Caring for the Caregivers of "Alternate Level Care" Patients: The Impact of Healthcare Organizational Factors on Nurse Health, Well-being, Recruitment, and Retention in the South Fraser Region of British Columbia

Key Implications for Decision Makers

Alternate-level patients - those who are in an acute-care hospital bed waiting for a transfer to another facility - are an inefficient use of the healthcare system. An equally important though overlooked aspect of these patients is the effect they have on the healthcare staff who care for them: registered nurses, licensed practical nurses, care aides, and rehabilitation staff.

  • Healthcare professionals are more likely to be injured when alternate-level patients are mixed in with general medical or surgical patients than when they have their own ward.
  • Staff members on geriatric units face a high risk of injury, partly because many patients there behave unpredictably. Hospital administrators need to improve injury prevention on geriatric units, especially for violence-related injuries.
  • Where alternate-level patients are cared for, the job position the staff members hold have more to do with the risk of injury than age, seniority, or the hospital the staff members work in. Licensed practical nurses and care aides are particularly vulnerable to injury.
  • Staff who are not told when they are hired that they will be working with alternate-level patients and who do not like working with these patients are at a higher risk for burnout, dissatisfaction with their jobs, and poor health.
  • Many of the factors that predict injury are not the same as those that predict burnout, dissatisfaction, poor health, and retention. Thus, decision makers need distinct strategies to:
    • decrease injuries;
    • increase recruitment and retention; and
    • enhance job satisfaction.

Executive Summary


In the former South Fraser Health Region of British Columbia (now a part of the larger Fraser Health Authority), the number of alternate-level care patients is increasing. Care for these patients - who occupy acute-care beds while waiting for a transfer to a chronic unit, home for the aged, nursing home, rehabilitation facility, other continuing care institution, or homecare program - is viewed as low-status by registered nurses, unchallenging, and not what they were trained or hired to provide (Kuhn 1990). Caring for these patients may therefore negatively affect nurses' morale and sense of control. It may also lead to more injuries, as alternate-level patients frequently need to be lifted and transferred.

To deal with the increasing alternate-level patient population, the South Fraser Health Region developed a dual strategy of building more community beds and, as an interim solution, improving alternate-level care within the acute-care system. This research study examined the effect different models of alternate-level care have on injury, recruitment, and resignation among patient-handling staff.


A total of 2,854 patient-handling staff, including all registered nurses, licensed practical nurses, care aides, and rehabilitation staff (consisting mainly of physiotherapists, occupational therapists, and social workers) working at the four acute-care facilities in the region on June 10th, 2001 were identified. The research team found information on age, seniority, job title, and injuries. Information on recruitment and resignation of registered nurses was also obtained.

Interviews and focus groups were conducted with senior managers and nursing staff at each facility, and with the managers responsible for the region-wide seniors' program. Patient-handling staff were given a questionnaire to determine what factors in the work environment were attributable to each model of alternate-level care. The research team contacted people who sustained injuries during the six-month follow-up period, and it obtained information on registered nurses who quit their jobs during the six-month follow-up period.


There are five different care models for alternate-level patients: 1) dedicated alternate-level wards, which are only for that type of patient; 2) extended-care/alternate-level wards, which are designed for medically stable patients; 3) geriatric units, which both assess and discharge medically fit paitents and house the most unstable and difficult-to-handle patients; 4) low-mix units, which are regular medical or surgical wards with less than 15 percent of its patients being alternate-level; and 5) high-mix units, which are regular medical or surgical wards with more than 15 percent of its patients being alternate-level patients.

We found that 1,654 study members (58 percent of all patient-care staff) worked on a unit with alternate-level patients. There were 319 study members who were injured during the six-month follow-up period (11.2 percent), of which 125 (3.9 percent) lost time from work. The fewest injuries overall were on dedicated alternate-level wards, followed by low-mix units, extended-care/alternate-level units, high-mix units, and geriatric units. The pattern was similar for injuries that caused the staff member to miss time from work. Age, seniority, and hospital were not associated with risk of injury. Licensed practical nurses and care aides were most likely to be injured, followed by registered nurses, who in turn suffered more injuries than rehabilitation staff.

Interviews with injured workers strongly supported the association between the care model and the risk of injury. Staff members believed having dedicated alternate-level wards was the second-most important way to reduce injuries, preceded only by improved staffing. Staff also believed that the characteristics of alternate-care patients - who are often seen as aggressive and unco-operative - contributed to a higher risk of injury. Factors that influenced work environment and personal satisfaction with jobs did not have an effect on injury rates; nor did injury rates have an effect on nurse retention.


The way in which care is organized for alternate-level patients has an important effect on the risk of injury and job satisfaction. The results suggest that dedicated alternate-level wards are a superior way to provide care, rather than mixing alternate-level patients into the general acute medical/surgical patient population.