Aims and objectives. To explore older patients' participation during hospital admission and discharge. Background. Patient participation is suggested as a means to improve the quality of transitional healthcare. Older people with chronic diseases, physical disabilities and cognitive impairments often need to transfer from primary to hospital healthcare and vice versa. Design. This study adopts a participant observational research design. Methods. Participant observations of 41 older patients (over 75 years of age) during hospital admission and discharge were conducted in two hospitals in Norway (in 2012). The observations included short conversations with the patient and their next of kin to capture their participation experiences. Systematic text condensation was used to analyse the data material from the field notes.Results. Varying degrees of information exchange between healthcare professionals and patients, and a lack of involvement of the patient in decision-making (in admission and discharge) were observed and experienced by patients and their next of kin. The next of kin appeared to be important advocates for the patients in admission and provided practical support both during admission and discharge. Data suggest that patient participation in admission and discharge is influenced by time constraints and the heavy workloads of healthcare professionals. Patients' health conditions and preferences also influence participation. Conclusions. Several issues influence the participation of the older patients during hospital admission and discharge. Participation of the older patients needs continuous support from healthcare professionals that acknowledges both the individual patient's preferences and their capacity to participate. Relevance to clinical practice. Study findings report discrepancies in the involvement of older people and their next of kin. There is a need to increase and support older patients' participation in hospital admission and discharge.Key words: experiences, observational study, older patients, patient participation, patient perspective, transitional careWhat does this paper contribute to the wider global clinical community?Older patients' preferences and their capacity for participation in hospital admission and discharge varied considerably. This information must be taken into consideration to assist in informing healthcare workers about the appropriate level of patient participation.Heavy work load, crowded hospital wards, time pressure on healthcare professionals, ward routines constrain the participation of older patients during hospital admission and discharge.Increased awareness and competencies for healthcare professionals can be useful to improve patient participation during hospital admission and discharge. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

IntroductionElderly people aged over 75 years with multifaceted care needs are often in need of hospital treatment. Transfer across care levels for this patient group increases the risk of adverse events. The aim of this paper is to establish knowledge of quality in transitional care of the elderly in two Norwegian hospital regions by identifying issues affecting the quality of transitional care and based on these issues suggest improvement measures.MethodologyIncluded in the study were elderly patients (75+) receiving health care in the municipality admitted to hospital emergency department or discharged to community health care with hip fracture or with a general medical diagnosis. Participant observations of admission and discharge transitions (n = 41) were carried out by two researchers.ResultsSix main challenges with belonging descriptions have been identified: (1) next of kin (bridging providers, advocacy, support, information brokering), (2) patient characteristics (level of satisfaction, level of insecurity, complex clinical conditions), (3) health care personnel's competence (professional, system, awareness of others’ roles), (4) information exchange (oral, written, electronic), (5) context (stability, variability, change incentives, number of patient handovers) and (6) patient assessment (complex clinical picture, patient description, clinical assessment).ConclusionRelated to the six main challenges, several measures have been suggested to improve quality in transitional care, e.g. information to and involvement of patients and next of kin, staff training, standardisation of routines and inter-organisational staff meetings.

When a patient's transition from the hospital to home is less than optimal, the repercussions can be far-reachinghospital readmission, adverse medical events, and even mortality. Elderly, especially frail older patients with complex health care problems appear to be a group particularly at risk for adverse events in general, and during transitions across health providers in particular. We undertook a systematic review to identify interventions designed to improve patient safety during transitional care of the elderly, with a particular focus on discharge interventions. We searched the literature for qualitative and quantitative studies on the subject published over the past ten years. The review revealed a set of potential intervention types aimed at the improvement of communication that contribute to safe transitional care. Intervention types included professionoriented interventions (e.g. education and training), organisational/culture interventions (e.g. transfer nurse, discharge protocol, discharge planning, medication reconciliation, standardized discharge letter, electronic tools), or patient and next of kin oriented interventions (e.g. patient awareness and empowerment, discharge support). Results strongly indicate that elderly discharged from hospital to the community will benefit from targeted interventions aimed to improve transfer across healthcare settings. Future interventions should take into account multi-component and multi-disciplinary interventions incorporating several single interventions combined.

BackgroundUnderstanding and improving hospital discharge has assumed major importance since it represents an error-prone transition in care. One barrier to improvement is the lack of detailed understanding of how hospital discharge is organized, including its interdependencies and influential performance-shaping factors (PSFs). This study examines the discharge of elderly patients using the Functional Resonance Analysis Method, developed to analyze performance variability in complex systems. Our main aim was to identify hospital discharge functions, variability, and PSFs that may explain the variability and different outcomes in discharge practices by incorporating multiple-stakeholder perceptions (health-care providers, patients, next of kin).MethodsThe data consisted of moderate participant observations of 20 elderly patients (>75) discharged from hospital to primary health care. The data comprised 90 hours’ observations at hospital wards, including 173 conversations with patients, next of kin, and health-care personnel involved in discharge.ResultsWe identified 10 common functions in the discharge of elderly patients to primary health care. We found substantial variability in terms of timing, duration, and precision. Duration is a significant source of variability, primarily determined by the time of day the patient was determined medically fit for discharge. Precision issues related to (1) decision-making criteria concerning the medical fitness decision and appropriate level of care, (2) quality of discharge planning, (3) degree of patient involvement, and (4) quality of information transfer. PSFs were temporal conditions (degree of time pressure), individual and team characteristics, patient factors, organizational factors (unit, specialization, leadership, institutionalized routines), work environment factors (bed availability, availability in municipal services, quality of discharge planning, familiarity with the patient, pressure from next of kin, doctor’s specialization) and regulatory influences (financial incentives).ConclusionsThe study provides a detailed understanding of the discharge of elderly patients by describing common functions and variability in performance caused by multiple PSFs. Our findings indicate the necessity for studying multiple factors related to discharge, interdependencies, and their effects on a range of discharge outcomes incorporating a multiple-stakeholder perspective. We argue that the existing sequential approaches to the complexity surrounding hospital discharge are inadequate. Given the interdependencies among functions, there is a need for corresponding multi-factorial interventions.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-365) contains supplementary material, which is available to authorized users.

Background A renewed interest in nursing homes as clinical placement settings for nursing students has been prompted by the growing healthcare needs of an ageing population. However, if future nurses are to be enthusiastic about working in this healthcare context, it is essential that higher education institutions that educate nurses and nursing homes that provide placement experiences to students do so with a supportive, positive, and enriched approach. Methods To explore first-year nursing students’ placement experience in nursing homes, we conducted an exploratory qualitative study in three city-based nursing homes in western Norway. Thirteen first-year nursing students participated in the study. Three focus group interviews were conducted to explore the students’ placement experiences. Data were analysed using thematic analysis. The findings were reported using the Standards for Reporting Qualitative Research (SRQR). Results The analysis describes five themes relating to first-year students’ placement experience in nursing homes; (1) variations in utility of pre-placement orientation and welcome at placement site; (2) a challenging learning environment; (3) spending considerable placement time with non-registered nurses; (4) considerable variability in supervision practices; and (5) a vulnerable and demanding student role. Conclusions The research provides insight into the contextual characteristics encountered by first-year students that influence the quality of their placement experiences. Consequently, these characteristics impede access to important role models who lend support to a student’s growth and professional development, preventing full utilisation of the learning potential offered in nursing homes. Hence, we propose that targeted efforts are warranted to foster positive placement experiences and enhance students’ clinical education in nursing homes.