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

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.

Barriers and facilitators for coherent rehabilitation among people with inflammatory arthritis – a qualitative interview study

“…The second discourse on NPM reflects a demand for high productivity and efficiency in the healthcare system, where professionals, having expert knowledge, seem best equipped to assess the most appropriate decision seen solely from a diagnostic and treatment perspective in relation to disease [ 76 ]. These two conflicting discourses can cause dilemmas for professionals in relation to who, what and which values they must consider when discussing and deciding on which measures and actions to implement in relation to the healthcare users [ 79 ].…”