferred to be on the correct specialty ward, many participants acknowledged the need for prioritization of a finite resource, assuming that beds on the correct specialty ward were needed for patients who were sicker than they were.

Interviewer: So did you mind being sent to an ENT ward?

Paul: Oh no, it didn't bother me, you know, because you're still being looked after, it weren't as if just because you weren't their department, you know, they were ignoring you, you still had the care there.

Sandra: You've got to understand haven't you that if there's a ward that's got beds that are nearly empty and a ward that's full, you're taking up a place for somebody who might be seriously ill to come in on that ward you're in…

However, four participants expressed either that they did not like being on a clinically inappropriate ward or that they would much prefer to be on the correct specialty ward. Underlying this appeared to be a desire for continuity in their care and ‘belonging’ to the ward they were placed on.

Belonging

Some participants suggested that being on a clinically inappropriate ward made them feel as though they were an ‘outsider’ and believed they were prioritized beneath the other patients on the ward.

Iris: …it was for ear, nose and throat, and they seemed to deal with them first, and they all just left, they didn't tell you anything at all, and I was the only one, the others were all in with ear, nose and throat complaints, so I wasn't very pleased about that.

Kash: It's horrible, it's not good, because they don't look after you as much as they look after the other patients on that ward, because you're like an outsider and that's how it feels. All the other patients, they do look after them more, and the care on [inappropriate ward], I'm not blaming them, it's not their fault, because it doesn't deal with asthmatics.

Amy: …there's no pain ward, so when I go in there's nowhere for me to be, which is why I often get sent from ward to ward and slept out because they've got nowhere to put me because I don't fit…

There was also a perception among participants of belonging to a condition and therefore segregation between people with different conditions.

Clare: I did sort of say to the other people, you know, they'd hear the cough and say ‘oh you've got a terrible cold’… and I was like, ‘no well I've got pneumonia’, and I left it at that, I didn't sort of say anything else because I didn't want people to, well be alarmed really, you know, they were in for skin conditions and just completely different stuff…

Kash: I felt really uncomfortable there, I was the only patient that had got asthma, the rest of them was all like with the [catheter] bags and everything you see, and it was really difficult for me in there … I felt uncomfortable to be honest, because I had asthma and I wasn't like, how can I explain to you, you're in a ward where the other patients all suffer with the same illness and it gets difficult because you see all these other people and they're like suffering from, you know, that part of that illness…

Feelings surrounding ward transfers

A key aspect of being placed on a clinically inappropriate ward is the transfer to that ward from either accident and emergency, admissions units, correct specialty wards or other inappropriate wards. It was evident that some participants had encountered issues surrounding the transfer. Being moved between wards late at night or very early in the morning often caused particular upset.

Alma: …what I can't understand is why did they have to move me at 1 o'clock in the morning? … I mean people might be fast asleep, it's not very nice. Yes, she just says to me ‘you're going up to [ward number]’, 1 o'clock in the morning! Yeah. I couldn't get over it, I thought what an odd time to move people… there's summat wrong with the organisation there you know, bad organisation…

Participants also highlighted a dislike of being moved between wards numerous times and suggested they would have preferred to stay on as few wards as possible.

Amy: …it's just really frustrating when you get moved there and then moved back and then moved somewhere else and then moved back, especially when you've been in quite a while like I have sometimes…

Furthermore, some participants reported that a particularly negative consequence of being moved between wards was that they were removed from friends they had made on the ward

Ivy: I just dislike change, and I wasn't very well, and the thought of having to unpack and re‐pack was all distressing, yes, and making new friends and, it was all, and they were so brusque about it you know, that I felt quite distressed … Well it was really a question of leaving friends I'd made and having to get to know other people, but I was so disorientated that it was very, well it was a distressing experience.

Clare suggested that her transfer to a clinically inappropriate ward had been hasty and posed a risk to other patients as she was potentially infectious when she was placed in a bay with surgical patients.

Clare: Yeah they just said ‘you haven't got swine flu, we can move you, yeah, we'll find you somewhere else, you can go out onto the main ward’. It turned out actually not to be true because I did still have influenza B, which is why then they had a bit of a panic! I was on this post surgery ward with influenza B and then it was extremely quick once they realised that, they moved me back down to [acute medicine] and back into an isolated room.

Staff availability, knowledge and expertise

Staff input – feeling forgotten on clinically inappropriate wards

The majority of participants were satisfied with the nursing input they had received across all of the wards they had stayed on. None of the participants expressly suggested that the nursing input had been consistently better on the correct specialty ward as opposed to clinically inappropriate wards. However, nursing staff on both correct specialty and clinically inappropriate wards were often reported to be excessively busy.

Similarly, some participants perceived no differences in the input they received from the doctors on the correct specialty ward vs. clinically inappropriate wards and were consistently satisfied with the medical care they received. However, 10 participants suggested that input from their medical team was compromised on clinically inappropriate wards. For example, Amy and Elsie had experienced delays in receiving medication on clinically inappropriate wards, apparently due to the difficulty that nursing staff face in getting a member of the patient's medical team to visit the ward and prescribe. Participants also spoke of a lack of continuity of care as they did not see the same doctor regularly and reported being left on clinically inappropriate wards without medical review for days at a time (often over weekends) without explanation. This made some participants anxious that that had been ‘forgotten’.

Interviewer: Did you get to see the doctor regularly?

Isobel: [exhale] First few days I did, he came every day, and then he came on the Thursday and I never saw him again then ‘til the Monday when I was being discharged and he apologised!… he says ‘I'm sorry I haven't been to see you since Thursday’, I think I'd been forgotten about or something being where I was!

Reduced input from the multidisciplinary team could lead to a feeling of isolation.

Carol: I think it's a bit far away, and I felt a bit isolated, especially with it being a surgical ward as well, and even some of the staff says ‘well really you shouldn't be on here’.

Sandra explained that the nurses on the clinically inappropriate ward arranged for her to be repatriated to the correct specialty ward as she needed regular physiotherapy but the physiotherapists had often failed to visit her.

Sandra: She said ‘we're going to try and get you back down onto the orthopaedic ward’… ‘I'm ringing them up because they're just going to forget about you’… she said ‘we've got a bed down on [orthopaedic surgery] because if we don't get you back down there they forget, if they don't see you or they're busy they don't want to come up here’…

nurses' knowledge compromised?

Some participants suggested that the nurses on clinically inappropriate wards were knowledgeable about them and their condition.

Sandra: …one of the nurses on [gynaecology] had been an orthopaedic nurse… so she were like, ‘don't have that leg like that, you want a cushion under the leg and you want it under here’ and you know, so she sort of took me under hand… so basically I suppose they're looking after the ones they're used to…

However, others indicated that the knowledge of nursing staff on clinically inappropriate wards was at times compromised in comparison with the knowledge of nurses on the correct specialty ward.

Hazel: …they didn't know much about that kind of illness. I suppose if it were a different ward, if it were for nose and throats and what have you they wouldn't know nothing about losing your body fluids.

Furthermore, a number of examples were described in which nursing staff had been unfamiliar with the nursing care required, had poor understanding of impaired mobility or had made minor mistakes in delivering nursing care.

Gary: …there were just a couple of questions I asked the nurses and they weren't right sure, you know, surgical stockings, I just asked if I had to take them off or sleep in them and she said she didn't really know… she admitted, she says ‘I don't really know about these things’…

Elsie: …if they move you to these other wards they don't know! They don't know about your medical background! I mean some nurses didn't even know about a nebuliser or even the oxygen!

Isobel: I could have gone mad sometimes, just stupid things, they didn't realise, you know like my buzzer back there [out of reach] and at the time I was really immobile, and then they'd push my table and then my drink was down there [out of reach] and I'd start laughing … they didn't do it on purpose, they just didn't think. They didn't realise I couldn't actually turn round in the bed and grab stuff.

Enid: …they had trouble finding somebody that could put the right bandages on, because they'd gone through the training and there was just one in one of the wards that knew what she was doing with a bandage, but she was always busy…. the only thing they did wrong, my leg was weeping and they put cotton wool onto that. So when I came home it wouldn't come off, it stuck.

Patients feel ‘in safe hands’

All participants were asked about both positive and negative aspects of their hospital stay, whether any problems were encountered or mistakes made and whether they felt as though they had been in safe hands while in hospital and across all the different hospital wards they had stayed on. While several participants recalled problems or negative experiences, only Clare and Iris specifically suggested that they were unsure whether or not they had been in safe hands while on a clinically inappropriate ward due to a lack of specialist staff input and expertise.

Interviewer: Did you feel as if you were in safe hands on all the different wards?

Clare: absolutely categorically on A&E [and specialty wards] for all aspects of the care including the pregnancy … on [orthopaedic surgery] their absolute focus was around ‘oh my god, if you go into labour what do we do?’ … but I didn't get the feeling that they knew necessarily whether if my actual medical condition deteriorated really quickly what they would have done…

Iris: Yes I did on most wards, felt I was in safe hands, it was just that nobody come to see me on [ear, nose and throat] you see because it wasn't my ward.

Some participants who felt ‘in safe hands’ clarified this by talking about the faith they had in hospital staff which helped to alleviate concerns.

Alma: …you put your faith in them don't you, you know what I mean? And you're just hoping that they don't make a cock up of it….

It is notable that a number of participants who reported feeling ‘in safe hands’ provided accounts of potentially unsafe care.

Communication

Lack of information giving

Participants often felt that the reason for being moved to an inappropriate was ill explained and expressed that they would have liked a full explanation of the reason they were being moved, greater detail about the ward they were being moved to and information about the implications this might have for their ongoing care.

Iris: …they just said ‘we're moving you, we need the bed’, that's all they said. …they never told you anything, they didn't tell you what was happening or anything, which is wrong really because people want to know don't they?

Interviewer: So when they move you how do they explain it to you, what do they say?

Kash: They don't! They just move you! Because you don't find out exactly, they just come and say ‘we're going to move you to another ward’, that's it. They don't say why they're going to move you, nothing at all.

Interviewer: Would you like it if they did explain it to you?

Kash: Definitely, yeah, they should tell you why you should be moved, but they don't, they definitely don't tell you.

In particular, some participants became concerned when they were not reviewed by the medical team as frequently as they expected and suggested that their worries may have been allayed if somebody had explained the reason for this to them. Additionally, several participants felt that it was harder to get information about their condition and care while on clinically inappropriate wards.

Amy: it does help to be on the right ward and to be able to ask those questions, but when you're not it just, the nurses on the ward you're on don't know what's going on, they're too busy to ring up and ask generally and so you just, you do feel very forgotten and unimportant.

Clare: What was interesting I guess, was when I moved back down from [orthopaedic surgery] to [acute medicine – correct specialty ward], it felt like I was talking to people who knew … instantly I was just able to talk about the whole thing and just say ‘oh but then this happened and then that, but I wasn't sure about this’, and you know, she just completely understood the context in which I was talking about, whereas on [orthopaedic surgery] that contextual understanding just wasn't there.

A particular communication failure raised by patients who were discharged from clinically inappropriate wards was that they were unsure of their aftercare requirements and often had little idea who to contact to ask for advice following discharge.

Gary: …they never even told me about my stitches, I don't even know if they're dissolvable, I don't know if they're clips, you know, or they've been glued, you know, so I really need to ring the ward up and ask them what the procedure is for the scar…

Isobel: …that's my main bugbear now, is that because I was on the wrong ward they haven't done the right follow up … obviously gynaecology is completely different to broken bones, somebody should take over the discharge I think from that ward, rather than them on that ward because it's been left in a bit of a mess to be honest with you.

Resources

Resources available

Some participants suggested that clinically inappropriate wards did not always have all of the necessary equipment or medication readily available for their care.

Kash: she goes ‘peak flow’ … she goes ‘we don't have stuff like that here because it's to do with plastics’ … They had the nebuliser, but the thing you blow to check your peak, they didn't have that, so I didn't have that at all all night. … On [respiratory ward] they're normally checking it every half hour and know how to check but there they didn't check at all.

Furthermore, Clare had been on a drip while she was on the correct specialty ward and had been instructed to take extra supplies with her when she was moved to a clinically inappropriate ward in case she required it and the ward could not source it.

Clare: …I went up there [to inappropriate ward] and they were like ‘oh, we don't think you're on a drip’, and they looked round and there weren't any hooks available, you're like ‘err, if I actually needed it, could you do that for me?’ you know, and that was then a concern…

Five participants raised issues relating to the availability and consequently timely administration of medication on clinically inappropriate wards. Elsie reported missing medication while on clinically inappropriate wards due to delays in prescription, ordering and delivery. Clare and Rachel noticed the nursing staff saying that they would have to order medication from the pharmacy as they were not stock items on the ward.

Clare: …there was a lot of comment that they [inappropriate ward] didn't have available to them all of the medication that they needed…

Rachel: …sometimes if I needed medication, if the doctors had come down and prescribed something for me, and they didn't have the medication they had to send out for that because ‘oh, we're not sure if we've got that’, like a nebuliser, they only had one on the ward and there was a couple of ladies that needed it…

Discussion

This qualitative interview study investigated 19 patients' perceptions of staying on a clinically inappropriate ward for their illness. Results demonstrated that patients would prefer to be treated on the correct specialty ward, but it is generally acknowledged that this may not be possible as beds are a finite resource which must be prioritized. When patients are placed on clinically inappropriate wards they may lack a sense of belonging which may in turn affect their perception of the quality of care provided. A body of existing literature supports the finding that patients may initially report overall satisfaction to globally framed questions about their hospital care but upon further probing, problems or concerns are revealed.29, 30, 31, 32, 33, 34, 35 Participants commented on potential failings in communication, medical staff availability, nurses' knowledge and the resources available, each of which may contribute to unsafe care. Comparably, previous studies that have investigated clinical staff members’ knowledge and perceptions of the care received by ‘outliers’ demonstrate communication difficulties,3, 9 a lack of input from specialist doctors,5, 9 suboptimal knowledge of nursing staff,9, 12, 13, 14 insufficient time to spend with patients from other specialties,4, 9, 14 recognition that patients prefer being treated alongside others with a similar diagnosis14 and fear that the inappropriate ward may be too far from the appropriate medical team and lack specialist equipment and resources.9

Reason's Swiss cheese model of accident causation36 suggests that patient safety issues are often underpinned by underlying (latent) conditions in the environment. We have suggested elsewhere that the placement of patients on clinically inappropriate wards constitutes a latent condition as patients are exposed to a number of contributory factors that could create patient safety issues.9 The findings presented in this paper support this proposition. The potential contributory factors highlighted by participants in this study fit within an empirically based framework of contributory factors which has been designed to aid the exploration of patient safety threats in hospital settings.37 Applying the results of this study, this framework encapsulates the following: staff factors (nursing staff may lack knowledge when dealing with patients from other specialties), team factors (input from the multidisciplinary team may be reduced on inappropriate wards), task factors (when caring for patients from other specialties nurses may be unfamiliar with aspects of nursing care), the physical environment (patients may be located some distance from their medical team), staff workload (input from staff may be reduced when patients are on inappropriate wards), equipment and supplies (necessary equipment or medication may not be available on inappropriate wards) and communications systems (communication and information giving may be compromised when patients are on inappropriate wards). The sheer number of contributory factors evidenced here serves to suggest that placement on an inappropriate ward is indeed a latent threat to patient safety.

The main limitation of this research is that interviews were conducted with patients from a single NHS Trust with recruitment on five selected wards. Further research is required to ascertain whether patients' perceptions are generalizable more widely. However, considering the parallels with concerns documented in the existing literature and the fact that almost all NHS hospitals place patients on inappropriate wards,1 it is not thought that the contributory factors identified are likely to be particularly different elsewhere. Future research would also benefit from detailed consideration of the degree of inappropriateness of the outlying ward. For example, reason for admission (planned/acute admission, uncomplicated/life‐threatening illness or procedure, new or exacerbation of existing illness), the timing of transfer to the inappropriate ward (while awaiting discharge, having had definitive treatment or still undergoing diagnosis/active treatment) and location of the patient at discharge may all influence patients' perspectives. In addition, further research is needed to quantify the risk associated with placement on an inappropriate ward to understand the full extent of this important and under‐researched problem. Research into the quality and safety issues created by placement on an inappropriate ward has thus far been neglected in the literature and as far as we are aware this is the first study which investigates patients' perceptions of this common event.

It is recommended that where possible the placement of patients on inappropriate wards should be avoided. However, theory suggests that such placement is inevitable as physicians’ decision to admit new patients varies as a function of the total number of beds available with patients consistently spilling over into the bed base of other specialties.10 Therefore, robust policies that mitigate the risks associated with placement on an inappropriate ward must be adopted. Such safeguards should include ensuring that patients are reviewed regularly by their medical team, explaining to patients the reason for their move and the implications this may have for their ongoing care and ensuring that necessary equipment and medication will be available on clinically inappropriate wards prior to the patient's ward transfer.

Conclusion

Patients often acknowledge the need for placement on inappropriate wards due to excess demand for inpatient beds, but may report dissatisfaction in terms of preference and belonging. Importantly, patients recount issues resulting from this placement that may compromise their safety. Hospital managers should be encouraged to appreciate this insight and potential threat to safe practice and where possible avoid inappropriate ward transfers and admissions. Where such admissions are unavoidable, staff should take action to address the gaps in safety of care that have been identified.

Funding

LG received a PhD studentship awarded by the University of York/Bradford Institute for Health Research and funded by the NIHR, JA, IW, and JW received no support from any organization for the submitted work.

Ethics

The study obtained NHS ethics and R&D approval. Interviewees gave their full informed consent prior to taking part in the study.

Conflicts of interest

None.

Appendix 1: Topic guide – interviews with outlying patients

• Would you tell me a bit about why you have been in hospital?

• How long were you in hospital for during this stay?

• Which wards did you stay on during this hospital stay? How long were you on each ward for?

• Were you transferred between different hospital wards?

• Were you ever transferred late at night or very early in the morning?

• Was it explained to you why you were placed on [outlying ward]? When was it explained & what did they say?

• How did you feel about being moved?

• What was your overall feeling about being on [the outlying ward]?

• Do you think there are any important differences in the care you received on [the outlying ward] and [the specialty ward]?

Prompts will be asked in relation to the specialty ward & in relation to the outlying ward.

• Were there any differences in the input you received from the doctor/s on the different wards?

• Did you see the doctor regularly? How often?

• Were there any times when you didn't see a doctor but felt that you should have?

• What time of day did the doctor visit you?

• Did your family get to see the doctor?

• Were you happy with the input that you received from the doctor?

• Were there any differences in the nursing care you received on the different wards?

• Did the nursing staff seem knowledgeable about your illness and the care you required?

• Did the nursing staff help you promptly when you needed them?

• Were the nursing staff knowledgeable about your medication?

• Did you receive your medication on time?

• Were you happy with the nursing care that you received?

• Did you receive help or advice from other staff members, for example occupational therapists, physiotherapists or social workers?

• Were there any differences in the information that was given to you on the different wards?

• Were you kept informed of the plans for your tests, treatment and discharge?

• Were there any delays in waiting to have a test or in getting test results?

• Did you feel that you could ask staff questions if you wanted to?

• What were the positive things about the ward?

• What were the negative things about the ward?

• Did you feel as if you were in ‘safe hands’ on the ward?

• Were any mistakes made in your health care?

• Did you fall?

• Were there ever any problems with your medication?

• Were there any other problems with your care?

• Finally, is there anything else you would like to say about your experience of being moved to [outlying ward] or the differences between the wards you stayed on?