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Westin E, Gustafsson IL, Svensson A, Sund-Levander M, Elmqvist C. Advising parents when their child has a fever: a phenomenographic analysis of nurses' perceptions when working at a telephone helpline, at primary care or at a paediatric emergency department in Sweden. BMJ Open 2024; 14:e074823. [PMID: 38286694 PMCID: PMC10826557 DOI: 10.1136/bmjopen-2023-074823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 01/11/2024] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVES To describe nurses' perceptions of advising parents when their child has a fever. DESIGN/METHOD Inductive, descriptive study with a qualitative, phenomenographic approach. PARTICIPANTS AND SETTING A purposive sampling was used. To be included, the 24 online interviewed nurses had to have experience advising parents of febrile children between birth and 5 years of age. They were recruited from three different parts of the healthcare system from four regions in the south of Sweden. RESULTS The nurses described advising parents when their child has a fever as four different kinds of balancing acts: balancing between the parents' story and objective assessment, balancing between listening and teaching, balancing between self-confidence and trust in the expert, and balancing between independence and having someone by one's side. CONCLUSIONS Giving advice to parents when their child has a fever is a process where the nurse needs to listen, assess and give advice based on the situation. This requires a correct assessment that depends on the parents' story. Creating a trusting relationship is perceived as necessary for parents to assimilate the advice that is provided. What dominates are the nurses' perceptions of the inner qualities required to achieve a balance in the process, for example, the importance of experience and security in their professional role, while it is also necessary to get support from colleagues.
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Affiliation(s)
- Emma Westin
- Department of Health and Caring Sciences, Linnaeus University Faculty of Health and Life Sciences, Vaxjo, Sweden
- Department of Pediatrics, Region Kronoberg, Vaxjo, Sweden
| | - Ingrid L Gustafsson
- Department of Health and Caring Sciences, Linnaeus University Faculty of Health and Life Sciences, Vaxjo, Sweden
- Department of Caring Sciences, University College of Boras Faculty of Caring Science Work Life and Social Welfare, Boras, Sweden
| | - Anders Svensson
- Department of Health and Caring Sciences, Linnaeus University Faculty of Health and Life Sciences, Vaxjo, Sweden
- Department of Ambulance Service, Region Kronoberg, Vaxjo, Sweden
| | | | - Carina Elmqvist
- Department of Health and Caring Sciences, Linnaeus University Faculty of Health and Life Sciences, Vaxjo, Sweden
- Head of Research, Region Kronoberg, Vaxjo, Sweden
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Martínez B, Aranda MP, Sanko S, Aguilar I, Vega WA. Older Adult Frequent 9-1-1 Callers for Emergency Medical Services in a Large Metropolitan City: Individual- and System-Level Considerations. J Emerg Med 2023; 65:e522-e530. [PMID: 37852810 PMCID: PMC10871157 DOI: 10.1016/j.jemermed.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/22/2023] [Accepted: 07/15/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND High utilizers of 9-1-1 place a substantial burden on emergency medical services (EMS). Results of a retrospective review of records data of the City of Los Angeles Fire Department (LAFD) showed a significant increase in older adult high utilizers of 9-1-1. OBJECTIVE The objective of this study was to explore individual- and system-level factors implicated in EMS use among older adults, and to provide system recommendations to mitigate overuse. METHODS A phenomenological study was conducted, drawing from LAFD EMS records between 2012 and 2016 to identify and contact high-utilizing patients older than 50 years, their family, agency representatives, and LAFD personnel. Interviews were recorded, transcribed, and coded and a thematic analysis was completed. RESULTS We conducted in-depth interviews with 27 participants, including patients (n = 8), their families (n = 6), social service agency representatives (n = 3), and LAFD personnel (n = 10). The following cross-cutting themes emerged: nature of 9-1-1 calls, barriers to access, and changing the system. In addition, LAFD and social service agency representatives identified the role of EMS responders and social agency representatives. Patients and their families agreed that previous encounters and interactions with emergency care responders were relevant factors. CONCLUSIONS This study described reasons for 9-1-1 calls related to medical and social service needs, including mental health care. Our analysis offers insight from different stakeholders' perspectives on access to medical care and types of barriers that interfere with medical care. All groups shared recommendations to advance access to medical and mental health care.
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Affiliation(s)
- Beatrice Martínez
- USC Edward R. Roybal Institute on Aging, Los Angeles, California; USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California; University of Southern California, Los Angeles, California
| | - María P Aranda
- USC Edward R. Roybal Institute on Aging, Los Angeles, California; USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California; University of Southern California, Los Angeles, California
| | - Stephen Sanko
- Keck School of Medicine of University Southern California, Los Angeles, California; Los Angeles Fire Department, Los Angeles, California
| | - Iris Aguilar
- USC Edward R. Roybal Institute on Aging, Los Angeles, California; USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California; University of Southern California, Los Angeles, California
| | - William A Vega
- USC Edward R. Roybal Institute on Aging, Los Angeles, California
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Sidhu M, Saunders CL, Davies C, McKenna G, Wu F, Litchfield I, Olumogba F, Sussex J. Vertical integration of general practices with acute hospitals in England: rapid impact evaluation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-114. [PMID: 37839807 DOI: 10.3310/prwq4012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Background Vertical integration means merging organisations that operate at different stages along the patient pathway. We focus on acute hospitals running primary care medical practices. Evidence is scarce concerning the impact on use of health-care services and patient experience. Objectives To assess the impact of vertical integration on use of hospital services, service delivery and patient experience and whether patients with multiple long-term conditions are affected differently from others. Design Rapid, mixed methods evaluation with four work packages: (1) review of NHS trust annual reports and other sources to understand the scale of vertical integration across England; (2) development of the statistical analysis; (3) analysis of national survey data on patient experience, and national data on use of hospital services over the 2 years preceding and following vertical integration, comparing vertically integrated practices with a variety of control practices; and (4) focus groups and interviews with staff and patients across three case study sites to explore the impact of vertical integration on patient experience of care. Results At 31 March 2021, 26 NHS trusts were in vertically integrated organisations, running 85 general practices across 116 practice sites. The earliest vertical integration between trusts and general practices was in 2015; a mean of 3.3 practices run by each trust (range 1-12). On average, integrated practices have fewer patients, are slightly more likely to be in the most deprived decile of areas, are more likely to hold an alternative provider medical services contract and have worse Quality and Outcomes Framework scores compared with non-integrated practices. Vertical integration is associated with statistically significant, modest reductions in rates of accident and emergency department attendances: 2% reduction (incidence rate ratio 0.98, 95% confidence interval 0.96 to 0.99; p < 0.0001); outpatient attendances: 1% reduction (incidence rate ratio 0.99, 95% confidence interval 0.99 to 1.00; p = 0.0061), emergency inpatient admissions: 3% reduction (incidence rate ratio 0.97, 95% confidence interval 0.95 to 0.99; p = 0.0062) and emergency readmissions: 5% reduction (incidence rate ratio 0.95, 95% confidence interval 0.91 to 1.00; p = 0.039), with no impact on length of stay, overall inpatient admissions or inpatient admissions for ambulatory care sensitive conditions. The falls in accident and emergency department and outpatient attendance rates are temporary. Focus groups and interviews with staff (N = 22) and interviews with patients (N = 14) showed that with vertical integration, health service improvements are introduced following a period of cultural interchange. Patients with multiple long-term conditions continue to encounter 'navigation work' choosing and accessing health-care provision, with diminishing continuity of care. Limitations In the quantitative analysis, we could not replicate the counterfactual of what would have happened in those specific locations had practices not merged with trusts. There was imbalance across three case study sites with regard to staff and patients recruited for interview, and the latter were drawn from patient participation groups who may not be representative of local populations. Conclusions Vertical integration can lead to modest reductions in use of hospital services and has minor or no impact on patient experience of care. Our analysis does not reveal a case for widespread roll-out of the approach. Future research Further quantitative follow-up of the longer-term impact of vertical integration on hospital usage and more extensive interviewing of patients and their carers about patient experiences of navigating care. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (BRACE Project no. 16/138/31) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Manbinder Sidhu
- University of Birmingham, Health Services Management Centre, Birmingham, UK
| | - Catherine L Saunders
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Gemma McKenna
- University of Birmingham, Health Services Management Centre, Birmingham, UK
| | | | - Ian Litchfield
- University of Birmingham, Institute of Applied Health Research, Birmingham, UK
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McIntyre A, Janzen S, Shepherd L, Kerr M, Booth R. An integrative review of adult patient-reported reasons for non-urgent use of the emergency department. BMC Nurs 2023; 22:85. [PMID: 36991388 DOI: 10.1186/s12912-023-01251-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/15/2023] [Indexed: 03/31/2023] Open
Abstract
OBJECTIVE To conduct an integrative review of the scientific literature to explore adult patient-reported reasons for using the emergency department (ED) non-urgently. METHOD A literature search of CINAHL, Cochrane, Embase, PsycINFO, and MEDLINE was conducted with filters for humans, published January 1, 1990-September 1, 2021, and English language. Methodological quality was assessed using Critical Appraisal Skills Programme Qualitative Checklist for qualitative and National Institutes Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies for quantitative studies. Data was abstracted on study and sample characteristics, and themes/reasons for ED use. Cited reasons were coded using thematic analysis. RESULTS Ninety-three studies met inclusion criteria. Seven themes were found: need to be risk averse with respect to the health issue; knowledge and awareness of alternative sources of care; dissatisfaction with primary care provider; satisfaction with ED; ED accessibility and convenience resulting in low access burden; referred to the ED by others; and relationships between patients and health care providers. DISCUSSION This integrative review examined patient-reported reasons for attending the ED on a non-urgent basis. The results suggest that ED patients are heterogenous and many factors influence their decision-making. Considering the complexity with which patients live, treating them as a single entity may be problematic. Limiting excessive non-urgent visits likely requires a multi-pronged approach. CONCLUSION For many ED patients, they have a very clear problem which needed to be addressed. Future studies should explore psychosocial factors driving decision-making (e.g., health literacy, health-related personal beliefs, stress and coping ability).
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Affiliation(s)
- Amanda McIntyre
- Arthur Labatt Family School of Nursing, University of Western Ontario, London, Canada.
- Department of Emergency Medicine, University Hospital, London Health Sciences Centre, London, Canada.
| | | | - Lisa Shepherd
- Department of Emergency Medicine, University Hospital, London Health Sciences Centre, London, Canada
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Mickey Kerr
- Arthur Labatt Family School of Nursing, University of Western Ontario, London, Canada
| | - Richard Booth
- Arthur Labatt Family School of Nursing, University of Western Ontario, London, Canada
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Brunelli VN, Beggs RL, Ehrlich CE. Case study discussion: The important partnership role of Disability Nurse Navigators in the context of abrupt system changes because of COVID-19 pandemic. Collegian 2021; 28:628-634. [PMID: 34924805 PMCID: PMC8669692 DOI: 10.1016/j.colegn.2021.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 04/06/2021] [Accepted: 04/28/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Rapidly implementing telehealth-facilitated healthcare services in a COVID-19 environment generates relational challenges for people with intellectual disability. Disability Nurse Navigators assume a critical intermediary role between the healthcare system and this population. AIM To discuss the impact that rapid service change, in response to the COVID-19 pandemic, can have on people with disability and the work of Disability Nurse Navigators who support them. METHODS This clinical case discussion comprises two parts. First, a discussion on the impact that COVID-19 pandemic management has had on one person with an intellectual disability is framed using intersecting notions of cumulative complexity and Burden of Treatment Theory. Following, through a Latourian lens, the role of the Disability Nurse Navigator is explored. FINDINGS During COVID-19, telehealth has proved an important tool for healthcare continuity. Yet, for some people with some disabilities who live with additional and cumulative layers of health and social complexity, the healthcare workload that is transferred to them is exacerbated as they try to interact with disabling infrastructure. DISCUSSION The Disability Nurse Navigator recognises that people with disability are not independent of the technologies and structures that make up the healthcare system but that they are mutually constitutive. The Disability Nurse Navigator thus works to stabilise the relationships between changed service provision and the healthcare workload and capacity of people with disability. CONCLUSION The work of the Disability Nurse Navigator ultimately mitigated the disruption and additional treatment burden that is transferred to people with disability because of unintended consequences arising from the rapid introduction of service change.
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Affiliation(s)
- Vanessa N. Brunelli
- Nursing Practice Development Unit, Princess Alexandra Hospital, Metro South Health, Brisbane, Qld, Australia,Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology, Brisbane, Qld, Australia,Corresponding author at: 199 Ipswich Road, Woolloongabba 4102, Australia. Tel.: +61 731767289
| | - Rhonda L. Beggs
- Division of Medicine, Logan Hospital, Metro South Health, Brisbane, Qld, Australia
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Greenhalgh T, Rosen R, Shaw SE, Byng R, Faulkner S, Finlay T, Grundy E, Husain L, Hughes G, Leone C, Moore L, Papoutsi C, Pope C, Rybczynska-Bunt S, Rushforth A, Wherton J, Wieringa S, Wood GW. Planning and Evaluating Remote Consultation Services: A New Conceptual Framework Incorporating Complexity and Practical Ethics. Front Digit Health 2021; 3:726095. [PMID: 34713199 PMCID: PMC8521880 DOI: 10.3389/fdgth.2021.726095] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/19/2021] [Indexed: 12/18/2022] Open
Abstract
Establishing and running remote consultation services is challenging politically (interest groups may gain or lose), organizationally (remote consulting requires implementation work and new roles and workflows), economically (costs and benefits are unevenly distributed across the system), technically (excellent care needs dependable links and high-quality audio and images), relationally (interpersonal interactions are altered), and clinically (patients are unique, some examinations require contact, and clinicians have deeply-held habits, dispositions and norms). Many of these challenges have an under-examined ethical dimension. In this paper, we present a novel framework, Planning and Evaluating Remote Consultation Services (PERCS), built from a literature review and ongoing research. PERCS has 7 domains-the reason for consulting, the patient, the clinical relationship, the home and family, technologies, staff, the healthcare organization, and the wider system-and considers how these domains interact and evolve over time as a complex system. It focuses attention on the organization's digital maturity and digital inclusion efforts. We have found that both during and beyond the pandemic, policymakers envisaged an efficient, safe and accessible remote consultation service delivered through state-of-the art digital technologies and implemented via rational allocation criteria and quality standards. In contrast, our empirical data reveal that strategic decisions about establishing remote consultation services, allocation decisions for appointment type (phone, video, e-, face-to-face), and clinical decisions when consulting remotely are fraught with contradictions and tensions-for example, between demand management and patient choice-leading to both large- and small-scale ethical dilemmas for managers, support staff, and clinicians. These dilemmas cannot be resolved by standard operating procedures or algorithms. Rather, they must be managed by attending to here-and-now practicalities and emergent narratives, drawing on guiding principles applied with contextual judgement. We complement the PERCS framework with a set of principles for informing its application in practice, including education of professionals and patients.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Sara E. Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard Byng
- Plymouth Institute of Health and Care Research, University of Plymouth, Plymouth, United Kingdom
| | - Stuart Faulkner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Teresa Finlay
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Laiba Husain
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gemma Hughes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Lucy Moore
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Catherine Pope
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah Rybczynska-Bunt
- Plymouth Institute of Health and Care Research, University of Plymouth, Plymouth, United Kingdom
| | - Alexander Rushforth
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sietse Wieringa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Gary W. Wood
- Independent Research Consultant, Birmingham, United Kingdom
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Long J, Knowles E, Bishop-Edwards L, O'Cathain A. Understanding young adults' reasons for seeking 'clinically unnecessary' urgent and emergency care: A qualitative interview study. Health Expect 2021; 24:1535-1544. [PMID: 34118177 PMCID: PMC8369113 DOI: 10.1111/hex.13301] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/03/2021] [Accepted: 05/27/2021] [Indexed: 01/15/2023] Open
Abstract
Background Studies have identified young adults as more likely to use emergency departments for ‘clinically unnecessary’ problems, with limited similar evidence for emergency ambulance use. Media portrayals depict young adults as motivated by ‘convenience’, but little research has explored the reasons for their help‐seeking behaviour. Methods Qualitative interviews with 16 young adults (18‐30) considered by clinicians to have made unnecessary use of emergency ambulance, emergency department or an urgent GP appointment. Data analysis was informed by interpretive phenomenological analysis. Findings A number of interrelated factors contributed to participants’ decisions. They were anxious about the seriousness of their symptoms, sometimes exacerbated by reduced coping capacity due to poor mental health or life stresses. They looked to others to facilitate their decision making, who sometimes encouraged urgent contact. They wanted to avoid impact on existing day‐to‐day commitments including work or study. They had strong views about different health services, sometimes based on frustration with lack of resolution of on‐going health problems. Convenience was not identified as a significant factor, although some actions could be interpreted in this light if the context was not considered. Conclusions Young adults make ‘clinically unnecessary’ use of urgent and emergency care for more than convenience. Their decisions need to be understood in relation to the complexity of their experience, including lack of confidence in making health‐related decisions, lowered coping capacity and concern to maintain normal daily life.
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Affiliation(s)
- Jaqui Long
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Knowles
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Alicia O'Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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