Transferring medical patients to outlying wards causes disruption to both staff and patients and is a poor way of relieving pressure on beds. Lesley Lack and Joy Warren report

Should the constant pressure on beds mean that medical patients are moved on to surgical wards? Such is the pressure that most hospitals now employ a designated bed manager whose job it is to organise transfers out of the medical wards on to other wards. But these raise a number of issues for nurses as well as patients.

Balancing the need of an acutely ill medical patient awaiting admission against disturbing an already installed, less ill patient is a decision that frequently has to be taken by nurses on an acute medical ward. The physical wellbeing of the patient may take priority over consideration of their psychological state and the effect a move to another ward would have. The need for the transfer itself usually means that this is carried out as quickly as possible in order to vacate a medical bed. Patients are asked if they would object to moving to another ward and usually do not feel able to refuse when the urgent need for the medical bed is explained.

Medical patients on surgical wards can be seen as a source of vexation to all concerned, particularly to the patient. Moving to a different ward with a different team of nurses can be frightening for someone already feeling ill and vulnerable. Nurses who may have cared for this patient for a considerable period and who have built up a meaningful therapeutic relationship may feel frustrated. The disruption can have a negative effect on the patient's healing process.

Choosing which patients will be transferred, usually the responsibility of the nurse in charge of the shift, is also problematic. As the less dependent patients are transferred to other wards, the patient dependency on the medical wards rises, increasing workload. Time is needed to inform the patient and their relatives.

On arriving on a non-medical ward, usually surgical, the patient is faced with conditions they may find difficult to relate to. There is often difficulty in relating to the other patients with surgical conditions. These patients may be seen as blocking surgical beds, thereby extending waiting lists. So medical patients on surgical wards can be a source of vexation to consultant surgeons and managers endeavouring to lower waiting lists.

Access to medical doctors is another issue that can cause stress for medical patients on surgical wards, who may wait for most of the day to be seen by doctors who are busy with emergency medical admissions. The culture of physicians also differs from that of surgeons, much as their distribution of the workload is set to a different regime. This sometimes makes it difficult for nurses on a surgical ward to access advice.

Nurses conversant with surgical procedures can experience a loss of confidence when faced with an unfamiliar complex medical condition.

Acutely ill and unstable medical patients should be nursed on a ward where skilled nurses have expert knowledge of their illness.

On most surgical wards there is a regime of 'planned' and 'emergency' admissions. Depending on the type of surgery and the patient's average length of stay, a weekly planned admission list can consist of a turnover of a large number of patients. Emergency admissions access the service according to their condition, but are usually acutely ill and requiring immediate attention. Patients undergoing surgery require a high nursing input during the perioperative period, frequently on a one-to-one basis for a short period when returning from theatre. Observations and judgements are made of the patient's condition and decisions made for interventions accordingly. Medical patients with an exacerbation of their previous condition are usually admitted as an emergency, particularly over the last winter when respiratory problems escalated.

The government promises more beds, but this is not guaranteed to solve the problem. The responsibility of ensuring that patients experience as little disruption as possible to their care if they need to be transferred lies with the nurses. To facilitate this process, it is essential that there is good communication between the transferring and receiving wards.

Traditional boundaries are constantly changing. Should we be aiming for a generic nurse, able to care for patients with any condition on any ward? Will this be an advantage or a deterrent to quality? Nurses have worked long and hard to develop their own unique body of knowledge to ensure that patients receive the appropriate care and attention. Will the next step be generic doctors, with no need for specialist training and skills? Probably not. However, in the current healthcare arena the transfer of medical patients to outlying wards appears likely to continue, and ensuring this takes place with as little disruption as possible is in everyone's best interests.