Experiences and perspectives of older patients with a return visit to the emergency department within 30 days: patient journey mapping

Aim

To achieve patient-centered care for older patients at the emergency department (ED) it is important to include their perspective and experience, and this can be done through the patient journey method.

Findings

By mapping the patient journey, we found that waiting times and suboptimal discharge communication are almost always related to a negative experience for older patients.

Message

The novelty of this study lies within the qualitative patient journey method, which allowed us to include the voice of the patient in issues that have been previously described (i.e. waiting times and discharge communication). We believe this can guide towards patient-centered improvement initiatives that can contribute to a positive ED experience in the future, for example a time-out at the ED and a discharge check list

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00581-6.

Purpose

Up to 22% of older patients who visit the emergency department (ED) have a return visit within 30 days. To achieve patient-centered care for this group at the ED it is important to involve the patient perspective and strive to provide the best possible experience. The aim of this study was to gain insight into the experiences and perspectives of older patients from initial to return ED visit by mapping their patient journey.

Methods

We performed a qualitative patient journey study with 13 patients of 70 years and older with a return ED visit within 30 days who presented at the Amsterdam UMC, a Dutch academic hospital. We used semi-structured interviews focusing on the patient experience during their journey and developed a conceptual framework for coding.

Results

Our sample consisted of 13 older patients with an average age of 80 years, and 62% of them were males. The framework contained a timeline of the patient journey with five chronological main themes, complemented with an ‘experience’ theme, these were divided into 34 subthemes. Health status, social system, contact with the general practitioner, aftercare, discharge and expectations were the five main themes. The experiences regarding these themes differed greatly between patients. The two most prominent subthemes were waiting time and discharge communication, which were mostly related to a negative experience.

Conclusions

This study provides insight into the experiences and perspectives of older patients from initial to return ED visit. The two major findings were that lack of clarity regarding waiting times and suboptimal discharge communication contributed to negative experiences. Recommendations regarding waiting time (i.e. a two-hour time out at the ED), and discharge communication (i.e. checklist for discharge) could contribute to a positive ED experience and thereby potentially improve patient-centered care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00581-6.

Who is in charge of the care of patients with acute abdominal pain? An interview study with managers across the acute care chain

AIM AND OBJECTIVES

To describe managers' perspectives on the care of patients with acute abdominal pain and explore how they influence the care.

BACKGROUND

Patients with acute abdominal pain form a common group of patients who often report poor pain management. Managers are key actors in ensuring that patients receive high-quality care. This stresses the need to deepen the understanding of their perspectives on these patients, in order to provide high-quality fundamental care across the acute care chain.

DESIGN

Qualitative descriptive semi-structured interview study, with an inductive approach. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was used.

METHODS

Individual interviews were conducted with managers (n = 17) from ambulance services, emergency departments and surgical departments at four hospitals in Sweden, representing managers at the micro- and macrolevels across the acute care chain.

RESULTS

The patient group was described as a challenging heterogeneous group, with a focus on medical care, shaped by clinical practice guidelines, for which others were responsible. Managers with a physician background expressed that nursing care was important for the outcome of the care, while managers with a nursing background focused solely on the medical care. Additionally, the managers described that they affected the care by providing resources and serving as role models.

CONCLUSIONS

The solely medical perspective is worrying. By being a stakeholder, the managers' responsibility should be to highlight the patient perspective in the care and promote and support all health professionals in redesigning the care, where achieving higher quality both in nursing and in medical care for patients with acute abdominal pain becomes a shared goal.

RELEVANCE TO CLINICAL PRACTICE

Managers should use their leadership to bridge the gap between medicine and nursing care by highlighting patients' need for fundamental care, and to support health professionals in providing evidence-based and high-quality care.

Clinical protocols for adults with acute abdominal pain in Australian emergency departments

RATIONALE, AIMS AND OBJECTIVES

Patients with acute abdominal pain are a common presentation in hospital emergency departments; however, international studies have demonstrated that hospitals often lack clinical protocols to guide care. This study aimed to investigate whether Australian hospital emergency departments have acute abdominal pain clinical protocols, identify hospital-level predictors of the presence of these clinical protocols, and assess the quality of protocols.

METHODS

A survey was sent to all Australian hospitals with emergency departments, collecting data on hospital characteristics and the presence of acute abdominal pain clinical protocols. Participating hospitals (n = 73, 26% response rate) were also asked to provide a copy of these protocols. The quality of these protocols was assessed using Appraisal of Guidelines for REsearch & Evaluation (AGREE) II.

RESULTS

Slightly more than half (n = 40) of the hospitals surveyed had acute abdominal pain clinical protocols, while 16 had a general pain protocol. In binomial logistic regression, two independent variables were related to the presence of a protocol, geographic region (P = 0.008) and advanced practice nurses/nurse practitioners' presence on staff (P = 0.024). The mean score for the overall quality assessment of these protocols was 4.2 on a seven-point Likert scale; in terms of the six domains of quality, "Clarity of presentation" and "Scope and purpose" were highest. The overall quality of clinical protocols increased with remoteness, χ² (3) = 8.341, P = 0.039, and was lower in hospitals with medical staff on site (U = 2.5, P = 0.007).

CONCLUSION

There is a documented standard for pain management of acute abdominal pain in about three quarters of participating Australian emergency departments. The use and quality of clinical protocols is influenced by the physical location of hospitals and staff and skill mix of clinicians.

Psychometric evaluation of the Danish version of a modified Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R-D) for patients hospitalized with acute abdominal pain

Background and aims This paper forms part of a study evaluating the effect of patient-controlled oral analgesia for patients admitted to hospital with acute abdominal pain. Pain is a subjective experience, and a multifaceted evaluation tool concerning patient-reported outcome measures is needed to monitor, evaluate, and guide health care professionals in the quality of pain management. The Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) is a validated multifaceted evaluation tool for measuring patient-reported pain experiences to evaluate different pain management interventions. The aim of this study was to evaluate the psychometric properties of a modified Danish version of the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R-D) used during and after hospitalization for patients with acute abdominal pain. Methods The APS-POQ-R was translated into Danish and two slightly different questionnaires were formed. Questionnaire one had 39 items and the six subscales pain severity (pain), perception of care (satisfaction), pain interference with function (activity) and emotions (emotion), side effects of treatment (safety), and patient-related barriers to pain management. The questionnaire focused on time during hospital stay and was to be completed at discharge. Questionnaire two included 25 items and the five subscales pain, satisfaction, activity, emotion, and safety and focused on time at home and was to be completed daily 1 week after discharge. The questionnaires were tested on 156 patients with acute abdominal pain. Internal consistency reliability and construct validity was examined. Results In both questionnaires, the results of correlations and tests for internal consistency reliability showed a Cronbach's alpha of >0.7 for the pain, activity, and emotion subscales, but the value was ≥0.69 for the satisfaction subscale. In questionnaire one, Cronbach's alpha was ≤0.64 for the safety subscale, but this was 0.73 when the item "itching" was deleted. In questionnaire two, Cronbach's alpha was ≤0.51 for the safety subscale. For the patient-barrier subscale in questionnaire one, Cronbach's alpha was ≤0.62 for any combination of the items in the subscale. The results of the construct validity and factor analysis showed a five-factor structure in questionnaire one and a three-factor structure in questionnaire two. In questionnaire one, items from the pain, activity, emotion, and safety subscales, except for the items "least pain" and "itching," loaded on factor one. In questionnaire two, all items from the pain, activity, and emotion subscales loaded on factor one. Conclusions The modified APS-POQ-R-D demonstrated adequate psychometric properties for the five subscales pain severity (pain), perception of care (satisfaction), pain interference with function (activity) and emotions (emotion), side effects of treatment (safety), but not for the patient-barrier subscale for patients hospitalized with acute abdominal pain. Consequently, the APS-POQ-R-D may be used without the patient-barrier subscale. Implications The clinical implications of this study may help clinicians with investigating how acute patients manage pain during and after hospital admission.

Providing high-quality fundamental care for patients with acute abdominal pain

PURPOSE

Globally, acute abdominal pain (AAP) is one of the most common reasons for emergency admissions, yet little is known about how this patient group experiences the delivery of fundamental care across the acute care delivery chain. The purpose of this paper is to describe how patients with AAP experienced fundamental care across their acute care presentation, and to explicate the health professional behaviours, reported by patients, that contributed to their positive experiences.

DESIGN/METHODOLOGY/APPROACH

A qualitative descriptive study, using repeated reflective interviews, was analysed thematically ( n=10 patients).

FINDINGS

Two themes were identified: developing genuine, caring relationships with health professionals and being informed about one's care. Patients reported that health professionals established genuine professional-patient relationships despite the busy care environment but perceived this environment as impeding information-provision. Patients were typically accepting of a lack of information, whereas poor professional-patient relationships were seen as inexcusable.

PRACTICAL IMPLICATIONS

To provide positive fundamental care experiences for patients with AAP, health professionals should establish caring relationships with patients, such as by using humour, being attentive, and acknowledging patients' physical pain and emotional distress; and should inform patients about their care, including allowing patients to ask questions and taking time to answer those questions.

ORIGINALITY/VALUE

This is the first Australian study to explore the experiences of patients with AAP across the acute care delivery chain, using a novel method of repeated interviews, and to demonstrate how fundamental care can be delivered, in clinical practice, to ensure positive patient experiences.

The state of Danish nursing ethnographic research: flowering, nurtured or malnurtured - a critical review

BACKGROUND

Nursing was established in Denmark as a scholarly tradition in the late nineteen eighties, and ethnography was a preferred method. No critical review has yet summarised accomplishments and gaps and pointing at directions for the future methodological development and research herein.

AIM

This review critically examines the current state of the use of ethnographic methodology in the body of knowledge from Danish nursing scholars.

METHODS

We performed a systematic literature search in relevant databases from 2003 to 2016. The studies included were critically appraised by all authors for methodological robustness using the ten-item instrument QARI from Joanna Briggs Institute.

RESULTS

Two hundred and eight studies met our inclusion criteria and 45 papers were included; the critical appraisal gave evidence of studies with certain robustness, except for the first question concerning the congruity between the papers philosophical perspective and methodology and the seventh question concerning reflections about the influence of the researcher on the study and vice versa. In most studies (n = 34), study aims and arguments for selecting ethnographic research are presented. Additionally, method sections in many studies illustrated that ethnographical methodology is nurtured by references such as Hammersley and Atkinson or Spradley.

CONCLUSIONS

Evidence exists that Danish nursing scholars' body of knowledge nurtures the ethnographic methodology mainly by the same few authors; however, whether this is an expression of a deliberate strategy or malnutrition in the form of lack of knowledge of other methodological options appears yet unanswered.