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‘Are decisions about dischargeof elderly hospital patients mainlyabout freeing blocked beds?’: A qualitative observational study
Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in East Östergötland, Department of Geriatric Medicine in Norrköping.
Valdemarsviks Primary Care Center, 615 30 Valdemarsvik, County Council of Eastern Gotland, Sweden.
Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in East Östergötland, Department of Geriatric Medicine in Norrköping.
Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.ORCID iD: 0000-0003-2191-4728
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2012 (English)In: BMJ. British Medical Journal, E-ISSN 1756-1833, Vol. 2, no 6, 1-9 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To explore the interactions concerning thefrail and elderly patients having to do with dischargefrom acute hospital wards and their participation inmedical decision-making. The views of the patients andthe medical staff were both investigated.

Design: A qualitative observational and interviewstudy using the grounded theory.

Setting and participants: The setting was threehospitals in rural and urban areas of two counties inSweden of which one was a teaching hospital. The datacomprised observations, healthcare staff interviews andpatient interviews. The selected patients were all aboutto be informed that they were going to be discharged.

Results: The patients were seldom invited toparticipate in the decision-making regarding discharge.Generally, most communications regarding dischargewere between the doctor and the nurse, after which thepatient was simply informed about the decision. It wasobserved that the discharge information was oftengiven in an indirect way as if other, albeit absent,people were responsible for the decision. Interviewswith the healthcare staff revealed their preoccupationwith the need to free up beds: ‘thinking aboutdischarge planning all the time’ was the core category.This focus not only failed to fulfil the complex needs ofelderly patients, it also generated feelings of frustrationand guilt in the staff, and made the patients feelunwelcome.

Conclusions: Frail elderly patients often did notparticipate in the medical decision-making regardingtheir discharge from hospital. The staff was highlyfocused on patients getting rapidly discharged, whichmade it difficult to fulfil the complex needs of thesepatients.

Place, publisher, year, edition, pages
2012. Vol. 2, no 6, 1-9 p.
Keyword [en]
Frail elderly, Patient Participation, Discharge Planning, Qualitative observational study, Grounded theory, Hospital
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-81401DOI: 10.1136/bmjopen-2012-002027ISI: 000315081400135OAI: oai:DiVA.org:liu-81401DiVA: diva2:552241
Note

On the day of the defence date the title of this article was: “Focusing on acquiring available beds!” : The process of discharging elderly patients: A qualitative observational study.

Available from: 2012-09-13 Created: 2012-09-13 Last updated: 2017-12-07
In thesis
1. Frail and Elderly Hospital Patients: The Challenge of Participation in Medical Decision Making
Open this publication in new window or tab >>Frail and Elderly Hospital Patients: The Challenge of Participation in Medical Decision Making
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: In research, patient participation in medical decision-making has been shown to be associated with higher patient satisfaction and improvement of treatment outcomes. But when it comes to patient participation when being old and frail there are pitfalls and the research in this area is sparse.

The aim of this thesis is to explore participation in medical decision making of the frail elderly patient in hospital from the perspectives of patients themselves and the health care staff. In this thesis frail, elderly patients is defined as individuals 75 years old or older, who during the past 12 months have received inpatient hospital care three or more times and who have three or more diagnoses in three or more diagnostic groups according to the classification system ICD-10.

The participants were frail patients’ in hospital or newly discharged and it was health care personnel working with frail elderly patients. In three of the studies the method was mainly qualitative (Paper I, III, IV) and in one (Paper II) quantitative. The qualitative methods were one-to-one tape-recorded interviews of 25 patients (Paper I and IV), 18 personnel (III and IV), 5 focus group interviews of physicians (Paper III) and 26 days of observations in hospital wards (IV). Chosen methodologies of analysis were content analysis and Grounded Theory. The quantitative study (II) was a cross-sectional survey using telephone interviews with patients (n= 156). This material was descriptively analysed and examined using weighted kappa statistics.

Results: The results reported in Paper II show that elderly patients generally want to participate more in medical decision making than they do, though preferences for degree of participation are highly individualized – both findings important to consider in clinical practice.

According to the patients important key concepts of patient participation in medical decision making are to be listened to and to be informed (Paper I). The main reasons for not being able to participate included having many illnesses and generally, overall bad medical condition (Paper II). Also, cited as a problem was difficulty in understanding medical information, for example when given by a foreign-speaking physician (Paper I, II and IV). Frail, elderly patients complained that they were less informed than was their preference (Paper I, II and IV).

Moderate agreement was obtained between patient’s preferred and actual roles in medical decision making. Patients often expressed gratitude and confidence in their health care (Paper I and IV), but also, sympathy for stressed health care personnel who had so much to do.

The frail elderly patients do sometimes feel like a burden to the health care (Paper I and IV). The professionals gave expressions of trying to avoid taking care of frail elderly patients and at the same time expressions of frustration and bad conscience not being able to take good care of them due to lack of time and lack of beds (Paper III, IV). Especially the physicians felt they were trapped between the needs of the patients’ and the remunerations system rewarding time-constricted health care production (number of investigations, operations, easy accessibility) – not a time-consuming holistic view on all illnesses and medications including communication with the patients and all caregivers involved (Paper III).

Both patients and the professionals perceive the hospital as some kind of “institution of power”, difficult to challenge, and the decisions of which one has to accept.

Conclusion: In this thesis there are shown a number of challenges to participation in medical decision making by frail, elderly patients, which thus limits quality of care for this patient group. Health care is revealed as not well adapted to meet these patients’ complex needs. A model is presented that explains how the organisation of health care, and the reimbursement system, does not facilitate a holistic view. The health care professionals appear to adapt to the organisation and the remuneration system, which leads to practices, such as, rapid discharges and a tendency to examine the patient for only one or a few problems. Finally a suggestion for a model to improve care of frail elderly patients is presented. This model includes the need of more hospital wards being able to work with a holistic view, better skills in gerontology and geriatrics and a more adapted remuneration system for the frail, elderly patients.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. 84 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1297
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81408 (URN)978-91-7519-947-4 (ISBN)
Public defence
2012-10-05, K1, Kåkenhus, Campus Norrköping, Linköpings universitet, Norrköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2012-09-13 Created: 2012-09-13 Last updated: 2017-07-07Bibliographically approved

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Wissendorff Ekdahl, AnneHellström, IngridAndersson, LarsFriedrichsen, Maria

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