"They were talking about me"--elderly women's experiences of taking part in a discharge planning conference

Patient Participation in Multidisciplinary Team Meetings in Residential Mental Health Services: An Explorative Study of Patients' Perception

INTRODUCTION

The lack of evidence of mental health patients' perception on patient participation in multidisciplinary team meetings (MTMs) is a potential threat to the person-centeredness of care.

AIM

To explore the perceptions of mental health patients regarding patient participation in MTMs and to identify factors associated with these perceptions.

METHOD

In a cross-sectional study, 127 former and 109 currently admitted mental health patients completed the Patient Participation during Team Meetings Questionnaire (PaPaT-Q). The STROBE-checklist was used for reporting the study.

RESULTS

Overall, patients' perceptions were positive. Former patients expressed greater willingness to participate in MTMs, considered participation as more important, and felt more competent. These patients also exhibited a stronger preference for an autonomous role in medical decision making when participating in MTMs. The perception varied across factors such as gender, educational level, nature of psychological complaints and prior experience(s) with participation in MTMs.

DISCUSSION

These findings may help mental healthcare professionals to become more aware to factors associated with mental health patients' perception of patient participation in MTMs.

IMPLICATIONS

The results can be used by mental healthcare professionals to motivate mental health patients in an even more tailor-made basis to participate in MTMs when admitted in a hospital.

Potentially Inadequate Real-Life Speech Levels by Healthcare Professionals during Communication with Older Inpatients

BACKGROUND

The aim of this study was to investigate real-life speech levels of health professionals during communication with older inpatients in small group settings.

METHODS

This is a prospective observational study assessing group interactions between geriatric inpatients and health professionals in a geriatric rehabilitation unit of a tertiary university hospital (Bern, Switzerland). We measured speech levels of health professionals during three typical group interactions (discharge planning meeting (n = 21), chair exercise group (n = 5), and memory training group (n = 5)) with older inpatients. Speech levels were measured using the CESVA LF010 (CESVA instruments s.l.u., Barcelona, Spain). A threshold of <60 dBA was defined as a potentially inadequate speech level.

RESULTS

Overall, mean talk time of recorded sessions was 23.2 (standard deviation 8.3) minutes. The mean proportion of talk time with potentially inadequate speech levels was 61.6% (sd 32.0%). The mean proportion of talk time with potentially inadequate speech levels was significantly higher in chair exercise groups (95.1% (sd 4.6%)) compared to discharge planning meetings (54.8% (sd 32.5%), p = 0.01) and memory training groups (56.3% (sd 25.4%), p = 0.01).

CONCLUSIONS

Our data show that real-life speech level differs between various types of group settings and suggest potentially inadequate speech levels by healthcare professionals requiring further study.

Transitional shared decision-making processes for patients with complex needs: A feasibility study

INTRODUCTION

Shared decision-making (SDM) processes, combining patients' and professionals' perspectives, are especially necessary for patients with complex needs (CNs) during their care transitions. In 2016, we started implementing interprofessional and interinstitutional SDM processes (IIPs) for patients admitted to a short-stay unit (SSU) for inpatient care and then followed-up by primary care providers. Two types of IIPs were identified: (a) iterative IIPs, and (b) meeting IIPs. These differed in terms of the timing of SDM processes: whereas the former were multilateral and iterative, meeting IIPs were simultaneous. However, the two processes had similar outcomes and participants had similar characteristics. The intervention included other components, such as CNs assessment and a care coordinator position. The present study aimed to assess the feasibility of the intervention's implementation.

METHODS

The intervention's feasibility was assessed using fidelity and coverage indicators. We collected data from the patients' records on (a) patients' and professionals' characteristics, (b) the fidelity (CNs evaluations and occurrences of IIPs), and (c) the intervention's coverage (types of IIPs, participants).

RESULTS

The study included 453 patients between September 2017 and February 2019: mean age of 82.3 years, 65.6% women and 61.1% considered to have CNs. For patients with CNs, iterative IIPs and meeting IIPs occurred in 78.3% and 23.8% of cases, respectively. 35.1% of iterative IIPs and 8.8% of meeting IIPs for patients with CNs involved patients or their informal caregivers, inpatient professionals, primary care physicians and homecare professionals.

DISCUSSION

These results showed that an intervention targeting the implementation of formalized IIPs for SDM in transitional care was feasible. However, to improve the evaluation of such interventions, other methods should be used to measure their appropriateness and acceptability. Additionally, assessing the effects of IIPs would legitimize their funding, supporting their sustainability and generalisability.

How latent patterns of interprofessional working may lead to delays in discharge from hospital of older people living with frailty – ‘Patient more confused than usual?’

Unnecessarily delayed discharges from hospital of older people living with frailty can have negative consequences for their health and add significant costs to health services. We report on an ethnographic study at two English hospitals and their respective health and social care systems where we followed 37 patient journeys. The study aim was to understand why delays occur. Our findings indicate that working practices in the study hospitals may have inadvertently contributed to delays. While many pieces of patients’ clinical and social information were collected, recorded and accessed in different ways by different professionals, to facilitate a discharge, these pieces needed to be re-found, integrated and re-constructed. A key component of this process was information related to patients’ social, family and functional background. This was often missing, not accessed or perceived to be of low value compared to other more readily available clinical information. Patients’ re-construction was thus often incomplete, or insufficient to reduce the clinical and prognostic uncertainty associated with frailty and to manage risks inherent in older people's discharge. Where this key component was present and integrated into decision-making in multi-disciplinary team working, uncertainty and risk were managed more constructively and sometimes avoided an escalation of care needs.

Elderly patients with complex health problems in the care trajectory: a qualitative case study

BACKGROUND

Elderly patients with multiple health problems often experience disease complications and functional failure, resulting in a need for health care across different health care systems during care trajectory. The patients' perspective of the care trajectory has been insufficiently described, and thus there is a need for new insights and understanding. The study aims to explore how elderly patients with complex health problems engage in and interact with their care trajectory across different health care systems where several health care personnel are involved.

METHODS

The study had an explorative design with a qualitative multi-case approach. Eleven patients (n = 11) aged 65-91 years participated. Patients were recruited from two hospitals in Norway. Observations and repeated interviews were conducted during patients' hospital stays, discharge and after they returned to their homes. A thematic analysis method was undertaken.

RESULTS

Patients engaged and positioned themselves in the care trajectory according to three identified themes: 1) the patients constantly considered opportunities and alternatives for handling the different challenges and situations they faced; 2) patients searched for appropriate alliance partners to support them and 3) patients sometimes circumvented the health care initiation of planned steps and took different directions in their care trajectory.

CONCLUSIONS

The patients' considerations of their health care needs and adjustments to living arrangements are constant throughout care trajectories. These considerations are often long term, and the patient engagement in and management of their care trajectory is not associated with particular times or situations. Achieving consistency between the health care system and the patient's pace in the decision-making process may lead to a more appropriate level of health care in line with the patient's preferences and goals.

Older Adults' Experiences of Goals in Health: A Systematic Review and Metasynthesis

Objective: To synthesize older adults' experiences and perceptions of goal setting and pursuit within health systems. Methods: Six databases were searched to May 2019 using a combination of MeSH and free text terms. Included papers were written in English and reported original qualitative research for participants aged 65 years and older. Participant quotes from the results sections of included studies were gathered for thematic analysis and synthesis. Results: Initial search yielded 9,845 articles, and 134 were identified for full-text review. Fifteen papers were included in the final synthesis. Two main themes were identified: enablers (intrinsic and extrinsic) and barriers (personal and system). Conclusion: Older adults' self-belief is the strongest enabler for goal activities, enhanced by a personalized coaching approach from health staff. Conversely, inconsistent goal terminology confuses patients and reduces engagement. Likewise, fatigue has profound physical and cognitive impact on patients' ability to engage and participate in goals.

Experiences of elderly patients regarding participation in their hospital discharge: a qualitative metasummary

BACKGROUND

Ageing patients are discharged from the hospital 'quicker and sicker' than before, and hospital discharge is a critical step in patient care. Older patients form a particularly vulnerable group due to multimorbidity and frailty. Patient participation in healthcare is influenced by government policy and an important part of quality improvement of care. There is need for greater insights into the complexity of patient participation for older patients in discharge processes based on aggregated knowledge.

OBJECTIVE

The aim of this study was to review reported evidence concerning the experiences of older patients aged 65 years and above regarding their participation in the hospital discharge process.

METHODS

We conducted a qualitative metasummary. Systematic searches of Medline, Embase, Cinahl, PsycINFO and SocINDEX were conducted. Data from 18 studies were included, based on specific selection criteria. All studies explored older patients' experience of participation during the discharge process in hospital, but varied when it came to type of discharge and diagnosis. The data were categorised into themes by using thematic analysis.

RESULTS

Our analysis indicated that participation in the discharge process varied among elderly patients. Five themes were identified: (1) complexity of the patients state of health, (2) management and hospital routines, (3) the norm and preference of returning home, (4) challenges of mutual communication and asymmetric relationships and (5) the significance of networks.

CONCLUSIONS

Collaboration between different levels in the health systems and user-friendly information between staff, patient and families are crucial. The complexity of patient participation for this patient group should be recognised to enhance user involvement during discharge from hospital. Interventions or follow-up studies of how healthcare professionals can improve their communication skills and address the tension between client-centred goals and organisational priorities are requested. Organisational structure may need to be restructured to ensure the participation of elderly patients.

Older persons' experiences of adapting to daily life at home after hospital discharge: a qualitative metasummary

Background

Researchers have shown that hospitalisation can decrease older persons’ ability to manage life at home after hospital discharge. Inadequate practices of discharge can be associated with adverse outcomes and an increased risk of readmission. This review systematically summarises qualitative findings portraying older persons’ experiences adapting to daily life at home after hospital discharge.

Methods

A metasummary of qualitative findings using Sandelowski and Barroso’s method. Data from 13 studies are included, following specific selection criteria, and categorised into four main themes.

Results

Four main themes emerged from the material: (1) Experiencing an insecure and unsafe transition, (2) settling into a new situation at home, (3) what would I do without my informal caregiver? and (4) experience of a paternalistic medical model.

Conclusions

The results emphasise the importance of assessment and planning, information and education, preparation of the home environment, the involvement of the older person and caregivers and supporting self-management in the discharge and follow-up care processes at home. Better communication between older persons, hospital providers and home care providers is needed to improve the coordination of care and facilitate recovery at home. The organisational structure may need to be redefined and reorganised to secure continuity of care and the wellbeing of older persons in transitional care situations.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4035-z) contains supplementary material, which is available to authorized users.

Rehabilitation as "destination triage": a critical examination of discharge planning

PURPOSE

In this paper we examine how the intersection of various social and political influences shapes discharge planning and rehabilitation practices in ways that may not meet the espoused aims of rehabilitation programs or the preferences of older adults and their families.

METHODS

Taking a critical bioethics perspective, we used microethnographic case study methods to examine discharge-planning processes in a well-established older adult inpatient rehabilitation setting in Canada. The data included observations of discharge-planning family conferences and semi-structured interviews conducted with older adults facing discharge, their family members and rehabilitation professionals involved in discharge planning.

RESULTS

From the time of admission, a contextual push to focus on discharge superseded program aims of providing interventions to increase older adults' functional capabilities. Professionals' primary commitment to safety limited consideration of discharge options and resulted in costly and potentially unnecessary recommendations for 24-hour care. The resulting "rehabilitation" stay was more akin to an extended process of "destination triage" biased towards the promotion of physical safety than optimizing functioning.

CONCLUSIONS

The resulting reduction of rehabilitation into "destination triage" has significant social, financial and occupational implications for older adults and their families, and broader implications for healthcare services and overarching healthcare systems. Implications for Rehabilitation Current trends promoting consideration of discharge planning from the point of admission and prioritizing physical safety are shifting the focus of rehabilitation away from interventions to maximize recovery of function, which are the stated aims of rehabilitation. Such practices furthermore promote assessments to determine prognosis early in the rehabilitation stay when accurate prognosis is difficult, which can lead to overly conservative recommendations for discharge from rehabilitation services, thus further negating the impact of rehabilitation. Further work is required to examine the social, occupational and functional implications of superseding rehabilitation interventions to maximize capabilities with practices that prioritize safety over quality of life for older adults and their family members.

Mediators of marginalisation in discharge planning with older adults

Returning home or moving to a more supportive setting upon discharge from inpatient health-care services can have a tremendous impact on the lives of older adults and their families. Institutional concerns with patient safety and expedience can overshadow health-care professionals' commitments to collaborative discharge planning. In light of many competing demands and agendas, it can be unclear what is driving discharge-planning processes and outcomes. This paper presents the results of a study examining discharge planning in an older adult rehabilitation unit in a Canadian urban setting. Using microethnographic case studies, we explored the perspectives of older adults, family members and health-care professionals. Drawing on concepts of relational autonomy to guide the analysis, we found that discourses of ageing-as-decline, beliefs privileging health-care professionals' expertise and conventions guiding discharge planning intersected to marginalise older adult patients in discharge-planning decision making. Discharge planning in the research setting was driven by norms of ‘protecting physical safety’ at the expense of older adults’ self-declared interests and values. Such practices resulted in frequent recommendations of 24-hour care, which have significant personal, social and financial implications for older adults and their families, and ultimately might undermine clients' or health-care systems' aims. The analysis revealed social, political and institutional biases that diminish the rights and autonomy of older adults.

Experiences and Views of the Discharge Planning Process Among Swedish District Nurses and Home Care Organizers

Discharge planning is an important care process, but deficits in planning are common. The aim of this study was to explore district nurses’ (DNs) and home care organizers’ (HCOs) experiences and views of the workflow during the discharge planning process (DPP). Demands, workload, time, collaboration, and engagement, together with knowledge and professional confidence, are factors that influence workflow and outcome of the DPP for DNs and HCOs. Strengths and obstacles at the organization, group, and individual levels affect the workflow during the discharge planning. Knowledge of these strengths and obstacles should help care providers in their practice as well as help management and politicians become more aware of prerequisites needed to achieve a safe and efficient workflow for securing the patient’s discharge.

"Keep it simple": older African Americans' preferences for a health literacy intervention in HIV management

PURPOSE

Health literacy is lower in minorities and older adults, and has been associated with nonadherence to medications, treatment, and care in people living with human immunodeficiency virus (HIV). Likewise, African Americans with HIV are more likely to be nonadherent to their HIV medications, less likely to keep their clinic appointments related to HIV treatment and care, and more likely to die during hospitalizations than their ethnic counterparts. The present study explored the preferences of older African Americans with HIV for a health literacy intervention to promote HIV management.

PATIENTS AND METHODS

In this qualitative study, 20 older adult African Americans living with HIV were recruited from an HIV/acquired immunodeficiency syndrome outpatient clinic in the southeastern region of the US. Using patient-centered participatory design methods, semi-structured individual interviews were conducted to determine patient preferences for intervention development and design. Health literacy was also measured using the Rapid Estimate of Adult Literacy in Medicine - Revised (REALM-R).

RESULTS

Four major themes emerged related to intervention development and design: keep health information simple; use a team-based approach for health education; tailor teaching strategies to patients' individual needs; and account for patients' low experience, but high interest, in technology. Forty-five percent of the study population had low health literacy based on the revised Rapid Estimate of Adult Literacy in Medicine.

CONCLUSION

Future interventions that target minorities and older adults living with HIV should consider patients' learning needs, sex-specific and mental health needs, and delivery approaches, in order to increase uptake and improve disease management and health outcomes.

Heart failure and chronic obstructive pulmonary disease multimorbidity at hospital discharge transition: a study of patient and carer experience

BACKGROUND

Care for patients with multimorbidity represents a major challenge not only for patients and carers but to health-care systems. Hospital discharge transition is a critical point at which challenges for multimorbidity may amplify.

OBJECTIVES

The main objective of the study was to explore the experiences of heart failure (HF) and chronic obstructive pulmonary disease (COPD) multimorbid patients and their carers on hospital discharge. Secondary objectives included identification of gaps in the health care of multimorbidity and optimal solutions from patients and carers' perspectives.

DESIGN

Mixed methods were applied to collect data using patient self-completion questionnaire from an adapted version of the American Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and in-depth interviews.

SETTING

Participants were recruited from two cardiology and respiratory wards at a large regional hospital in England, and all had a multimorbidity diagnosis of COPD and HF.

RESULTS AND CONCLUSIONS

Findings revealed that patients experienced difficulties in their communication with health-care professionals and there were specific challenges with information about medication. Qualitative descriptions revealed that experiences fell into two main categories: (i) information transfer to patients with multimorbidity in terms of issues with medication and clarity of information on diagnosis and (ii) communication and continuity of care after discharge. Respondents highlighted gaps in the management of patients with multimorbidity of HF and COPD at the critical time of care transition. They suggested the need for a comprehensive, coordinated and integrated approach to incorporate patients, carers and staff preferences for treatment on discharge from hospital.

"It made me feel human"-a phenomenological study of older patients' experiences of participating in a team meeting

This study focused on older patients participating in a team meeting (TM) in a hospital ward in Sweden. A process had taken place on the ward, in which the traditional round had developed into a TM and understanding what participating in a TM means for the older patient is necessary for the development of care that facilitates older patient's participation. The aim of this study was to describe the caring, as experienced by the older patients on a ward for older persons, with a specific focus on the team meeting. A reflective lifeworld research (RLR) design was used. Fifteen patients, 12 women and three men (mean age of 82 years) were interviewed while they were hospitalized in a hospital ward for older people. In the essential meaning of the phenomenon, the TM is described as being a part of a wider context of both caring and life. The need for hospitalization is an emotional struggle to overcome vulnerability and regain everyday freedom. The way in which the professionals are able to confirm vulnerability and create a caring relationship affects both the struggle for well-being and the possibilities for maintaining dignity. The essence is further explicated through its constituents; Vulnerability limits life; Life is left in the hands of someone else; Life is a whole and Space for existence. The result raises concern about how the care needs to be adjusted to older people's needs as lived bodies. The encounter between the carer and the patient needs to be developed in order to get away from the view of the patient as object. An expanded vision may open up for existential dimensions of what brings meaning to life. One way, as described by the patients, is via the patient's life stories, through which the patients can be seen as a whole human being.

The impact of concordant communication in outpatient care planning - nurses' perspective

AIM

To elucidate registered nurses' experiences of coordinated care planning in outpatient care.

BACKGROUND

Coordinated care planning has been studied from the perspectives of both patients and nurses in inpatient care, but it is deficient in outpatient care.

METHOD

Qualitative content analysis of interviews with 10 registered nurses participating in two focus groups.

RESULTS

An overall theme was identified: creating concordant communication in relation to patient and health-care providers. The result is based on four categories and nine subcategories.

CONCLUSIONS

Nurses need extraordinary communication skills to reach concordance in outpatient care planning. In addition to involving and supporting the patients and next of kin in the decision-making process, the outcome of the nursing process must be understood by colleagues and members of other professions and health-care providers (non-nursing).

IMPLICATIONS FOR NURSING MANAGEMENT

An effective outpatient care-planning process requires that care managers understand the impact of communicating, transferring information and reaching consensus with other health-care providers, actively supporting employees in the outpatient care-planning process and contributing to the development of common goals and policy documents across organisational boundaries.

Being in-between and lost in the discharge process--an excursus of two empirical studies of older persons', their relatives', and care professionals' experience

The discharge process (DP) is full of well-known risks, and a comprehensive and well-executed DP is especially important for older people with multiple health problems and continuing care needs, as well as for their relatives. Few studies focus on the experiences with the DP by older people in need of home care nursing and their relatives. Therefore, the aim was to deepen the understanding of the DP as a phenomenon described by older people, their relatives, and care professionals. The method is an excursus of the findings of two previously published research studies. By using the Reflective Lifeworld Research approach, the empirical findings were further interpreted with lifeworld theory. The results describe the essential meaning of the phenomenon of DP in relation to healthcare needs. The illness and the DP can be viewed as a course of action where the familiar becomes unfamiliar for older people and their relatives, entailing an insecure future existence characterized by the experience of being in-between. The DP is marked by bodily and existential needs. The older persons and their relatives are lost in the hospital context and trying to influence life and adapt to life circumstances, while being relentlessly dependent on care professionals. Care professionals work from both an organizational and a medical approach. Disharmony and disagreement seem to arise easily among the professionals regarding the planning negatively affecting the patients and their relatives.

More efforts are needed in the DP to empower older people and their relatives to go on with their life at home. The caring practice needs to more clearly meet and address the individual needs of older people and their relatives and their understanding of their illness. It needs to give them lifeworld and life goals to alleviate their suffering and to help them adjust to their new situation.

Elderly persons' experiences of participation in hospital discharge process

OBJECTIVE

The purpose of this study was to describe older hospital patients' discharge experiences on participation in the discharge planning.

METHODS

A sample of 254 patients aged 80+ was interviewed using a questionnaire developed by the research team. Data were collected by face-to-face interviewing during the first two weeks following patients discharge from hospital.

RESULTS

In spite of their advanced age the patients in this study did express a clear preference for participation. However, there were no significant correlation between patients' wish for participation and experienced opportunity to share decisions. Hearing ability was the only significant factor affecting the chance to participate, whereas sociodemographic factors did not significantly affect on the likelihood participation the discharge process.

CONCLUSION

The actual practice of involving old people in the discharge process is not well developed as experienced by old patients themselves. The fact that factors like gender and education have little influence on participation in the oldest patients might be related to age; when you get old enough, old is all that is 'visible'.

PRACTICE IMPLICATIONS

To determine the extent of elderly patients' desire to participate, one must actively look for it both through research and in the hands-on process of discharge.

Patients' perceptions of nurses' behaviour that influence patient participation in nursing care: a critical incident study

Patient participation is an important basis for nursing care and medical treatment and is a legal right in many Western countries. Studies have established that patients consider participation to be both obvious and important, but there are also findings showing the opposite and patients often prefer a passive recipient role. Knowledge of what may influence patients' participation is thus of great importance. The aim was to identify incidents and nurses' behaviours that influence patients' participation in nursing care based on patients' experiences from inpatient somatic care. The Critical Incident Technique (CIT) was employed. Interviews were performed with patients (n = 17), recruited from somatic inpatient care at an internal medical clinic in West Sweden. This study provided a picture of incidents, nurses' behaviours that stimulate or inhibit patients' participation, and patient reactions on nurses' behaviours. Incidents took place during medical ward round, nursing ward round, information session, nursing documentation, drug administration, and meal.

Measuring the participation of elderly patients in the discharge process from hospital: a critical review of existing instruments

Measuring patients' experiences has been a major task for health care organisations during the past decade. The discharge process is identified as a vulnerable component of health care in need of assessment, especially when it concerns elderly persons. There are no published reviews or systematic assessment of the existing instruments developed to capture patients' perspective on the discharge process. This study gives a review of existing survey instruments designed to assess patients' perspectives on the discharge process. We used systematic searches for potentially relevant instruments in MEDLINE, PubMed, CINAHL, and the Cochrane Database of Systematic Reviews for English language studies published between 1998 and 2009 was considered to evaluate the patients' perspective on the discharge process. Ten studies were included and assessed according to the established criteria, and the studies presented a total of 47 items related to participation. The review identified only one instrument designed specifically to capture participation in the discharge process. The main focus is on the information flow from the professional to the patient and never vice versa. Few of the instruments studied/analysed to what degree the patients were invited to share their knowledge, and none of the instruments inquired whether, in the patients' experiences, their perspective was taken into account. The major finding of the review is that none of the existing instruments capture the full range of participation, nor do they cover those areas of the discharge process identified by elderly patients themselves as the most essential.

Discharge planning: communication, education and patient participation

For the most part, discharge from hospital is routine and uneventful. However, for a percentage of people, discharge from acute care requires careful planning to ensure continuity of care. This is particularly the case with older patients who have complex medical needs. This literature review reveals that the essential elements for discharge planning are: communication, coordination, education, patient participation and collaboration between medical personnel. Outcomes measures of successful discharge planning include patient satisfaction and quality of life. Smooth and efficient coordination of this process reduces stress and anxiety for the patient, family, nurse, doctor, hospital and community services.