Balancing standardisation and individualisation in transitional care pathways: a meta-ethnography of the perspectives of older patients, informal caregivers and healthcare professionals

BACKGROUND

Transitional care implies the transfer of patients within or across care settings in a seamless and safe way. For frail, older patients with complex health issues, high-quality transitions are especially important as these patients typically move more frequently within healthcare settings, requiring treatment from different providers. As transitions of care for frail people are considered risky, securing the quality and safety of these transitions is of great international interest. Nevertheless, despite efforts to improve quality in transitional care, research indicates that there is a lack of clear guidance to deal with practical challenges that may arise. The aim of this article is to synthesise older patients, informal caregivers and healthcare professionals' experiences of challenges to achieving high-quality transitional care.

METHODS

We used the seven-step method for meta-ethnography originally developed by Noblit and Hare. In four different but connected qualitative projects, the authors investigated the challenges to transitional care for older people in the Norwegian healthcare system from the perspectives of older patients, informal caregivers and healthcare professionals. In this paper, we highlight and discuss the cruciality of these challenging issues by synthesising the results from twelve articles.

RESULTS

The analysis resulted in four themes: i) balancing person-centred versus efficient care, ii) balancing everyday patient life versus the treatment of illness, iii) balancing user choice versus "What Matters to You", and iv) balancing relational versus practical care. These expressed challenges represent tensions at the system, organisation and individual levels based on partial competing assumptions on person-centred-care-inspired individualisation endeavours and standardisation requirements in transitional care.

CONCLUSIONS

There is an urgent need for a clearer understanding of the tension between standardisation and individualisation in transitional care pathways for older patients to ensure better healthcare quality for patients and more realistic working environments for healthcare professionals. Incorporating a certain professional flexibility within the wider boundary of standardisation may give healthcare professionals room for negotiation to meet patients' individual needs, while at the same time ensuring patient flow, equity and evidence-based practice.

After Hospital: Should Older Care-Needing Patients Be Transferred to Their Homes or to an Intermediate Care Institution?

Background: In most European countries, communities need to provide health and social care services to an increasing number of severely ill patients discharged from hospitals. We investigated whether nurses in hospitals and in the communities’ health and social care services experienced that the administration in the municipalities allocated older patients the right type of services after hospital discharge. Methods: We used data from Norway, with a qualitative pilot study and quantitative analysis (structural equation modeling) of surveys involving 2431 nurses on inpatient wards in acute hospitals and 4312 nurses working in nursing homes or home nursing. Results: Dissatisfaction was widespread with the use of patients’ homes the first days after hospital discharge. Among nurses working in hospitals, 38% were commonly or very commonly disagreeing with the use of the patient’s home after hospital discharge, 25% among home nurses, and 18% among nurses in nursing homes. Home nurses were more prone to oppose the use of patients’ homes if they also experienced that their service had inadequate staffing or inadequate medical equipment. Conclusions: This research indicates conflicting priorities between the bureaucracy and nurses involved in actual work with older patients. From the nurses’ perspective, the municipalities’ administration was offering too few older patients short-term-stay in an intermediate care institution as part of the clinical pathway from hospital to home. However, providing more recourses to home nursing would improve their ability to provide sufficient care to older patients discharged from hospital.