Unpacking Healthcare Professionals' Work to Achieve Coherence in the Healthcare Journey of Elderly Patients: An Interview Study

'You're Just Thinking About Going Home': Exploring Person-Centred Medication Communication With Older Patients at Hospital Discharge

BACKGROUND

The hospital discharge process poses significant safety risks for older patients due to complexities in communication and coordination among stakeholders, leading to potential drug-related problems post-discharge. Adopting a person-centred care (PCC) approach in medication communication by healthcare professionals (HCPs) is crucial to ensure positive health outcomes. This study aimed to explore the practice of PCC in medication communication between older patients and HCPs during the hospital discharge process.

METHODS

We conducted a qualitative study using non-participatory direct observations of patient-HCP consultations during hospital discharge, followed by semi-structured interviews with observed patients and, when applicable, their informal caregivers. Data collection occurred from October 2020 to May 2021 at two Swedish hospitals. We gathered data using an observational form and audio-recorded all consultations and interviews. The data were analysed thematically using the systematic text condensation method.

RESULTS

Twenty patients were included (median age: 81 years [range: 65-94]; 9 female) in observations and 13 of them participated in interviews. Two patients were accompanied by an informal caregiver during the interviews. Three main themes were identified: (1) The impact of traditional authoritarian structures, depicts power dynamics between patients and their HCPs, showing how traditional structures influence the practice of PCC in medication communication during hospital discharge; (2) Consultation timing and mode not on patients' terms, describes suboptimal times and settings for consultations, along with the use of complex language that hinders effective communication; and (3) Discrepancy in expectations of self-care ability, illustrates a mismatch between the self-care guidance provided by HCPs during hospital discharge and the actual needs and preferences of patients and informal caregivers.

CONCLUSION

Medication communication between older patients and HCPs during hospital discharge is frequently inconsistent with the practice of PCC. Not only must HCPs improve their communication strategies, but patients and their informal caregivers should also be better prepared for discharge communication and encouraged to participate in their care. This involvement would give them relevant knowledge and tailor communication to their individual needs, preventing problems in managing their medications after discharge.

PATIENT OR PUBLIC CONTRIBUTION

An advisory group of six patients and/or informal caregiver contributors provided input on the study design, edited the consent forms, and helped develop the interview guide.

Experiences of hospital care for people with multiple long-term conditions: a scoping review of qualitative research

BACKGROUND

Multiple long-term conditions-the co-existence of two or more chronic health conditions in an individual-present an increasing challenge to populations and healthcare systems worldwide. This challenge is keenly felt in hospital settings where care is oriented around specialist provision for single conditions. The aim of this scoping review was to identify and summarise published qualitative research on the experiences of hospital care for people living with multiple long-term conditions, their informal caregivers and healthcare professionals.

METHODS

We undertook a scoping review, following established guidelines, of primary qualitative research on experiences of hospital care for people living with multiple long-term conditions published in peer-reviewed journals between Jan 2010 and June 2022. We conducted systematic electronic searches of MEDLINE, CINAHL, PsycInfo, Proquest Social Science Premium, Web of Science, Scopus and Embase, supplemented by citation tracking. Studies were selected for inclusion by two reviewers using an independent screening process. Data extraction included study populations, study design, findings and author conclusions. We took a narrative approach to reporting the findings.

RESULTS

Of 8002 titles and abstracts screened, 54 papers reporting findings from 41 studies conducted in 14 countries were identified as eligible for inclusion. The perspectives of people living with multiple long-term conditions (21 studies), informal caregivers (n = 13) and healthcare professionals (n = 27) were represented, with 15 studies reporting experiences of more than one group. Findings included poor service integration and lack of person-centred care, limited confidence of healthcare professionals to treat conditions outside of their specialty, and time pressures leading to hurried care transitions. Few studies explored inequities in experiences of hospital care.

CONCLUSIONS

Qualitative research evidence on the experiences of hospital care for multiple long-term conditions illuminates a tension between the desire to provide and receive person-centred care and time pressures inherent within a target-driven system focussed on increasing specialisation, reduced inpatient provision and accelerated journeys through the care system. A move towards more integrated models of care may enable the needs of people living with multiple long-term conditions to be better met. Future research should address how social circumstances shape experiences of care.

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views

BACKGROUND

Hospital discharge of older patients is a high-risk situation in terms of patient safety. Due to the fragmentation of the healthcare system, communication and coordination between stakeholders are required at discharge. The aim of this study was to explore communication in general and medication information transfer in particular at hospital discharge of older patients from the perspective of healthcare professionals (HCPs) across different organisations within the healthcare system.

METHODS

We conducted a qualitative study using focus group and individual or group interviews with HCPs (physicians, nurses and pharmacists) across different healthcare organisations in Sweden. Data were collected from September to October 2021. A semi-structured interview guide including questions on current medication communication practices, possible improvements and feedback on suggestions for alternative processes was used. The data were analysed thematically, guided by the systematic text condensation method.

RESULTS

In total, four focus group and three semi-structured interviews were conducted with 23 HCPs. Three main themes were identified: 1) Support systems that help and hinder describes the use of support systems in the discharge process to compensate for the fragmentation of the healthcare system and the impact of these systems on HCPs' communication; 2) Communication between two separate worlds depicts the difficulties in communication experienced by HCPs in different healthcare organisations and how they cope with them; and 3) The large number of medically complex patients disrupts the communication reveals how the highly pressurised healthcare system impacts on HCPs' communication at hospital discharge.

CONCLUSIONS

Communication at hospital discharge is hindered by the fragmented, highly pressurised healthcare system. HCPs are at risk of moral distress when coping with communication difficulties. Improved communication methods at hospital discharge are needed for the benefit of both patients and HCPs.

Technology-based interprofessional collaboration in primary care for home rehabilitation of the older adults: A dutch exploratory study

Primary healthcare professionals face an increasing number of geriatrics patients, and patient care often involves different disciplines. eHealth offers opportunities to support interprofessional collaboration (IPC). This exploratory study aimed to gain insight in 1) IPC in community-based rehabilitation, 2) facilitators and barriers for technology-based IPC and 3) technological IPC solutions envisioned by the primary healthcare professionals An focus group with six primary healthcare professionals and a design thinking session with four participants were conducted. Data analysis was based upon an IPC model. Results indicate that facilitators and barriers for IPC can be clustered in three categories: human, organization and technology, and provide some requirements to develop suitable IPC technological solutions Primary healthcare professionals recognise the urgency of working collaboratively. Current barriers are understanding each other's professional vocabulary, engaging the older adults, and using technology within the patient's environment. Further research is needed to integrate IPC components in a technological solution.

Dilemmas and deliberations in managing the care trajectory of elderly patients with complex health needs: a single-case study

Background

Today, the ageing population is larger than ever before, and people who are living longer with chronic illnesses and multimorbidity need support from multiple healthcare service levels. Similarly, healthcare systems are becoming increasingly specialised and fragmented. The World Health Organization has highlighted novel policies for developing integrated and person-centred services. However, patients, next of kin and health professionals face several challenges in managing healthcare during the care trajectory. Limited literature has addressed the challenges experienced by these groups. Therefore, this study aimed to identify the dilemmas and deliberations faced by patients, next of kin and health professionals during the care trajectory of elderly patients with complex healthcare needs.

Method

The study had a qualitative single-case design. The case was taken from a multi-case study exploring the care trajectory of elderly patients. The participants were the patient, their next of kin and the health professionals involved in the patient’s care trajectory. Data were obtained via observation and individual interviews conducted during the patient’s hospital stay and after the patient returned home.

Results

The dilemmas and deliberations in managing the care trajectory were divided into four main themes: the health professionals’ pursuit of appropriate and feasible healthcare services, the next of kin’s planning horizons, being the person left in limbo and reorganising the home for comprehensive healthcare.

Conclusion

The pursuit of a tailored and suitable healthcare service lead to a comprehensive mobilisation of and work by all actors involved. Having a comprehensive understanding of these conditions are of importance in developing an appropriate care trajectory for the elderly patient with complex need.

Municipal healthcare professionals' interprofessional collaboration during older patients' transitions in the municipal health and care services: a qualitative study

Background

Interprofessional collaboration is vital to assist patients towards a healthy transition in the municipal health and care services. However, no study has so far investigated municipal health care providers’ inter-professional collaboration during older patients’ transition in the municipal health and care services. The aim of this study is therefore to describe and explore what influence health care providers’ inter-professional collaboration within and across municipal facilities during older patients’ transitions in the municipal health and care services.

Method

The study has a descriptive, interpretive design. Focus group interviews and individual interviews with municipal health care providers different professions were performed.

Results

Municipal health care providers’ inter-professional collaboration during older patients transitions in the municipal health and care services was challenging. Two main themes were identified: The patient situation itself and Professional. Personal, and Practical circumstances. The results show that the municipal priority of patients staying at home as long as possible facilitated inter-professional collaboration across the short-term care facility and the home care services. Inter-professional collaboration across facilities with the long-term care facility was downgraded and health care providers in this facility had to cope as best they could.

Conclusion

Prioritising and facilitating inter-professional collaboration between the short-term care facility and the home care services, contributed to health care providers experiencing doing a proper and safe patient assistance. Yet, this priority was at a cost: Health care providers in the long-term care facility, and in particular registered nurses felt squeezed and of less worth in the municipal health and care services. It was a strain on them to experiencing unplanned and often rushed patient transition into long-term care facility. To focus on municipal inter-professional and inter-facility collaboration during patients in transition to long-term care placement is vital to maintain the patients, and the health care providers working in these facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08226-5.

Hospital physicians' experiences and reflections on their work and role in relation to older patients' pathways - a qualitative study in two Norwegian hospitals

Background

Older patients are the most frequent users of initial hospital admissions and readmissions. Both hospital admission and discharge require communication and coordination between healthcare professionals within the hospital, and between professionals in hospitals and primary healthcare. We have identified few studies exploring hospital physicians’ perspectives on older patients’ pathways in the interface between hospital and primary healthcare services. The aim of this study was to explore hospital physicians’ experiences and reflections on their work and role in relation to older patients’ pathways between hospital and primary healthcare. Specifically, we focused on the challenges they faced and how they dealt with these in relation to admission and discharge, and their suggestions for service improvements that could facilitate older patients’ pathway.

Methods

We used a qualitative approach, conducting individual in-depth interviews with 18 hospital physicians from two hospitals in eastern Norway. Data were analyzed using systematic text condensation, in line with a four-step prosedure developed by Malterud.

Results

The participants emphasized challenges in the communication about patients across the two service levels. Moreover, they described being in a squeeze between prioritizing patients and trying to ensure a proper flow of patients through the hospital wards, but with restricted possibilities to influence on the admissions. They also described a frustration regarding the lack of influence on the healthcare delivery after discharge. The participants had various suggestions for service improvements which might be beneficial to older patients.

Conclusions

The results demonstrate that the hospital physicians perceived being squeezed between professional autonomy and limited capacity at the hospital, and between their medical judgement as a specialist and their power to decide on hospital admissions for old patients and also on the delivery of health care services to patients after discharge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07846-1.

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.

Temporal patient trajectories: long stories in short admissions

Purpose

The purpose of this paper is to explain how trajectory management in hospitals is challenged by the introduction of accelerated discharge schemes. The patient trajectory is formed by short stays within health-care organizations, which requires a substantial effort for professionals to be successful in clarifying each patient's medical situation. The patients, at the same time, often have complicated illness stories, and professionals only see a limited part of the patient's trajectory.

Design/methodology/approach

This paper is based on extensive ethnographic studies in a newly established cardiac day unit introducing same-day discharge schemes for patients with ischemic and arrhythmic heart disease.

Findings

The findings demonstrate that the patient trajectory becomes a “temporal patient trajectory” and encounters a short-term reality, where tensions arise between admission time and the trajectory as a whole. In managing temporal patient trajectories, formal organizing and patient experiences intersect in events that emerge from conversations and span past, present and future in relation to patient treatment. Professionals engage in articulation work to maintain coherence by allowing patients to hold different events together over time.

Originality/value

The paper provides new insights into the challenges of managing trajectories in same-day discharge schemes where the pressure to move quickly and ensure patient discharge is intense. The paper offers a novel theoretical perspective on trajectory management as an ongoing temporal process. The analysis displays temporal tensions between patient experiences and the accelerated discharge scheme and how professionals manage to overcome these tensions by bridging the patient's long illness story and the short trajectory within the cardiac day unit.