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Open Access 01-12-2021 | Care | Research

Healthcare professionals’ practice and interactions in older peoples’ cross-sectoral clinical care trajectories when acutely hospitalized - a qualitative observation study

Authors: Maiken Hjuler Persson, Christian Backer Mogensen, Jens Søndergaard, Helene Skjøt-Arkil, Pernille Tanggaard Andersen

Published in: BMC Health Services Research | Issue 1/2021

Abstract

Background

Healthcare services have become more complex, globally and nationally. Denmark is renowned for an advanced and robust healthcare system, aiming at a less fragmented structure. However, challenges within the coordination of care remain. Comprehensive restructures based on marketization and efficiency, e.g. New Public Management (NPM) strategies has gained momentum in Denmark including. Simultaneously, changes to healthcare professionals’ identities have affected the relationship between patients and healthcare professionals, and patient involvement in decision-making was acknowledged as a quality- and safety measure. An understanding of a less linear patient pathway can give rise to conflict in the care practice. Social scientists, including Jürgen Habermas, have highlighted the importance of communication, particularly when shared decision-making models were introduced. Healthcare professionals must simultaneously deliver highly effective services and practice person-centered care. Co-morbidities of older people further complicate healthcare professionals’ practice.

Aim

This study aimed to explore and analyse how healthcare professionals’ interactions and practice influence older peoples’ clinical care trajectory when admitted to an emergency department (ED) and the challenges that emerged.

Methods

This qualitative study arises from a hermeneutical stand within the interpretative paradigm.

Focusing on the healthcare professionals’ interactions and practice we followed the clinical care trajectories of seven older people (aged > 65, receiving daily homecare) acutely hospitalized to the ED. Participant observations were combined with interviews with healthcare professionals involved in the clinical care trajectory. We followed-up with the older person by phone call until four weeks after discharge. The study followed the code of conduct for research integrity and is reported in accordance with the Standards for Reporting Qualitative Research (SRQR) guidelines.

Results

The analysis revealed four themes: 1)“The end justifies the means – ‘I know what is best for you’”, 2)“Basic needs of care overruled by system effectiveness”, 3)“Treatment as a bargain”, and 4)“Healthcare professionals as solo detectives”.

Conclusion

Dissonance between system logics and the goal of person-centered care disturb the healthcare practice and service culture negatively affecting the clinical care trajectory. A practice culture embracing better communication and more person-centered care should be enhanced to improve the quality of care in cross-sectoral trajectories.

Which type of healthcare professionals are observed is not given on before-hand but guided by the clinical care trajectory. Thus, the helhcare professionals potentially recruited are those involved in the older person’s clinical care trajectory.

All new trajectories were initiated within the acute medical ward of the ED.

Begun JW, Zimmerman B, Dooley K. Healthcare organizations as complex adaptive systems. In: Mick SM, Wyttenbach M, editors. Advances in Health Care Organization Theory. San Francisco: Jossey-Bass; 2003. p. 253–88.

Olejaz M, Nielsen AJ, Rudkjøbing A, Okkels HB, Krasnik A, Hernández-Quevedo C. Denmark: health system review. Health Syst Transit. 2012;14(2):1–192.

Vrangbæk C. Denmark in [International Health Care System Profiles] 2020 [Available from: https://www.commonwealthfund.org/international-health-policy-center/countries/denmark.

Seemann J, Gustafsson J. Integration in the spotlight: Fighting silo barriers and fragmented healthcare in Denmark. In: Giarelli G, Jacobsen B, Nielsen M, Reinbacher GS, editors. Future Challenges: For Health and Healthcare in Europe. 1st ed. Denmark: Aalborg University Press; 2016. p. 49–70.

World Health Organisation. Continuity and coordination of care - A practice brief to support implementation of the WHO Framework on integrated people-centred health services. Geneva: World Health Organization; 2018.

Andersen PT, Jensen JJ. Healthcare reform in Denmark. Scand J Public Health. 2010;38(3):246–52. https://doi.org/10.1177/1403494809350521.CrossRefPubMed

Pierre J. The Marketization of the State. In: Peters GB, Savoie DJ, editors. Citizens, Consumers, and the Emergence of a Public Market: Governance in a changing environment. McGill-Queen's University Press; 1995. p. 55–81.

Dybbroe B. Professionssociologi - Sundhedsprofesioner under pres [Professions Sociology - Helathprofessions under pressure]. In: Sundhedssociologi: en grundbog [Health Sociology - the basics]. 1st ed. Copenhagen: Nota; 2010. p. 191–212.

Zeitler U. Ny professionalisme - samskabelse som vej til et bæredygtigt samfund. [new professionalism - co-creation as a new way of creating a sustainable society]. Copenhagen: Akademisk Forlag; 2016. p. 240.

10.

Eklund JH, Holmström IK, Kumlin T, Kaminsky E, Skoglund K, Höglander J, et al. "same same or different?" a review of reviews of person-centered and patient-centered care. Patient Educ Couns. 2019;102(1):3–11. https://doi.org/10.1016/j.pec.2018.08.029.CrossRef

11.

Jacobsen CB, Pedersen VH, Albeck K. Patientinddragelse mellem ideal og virkelighed - en empirisk undersøgelse af fælles beslutningstagning og dagligdagens møder mellem patient og behandler. In: Patientinvolvement between ideology and reality - an empirical assessment of mutual decision-making and everyday meetings between patient and carer. København: Sundhedsstyrelsen, Monitorering & Medicinsk Teknologivurdering; 2008.

12.

Dyrstad DN, Testad I, Aase K, Storm M. A review of the literature on patient participation in transitions of the elderly. Cogn Tech Work. 2015;17(1):15–34. https://doi.org/10.1007/s10111-014-0300-4.CrossRef

13.

Porter S. New nursing: the road to freedom? J Adv Nurs. 1994;20(2):269–74. https://doi.org/10.1046/j.1365-2648.1994.20020269.x.CrossRefPubMed

14.

Region of Southern Denmark. Center for fælles beslutningstagning [Center for Shared Decision-Making] [Available from: https://www.cffb.dk/.

15.

Vanhaecht K, Massimiliano P, van Zelm R, Sermeus W. An overview on the history and concept of care pathways as complex interventions. Int J Care Pathways. 2010;14:117–23.CrossRef

16.

Bower KA. Clinical pathways: 12 lessons learned over 25 years of experience. Int J Care Pathways. 2009;13(2):78–81. https://doi.org/10.1258/jicp.2009.009008.CrossRef

17.

Pinder R, Petchey R, Shaw S, Carter Y. What's in a care pathway? Towards a cultural cartography of the new NHS. Sociol Health Illness. 2005;27(6):759–79. https://doi.org/10.1111/j.1467-9566.2005.00473.x.CrossRef

18.

World Health Organisation (WHO), Regional Office for Europe. The Vienna Recommendations on Health Promoting Hospitals adopted at the 3rd Workshop of National/ Regional Health Promoting Hospitals Coordinators, Vienna, 1997. Copenhagen: WHO, Regional Office for Europe; 1997.

19.

World Health Organisation (WHO). Patient Safety Curriculum Guide -Multi-professional Edition 2011.

20.

ten Dam EM, Waardenburg M. Logic fluidity: how frontline professionals use institutional logics in their day-to-day work. J Prof Organ. 2020;7:188–204.

21.

Beedholm K. Patient involvement and institutional logics: a discussion paper. Nurs Philos. 2019;20(2):e12234. https://doi.org/10.1111/nup.12234.CrossRefPubMed

22.

Bode I, Lange J, Märker M. Caught in organized ambivalence: institutional complexity and its implications in the German hospital sector. Public Manag Rev. 2017;19(4):501–17. https://doi.org/10.1080/14719037.2016.1195437.CrossRef

23.

Lennox A, Braaf S, Smit V, Cameron P, Lowthian JA. Caring for older patients in the emergency department: health professionals' perspectives from Australia - the safe elderly emergency discharge project. Emerg Med Australas. 2019;31(1):83–9. https://doi.org/10.1111/1742-6723.13108.CrossRefPubMed

24.

World Health Organisation (WHO). World report on ageing and health. 2015.

25.

Boye LK, Mogensen CB, Mechlenborg T, Waldorff FB, Andersen PT. Older multimorbid patients’ experiences on integration of services: a systematic review. BMC Health Serv Res. 2019;19(1):795. https://doi.org/10.1186/s12913-019-4644-6.CrossRefPubMedPubMedCentral

26.

McCabe JJ, Kennelly SP. Acute care of older patients in the emergency department: strategies to improve patient outcomes. Open Access Emerg Med. 2015;7:45–54. https://doi.org/10.2147/OAEM.S69974.CrossRefPubMedPubMedCentral

27.

Pedersen KM, Andersen JS, Sondergaard J. General practice and primary health care in Denmark. J Am Board Fam Med. 2012;25(Suppl 1):S34–8. https://doi.org/10.3122/jabfm.2012.02.110216.CrossRefPubMed

28.

Lyngsø AM, Godtfredsen NS, Frølich A. Interorganisational Integration: Healthcare Professionals’ Perspectives on Barriers and Facilitators within the Danish Healthcare System. Int J Integr Care. 2016;16(1):4.CrossRef

29.

Rudkjøbing A, Strandberg-Larsen M, Vrangbaek K, Andersen JS, Krasnik A. Health care agreements as a tool for coordinating health and social services. Int J Integr Care. 2014;14(4). https://doi.org/10.5334/ijic.1452.

30.

Bak CK, Vrangbæk K, Winslow NT, Lau CB, Kousgaard MB, Holm J, et al. Sundhedsfremme i kommuner og lokalsamfund: mellem forskning, planlægning og praksis [health promotion in municipalities and local communities: between research, planning, and practice]. 1. Udgave ed. Copenhagen: Hans Reitzel; 2020. p. 253.

31.

The National Board of Health. Styrket akutberedskab - planlægningsgrundlag for det regionale sundhedsvæsen [An intensification of the emergency care - planning basis of the regional healthcare]. 2007 26. juni 2007.

32.

VIVE – Viden til Velfærd [Knowledge for wealth]. Akutmodtagelserne i Danmark. Forudsætninger, udfordringer og fremtidige pejlemærker. [The emergency rooms in Denmark - preconditions, challenges, and future landmarks] 2018. Report No.: e-ISBN: 978–87–7119-549-1.

33.

Danske Regioner [Danish Regions], Sundhedsstyrelsen [the National Board of Health], Sundheds- og Ældreministeriet [Ministry of Health and Eldercare]. De danske akutmodtagelser - status 2016. [The Danish emergency departments - A status]. 2016. Retrieved from: https://www.regioner.dk/media/3084/statusrapport-om-akutmodtagelserne.pdf.

34.

Andersen AB, Beedholm K, Kolbaek R, Frederiksen K. When clock time governs interaction: how time influences health Professionals' Intersectoral collaboration. Qual Health Res. 2018;28(13):2059–70. https://doi.org/10.1177/1049732318779046.CrossRef

35.

Dilthey W, Simmel G, Weber M, Freud S, Cassirer E, Mannheim K, et al. The interpretative tradition. In: Delanty G, Strydom P, editors. Philosophies of social science : the classic and contemporary readings, part two. Maidenhead, Philadelphia: Open University Press; 2003. p. 85–206.

36.

Spradley J. Participant observation. Wadsworth Cengage Learning: USA; 1980. p. 195.

37.

Robson C. Real world research: a resource for social scientists and practitioner-researchers. 2nd ed. Malden, Massachusetts:USA: Blackwell Publishers; 2002.

38.

Hoffmann E, Andersen PT, Mogensen CB, Prinds C, Primdahl J. Relatives’ negotiation power in relation to older people’s acute hospital admission: A qualitative interview study. Scand J Caring Sci. 2021;00:1–11. https://doi.org/10.1111/scs.13012.

39.

Boye LK, Mogensen CB, Andersen PT, Waldorff FB, Mikkelsen TH. 'One feels somewhere that one is insignificant in that system' - older multimorbid patients' between lifeworld and system in healthcare. BMC Geriatr. 2021;21(1):397.CrossRef

40.

World Medical Association. World Medical Association Declaration of Helsinki – Ethical principles for medical research involving human subjects 2018 [Available from: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/.

41.

Robson C. Additional Methods of Data Collection. In: Real World Research. Malden,Massachusetts:USA: Blackwell Publishers Inc; 2002. p. 379.

42.

Malterud K. Kvalitative forskningsmetoder for medisin og helsefag [qualitative research methods in medicine and healthcare]. 4th ed. Oslo, Norway: Universitetsforlaget; 2017. p. 254.

43.

British Geriatric Society - Improving healthcare for older people. Is it time to redefine old age? 2017 [Available from: https://www.bgs.org.uk/blog/is-it-time-to-redefine-old-age.

44.

Emerson RM. Writing ethnographic fieldnotes. 2nd ed: The University of Chicago Press; 2011.

45.

Blumer H. Symbolic interactionism: perspectives and method. 1st ed. Englewood Cliffs: New Jersey Prentice-Hall, Inc.; 1969.

46.

Habermas J. Theorie des kommunikativen Handelns. Cambridge: Polity; 1981. 465 (English edition, vol. 1) 57 (English edition, vol. 2).

47.

Habermas J. The theory of communicative action - the critique of functionalist reason. Cambridge: Polity Press; 1987.

48.

Christiansen K. Jürgen Habermas. In: Andersen PT, Timm H, editors. Sundhedssociologi - en grundbog. Copenhagen: Hans Reitzels Forlag; 2010. p. 100–17.

49.

Birkler J. Videnskabsteori: en grundbog [Scientific Theory - the basics]. 1 ed. Copenhagen: Munksgaard Danmark; 2005. 151 sider p.

50.

Mishler EG. The discourse of medicine. Dialectics of medical interviews. Noorwwod, New Jersey: Ablex Publishing Coorporation; 1984.

51.

Greenhalgh T, Robb N, Scambler G. Communicative and strategic action in interpreted consultations in primary health care: a Habermasian perspective. Soc Sci Med. 2006;63(5):1170–87. https://doi.org/10.1016/j.socscimed.2006.03.033.CrossRefPubMed

52.

Kjær P, Vikkelsø S. Organisationssociologi [Organisational Sociology]. In: Andersen PT, Timm H, editors. Sundhedssociologi: en grundbog [health sociology - the basics]. 1st ed. Copenhagen: Nota; 2010. p. 163–84.

53.

Møller JL, Hohnen P, Ajslev JZN, Hansen AM. Omsorg på arbejdsmarkedsvilkår - arbejdsvilkår og orienteringer i den fragmenterede danske hjemmepleje [Care at market conditions - Working conditions and orientations within the fragmented danish homecare]. Tidsskrift for Arbejdsliv [Journal of Worklife]. 2014;16(4):85–101. https://doi.org/10.7146/tfa.v16i4.108979.CrossRef

54.

Power M. The audit society - rituals of verification. Oxford: Oxford University Press; 1997. 183 p.

55.

Porter S. The poverty of professionalization - a critical analysis of strategies for occupational advancement of nursing. J Adv Nurs. 1992;17(6):720–6. https://doi.org/10.1111/j.1365-2648.1992.tb01970.x.CrossRefPubMed

56.

Vardinghus-Nielsen H, Bak CK. Sundheds- og sygdomskultur i et sociologisk og sundhedsteknologisk perspektiv [Health- and sickness culture in a sociological and health-technological perspective]. In: Andersen PT, Jacobsen MH, editors. Kultursociologi og kulturanalyse [Culture Sociology and Culture Analysis]. 1st ed. Copenhagen: Hans Reitzels Forlag; 2017. p. 475–95.

57.

Harmon J, Summons P, Higgins I. Nurses' culturally mediated practices influencing pain care provision for older people in acute care: ethnographic study. Appl Nurs Res. 2019;48:22–9. https://doi.org/10.1016/j.apnr.2019.05.010.CrossRefPubMed

58.

Lehn-Christiansen S. Tværprofessionelt samarbejde i sundhedsfaglig praksis [Interprofessional collaboration in healthcare practice]. 1st ed. Copenhagen: Munksgaard; 2016. 257 p.

59.

Dansish Ministry of Higher Education and Science. The Danish Code of Conduct for Research Integrity: Dansish Ministry of Higher Education and Science; 2014. Available from: https://ufm.dk/publikationer/2014/the-danish-code-of-conduct-for-research-integrity.

Title: Healthcare professionals’ practice and interactions in older peoples’ cross-sectoral clinical care trajectories when acutely hospitalized - a qualitative observation study
Authors: Maiken Hjuler Persson
Christian Backer Mogensen
Jens Søndergaard
Helene Skjøt-Arkil
Pernille Tanggaard Andersen
Publication date: 01-12-2021
Publisher: BioMed Central
Keyword: Care
Published in: BMC Health Services Research / Issue 1/2021
Electronic ISSN: 1472-6963
DOI: https://doi.org/10.1186/s12913-021-06953-9

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Healthcare professionals’ practice and interactions in older peoples’ cross-sectoral clinical care trajectories when acutely hospitalized - a qualitative observation study

Abstract

Background

Aim

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Aim

Methods

Results

Conclusion

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