This study aimed at exploring and describing what influenced municipal health care providers’ IPC during older patients’ transitions in the municipality. Two distinct and closely related main themes were identified, each illuminating intertwining features of the complexity that challenged IPC during older patients’ transition in the municipality at inter- and intra-facility health and care levels. The themes: Patient situations that influenced IPC during older patients’ transitions in the municipality, and Professional, Personal, and Practical circumstances that influenced IPC during older patients’ transitions in the municipality.
Patient situations that influenced IPC during older patients’ transitions in the municipality
The findings imply that patient situations influencing IPC had common features at intra- and inter-facility levels, related to prioritizations, expectations, relationships, and dilemmas.
The municipal priority of patients living at home longer, patient- and family situation and expectations, and professional knowledge, attitudes and standards influenced IPC.
To successfully manage the priority of patients with the potential of moving and staying at home, health care providers at the STCF and the HCS shared information and collaborated face-to face at formal and informal levels. I.e., as a rule, health care providers in the STCF informed the HCS about when a patient moved from the STCF back home (FG1, FG2). Moreover, health care providers in the HCS participated at decisive points in the patient’s trajectory during his/her stay at the STCF. I.e., the physiotherapist and occupational therapist collaborated with the nursing staff and the patient to investigate the need for installing helping aids in the patient’s home (FG1, FG2). Furthermore, licensed nursing staff at the HCS sometimes participated in direct care situations at the STCF, to better assist and support the patient at home. Often patients moved between municipal facilities, and health care providers in the HCS may have had previous experience with the patient now staying in the STCF. This encouraged the sharing of knowledge and experiences both ways when they met across these two facilities. This way, health care providers complemented each other’s knowledge and competence to ensure a healthy transition for the patients.
Individual auxiliaries and registered nurses specialised in different patient conditions. It was expected that they should share knowledge and skills with each other at formalised meetings and when needed. For instance, when a patient arrived in the STCF with a rehabilitation potential, the “specialist” rehabilitation nurse was primary nurse for that patient, if possible, and collaborated closely with the nursing staff and the physiotherapists.
When in doubt about whether the patient was capable of moving home and staying at home, health care providers within and across the facilities prioritised doing a proper job. I.e., licensed nursing staff, physiotherapists and physician collaborated closely with each other across the STCF and the HCS at three separate time intervals to assist the same patient to live at home (FG1, FG2). Moreover, prioritising patients’ psychosocial needs before moving home appeared a professional standard and a collective enterprise. Assisting patients could be time-consuming, and the findings suggest a culture of staff flexibility and willingness to help out so that the health care provider had sufficient time to support the patient properly:
“I remember we had a patient who did not want to go outside of the facility, because she was afraid of meeting acquaintances in the neighbourhood. Therefore, we travelled to a nearby village to shops and such. It functioned well, and eventually she moved back home to see if she could manage. This worked out fine, and the transition was good at the end. It was a satisfying experience for us also, to see it was successful – it’s that safety issue, you know” (FG2).
Different functions and interests at the facilities seemed to challenge IPC and create dilemmas. I.e., nursing staff in the HCS and the nursing home had different views about when a transition home was acceptable. Nursing staff at the nursing home underscored the importance of respecting the patients’ autonomy and that health care providers in the HCS be willing to live with uncertainty and unpredictability regarding patients who wanted to live at home:
“Sometimes, the dangers are too much the focus instead of the possibility to try it out. Some patients prefer living at home half a year instead of staying here for three years” (FG1).
In the HCS, the nursing staff were concerned about maintaining justifiable health care services when faced with unrealistic expectations from the patients, their next of kin and colleagues at the nursing home:
“…that they believe they can move home and then there is 24- hour service, it is not like that when you live at home. It demands a little from, yes, next of kin and the patients themselves – that is how it is” (FG1).
Some families expected and demanded considerable assistance from especially the nursing staff in the HCS regarding physically demanding patients. This stimulated relationships and alliances between the registered nurses and the patient’s General Practitioner (GP). The GP supported the nurses and together they argued against the patient moving home. Moreover, at the STCF, the findings indicate that shared interests and professional standards to protect the patients’ rights, stimulated IPC between the nursing staff and the GP. I.e., when next of kin overruled the patients and decided on behalf of them, the licensed nursing staff and the GP collaborated closely and developed coherent arguments to protect the patients’ rights:
“The patient is our highest priority, and our focus has to be there. We cannot let the next of kin control too much as long as the patient is consent competent” (individual interview).
Rushed care transitions from the HCS to the STCF due to sudden deterioration of patients’ health or next of kin’s health seemed to create some friction in the IPC between health care providers in the HCS and the STCF, because the “information about the patient may be messier” (FG2). During the focus group interview, the interaction between the nursing staff became tense regarding inadequate or lack of written information from the HCS. However, the participants quickly prevented further disagreement by the home care nurse’s agreeable solution: “…just call us” (FG2). in addition to reading documentation, e-messages, and consulting the patient and their next of kin, nursing staff in the STCF relied on getting up-dated information by phone from colleagues in the HCS.
Care transitions from the STCF to the long-term care facility (LTCF) could also happen quickly due to patient situation as well as circumstances. The nursing staff had little influence on this and were frustrated on behalf of the patient and next of kin:
“It is a challenge to support the patient and the next of kin during that phase because, perhaps the more efficient the services are, maybe it is at the expense of next of kin and patients (FG1).
Health care providers in the LTCF regarded moving into LTCF a stressful change and “a very serious process for the patient concerned” (FG1). However, they did not participate in the formalised IPC meetings across facilities. It disturbed the nursing staff that patients with a potential for moving back home was prioritised at the expense of patients moving into LTCF:
“If you say yes to a patient, then you say maybe no to another patient… so one has to attempt a holistic approach” (FG1).
Yet, sometimes when patients in spite of comprehensive IPC within and across the STCF and HCS were unable to live at home, this contributed to a planned transition to the LTCF. During the process of trying to live and manage at home, the patient realised and accepted that moving to LTCF was a better option:
“With the support from us, she tried living at home again just to experience it. I believe the patient hoped to be able to stay in her home on a permanent basis. I think it was a difficult process for the patient to accept that she could not live at home any longer. Yet, she had had the opportunity to experience living at home. She appeared incapable to grasp this, but when she eventually moved into LTCF, I believe it was an ok process. A process many health care providers engaged in, both in the out-and in-services (FG3).
Professional, Personal, and Practical circumstances that influenced IPC during older patients’ transitions in the municipality
The professional, personal, and practical circumstances that influenced IPC during older patients’ transition were related to prioritisations, competence, roles, compensation, expectations, and local contexts. Hospital discharges, municipal policy, facilities and professionals with different functions and roles influenced IPC. Limited municipal resources paired with the priority of patients living at home longer appeared to impact less IPC between health care providers in the LTCF and the STCF and HCS.
The municipality has to receive patients from hospital at short notice. Then patients often moved from the STCF to the LTCF in a hurry, to provide a vacant bed for the new patient at the STCF. This seemed to have a negative impact on IPC. Nursing staff at both facilities were squeezed:
“It is a challenge for us to assist and support everybody in this situation and be able to pass on information to the LTCF. I believe the reason is that we take this for granted because it is so common for us. Regarding the patient, this is once in a lifetime, so I think, perhaps it would have been better if we spent some more time on it. Yet, what is the most important here? Should we prioritize to spend the time we have on this? And then others must line up in another que to wait” (FG1).
Nursing staff in the LTCF seemed frustrated because they had little influence on when the patients arrived from the STCF: “we have to be allowed to decide that the patient arrive on Wednesday instead of Tuesday” (FG1), and suggested:
“We can be better at talking together, or that health care providers in the LTCF are present at the STCF and collaborate with the patient and colleagues to make the transition to LTCF easier for the patient. There is only one floor separating us” (FG3).
They made efforts to make the patient and next of kin feel welcome despite the unfavourable circumstances:
“…at least we can show them that we think about this person and are well prepared. That the room is ready and that there is a name on the door, and that this particular person experiences that he/she is expected (FG3).
The admission team meeting members appeared to collaborate closely with each other. The overview they had of the patients paired with the members’ different professional roles and work contexts, contributed to “heated discussions, negotiations and dialogues” (FG1). These interactions were considered a thorough base for making the right prioritizations when allocating services to patients. They seemed familiar with, and expected the potential benefits for the patients inherent at the different health care settings:
I believe the admission team meeting is a good arena to support patients in transition - at least regarding new patients or patients who have lived at home and been to the nursing home - and see changes, and if they function better when they are going back home. At least, this is my experience, that they get another type of care (i.e. improved nutritional-, functional- and social status) during a period in the nursing home that help them function better at home” (FG1).
Decisions made at the meetings influenced IPC within and across facilities. As leaders of their respective facilities, they worked together with their front-line staff on weekdays. The findings suggest that front-line staff considered the information from the facility leaders assisted them, i.e. to “be able to take good care of the patient at home” (FG2). Equally, the admission team members acted on requests from their staff:
«…. I think about being short of time…. I have occasionally participated in admission team meetings. The focus there is on healthy transition process. The members give room for extending the stay at the STCF, if we consider it necessary. You know, to support a safe and healthy transition for the patient. So at least, I think they try in many situations, to support the patients and their next of kin (FG2).
Different facilities with different functions, professional resources and contexts influenced IPC. The municipal health and care services depend on using unlicensed assistants to have enough health care providers at work at any time. The findings demonstrate that it varied between the facilities how this influenced IPC.
At the LTCF, the licensed nursing staff worked side-by-side with their assistants during dayshifts weekdays (FG3). They then had opportunity to supervise and delegate tasks to the assistants and the assistants had the opportunity to ask questions. At weekends and nights, however, there were fewer licensed nursing staff at each shift, which limited close interaction between the unlicensed and licensed staff:
“Especially when a new patient arrives, then I get nearly always information from the registered nurse and I get the rest myself, or ask the patient himself, what he can do. I experience I get all the information I need. Yet, when it is night or weekend and such – I can wait a little, but I ask the patient and it helps a lot” (FG2).
At the HCS, nursing staff mostly operate on their own in the patients’ homes, and licensed nurses have restricted opportunity to work side-by-side with assistants. The findings suggest that geographical distances paired with professional and municipal policy, challenged IPC between licenced and unlicensed nursing staff. I.e., regardless of geographical distance, the licensed nurses did the tasks that required professional competence. This could mean too much time spent on driving between patients (FG2) instead of spending time with patients. Moreover, some assistants did not have password and access to the computer program (FG2). In these cases, the licensed nursing staff compensated, and wrote in their shift reports what the assistants reported to them. These circumstances created frustration among licensed nursing staff, and some tension in the collaboration with assistants. Moreover, it contributed to random and insufficient follow-up of patients in transition (FG2).
Due to limited physiotherapy services, two auxiliaries in the HCS had extended roles with a great degree of autonomy to i.e., compensate for the lack of physiotherapy services during patients’ transition home. They had regular supervisions from the physiotherapist regarding physical training and combined these skills with their competence as auxiliaries. The GP at the STCF, however, considered nursing staff incompetent regarding rehabilitation of stroke patients, and applied for rehabilitation stays outside the municipality.
The GPs’ involvement, expectations and roles concerning IPC varied. Some highlighted their focus was the patients’ medical condition and appeared to leave the rest to the other professional groups. Others seemed more involved with the patients’ transition and their next of kin. I.e. when next of kin insisted on supporting their older, multimorbid and cognitively impaired family member stay at home, the GP had a central role in supporting the next of kin and collaborated closely with health care providers in the HCS.
The findings hint that some GPs experienced being apart from IPC in the municipal health care services:
“ …… at the medical centre, we get in a way a task or at least some inquiries from health care providers at the nursing home or the HCS. So, we in a way participate in those processes, either with medical information or multi dosage medications which need to be done something about. And if there is information the health care providers need, like patients’ journals” (FG1).
At the medical centre, the GPs depended on and expected their colleagues in the HCS to do a proper mapping of the patient and next of kin situation: “That we are told what the reality is concerning this patient….” (FG1). The findings imply some GPs regarded the communication and information sometimes lacking:
“If the HCS is good at notifying us about someone needing more treatment and care, that we are being informed about this via nursing and care reports, or if they are ill and incapable of managing at home, that we are informed, or if we have to do something there and then, and then act from the information we have” (FG1).
The findings indicate that the nursing staff in the HCS had difficulty getting in contact with the patient’s GP when in need, especially the GPs with most patients on their General Practitioner lists (FG2). It appeared especially challenging for the health care providers in the zone geographically further away from the medical centre to have a dialogue with the patient’s GP: “We use a lot of time (on the phone) to get through to the GP” (FG2). In the zone closer to the medical centre, it seemed the health care providers had easier access, and regular meeting points (individual interviews, FG2).
Health care providers appeared to recognise their own limitations when assisting patients in care transitions and regarded IPC essential:
“….. the inter-professional part, that many professionals participate so that we get the views from several …it is very positive - to have good dialogues” (FG2).
The formalized meeting points across the STCF and the HCS appeared to encourage licensed nursing staff and physiotherapists developing relationships and understanding of each other’s complementary roles. Similarly, keeping the patient safe during transition seemed paramount for most health care providers. They experienced that standing together made them feel they had done their best, and that their assistance provided safety for the patient, and peace of mind for themselves. Standing together implied a culture of flexibility, mutual dependency, and cognitive diversity where health care providers present shared their insights, worries, experiences, and knowledge about the patient with each other. Especially the physiotherapists expressed the need for close collaboration with the nursing staff at both facilities (FG1, FG2) to complement them in their assistance of patients with the potential of moving back home and staying at home.
The findings suggest, however, that IPC depended on group dynamics:
“Regarding a good group, “chemistry” is important. I think, you can have loads of procedures and if it is somehow bad “chemistry” in the group, then things go slowly - there are huge differences how one gets it done” (FG2).
In addition to face-to face IPC, health care providers shared information with each other via the computer program, telephone, and whiteboard. The findings indicate, however, that the written documentation in the computer program was not always read. Some facilities printed the information on paper, to ensure that everybody at the shift was updated on patient information (FG3).
Using the telephone to get updated information from colleagues appeared significant during older patients’ care transitions:
“….. finally, it is the contact by phone to ensure that we are aware of the correct date - that is ok. Still, we do most of the communication and have a dialogue through x (computer program). The admission team meeting has prepared the transition beforehand, so that gives us insights into their assessment” (FG2).
In the HCS, nursing staff and physiotherapists used whiteboards to inform and be updated on information about each patient and also each health care provider’s roles and functions at the shift. In addition to maintaining a consistent approach to the patient in transition, it seemed to encourage blending complementary competence and skills:
“…… we have good descriptions of how to assist the patient that depend on what the patient’s aim is. And we have a dialogue with the patient, and work towards consistency in our approaches, and use the whiteboard in the rooms before we prioritize what is important for the patient to master, and the physiotherapists write exercises for the patients on the whiteboard and what we can do to assist in that respect. It is a very good tool to help us being updated. So, I agree with x that when roles are clear and everybody knows what to do, then it flows smoothly” (auxiliary, FG2).
Across all facilities, the findings imply that the taken for granted challenged IPC. I.e., regarding patients in transition from the STCF to the LTCF, sharing information about the patient seemed at chance. These facilities were in the same building, and most health care providers were familiar with each other across the facilities. Just as this gave health care providers the opportunity to share information about the patient, it also seemed to contribute to the opposite; that health care providers ignored the sharing of what appeared to be obvious (FG1).
At the LTCF, little or lack of IPC with colleagues at the STCF and the HCS, seemed to contribute to some registered nurses feeling less worth. Their only collaborative partner was the part-time GP. Yet, at the focus group interviews, the GP appeared mainly focused on collaborating with GP colleagues and did not mention or talk about collaboration with the nursing staff (FG1). Likewise, the nursing staff did not talk about collaboration with the GP (FG3).
The findings indicate that being apart from IPC with the other facilities contributed to close intra-facility collaboration between the nursing staff all levels. Attitudes among them seemed to be to stick together and take as good care of the patients as possible:
“When a new patient is expected at our facility, we in the group often talk together and plan the arrival. If some colleagues are good at something, then they can do that – we plan who will do what. I have noticed that things go smoothly then, and I (registered nurse) can focus on one thing instead of knowing that I have twenty other tasks to do. I have good help from the assistants then (FG3).
The participants expressed that they thrived in the LTCF, which they believed contributed to patients feeling welcome: “That you see, in a way, that the staff collaborate well together.” (FG3).
At the STCF, the findings indicate that the facility aimed at a culture of generosity, where health care providers took advantage of each other’s strengths, and accepted “that some succeed while others do not” (individual interview) when assisting patients with multifaceted needs in transition. The findings imply clear roles and expectations between the staff. Moreover, the facility nurse regarded a good relationship with the GP employed at the STCF crucial to the quality of their work. The registered nurses knew what the GP expected them to map regarding patients in transition, which assisted the GP in efficient medical treatment and follow-up of the patients (Individual interviews). Similarly, the GP believed that the nursing staff and the physiotherapists were the main contributors during patients’ transitions. The GP at the STCF, however, expressed a need for closer collaboration with colleagues at the medical centre about plans they had made together with the patients, next of kin, and the HCS concerning the patients currently staying in the STCF.
