Continuity in care trajectories of older chronically ill patients in a battlefield of competing rationales

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Abstract
Background: Continuity is crucial when caring for older chronically ill patients. Research has shown that the integration of patients' own perspectives on their situation is of utmost importance for continuity and quality of care. Studies have, however, demonstrated a number of problems with health professionals' communication concerning older patients, leading to lack of continuity and integration of the patient perspective in care and treatment. In spite of these problems being well investigated, they continue to prevail.Objectives: To examine conditions for continuity and integration of the patient perspective in older, chronically ill patients' care as reflected in nursing staff's communication about the patients.Design: Explorative Participatory Action Research (PAR).Setting: An acute, general medical ward at a Danish university hospital.Participants: Hospital and municipality nurses (n = 29). Nursing records (n = 12).Method: Field studies: observations, interviews, nursing records audits and logs. Data were subject to manifest and latent content analysis.Results: Participants were aware of the importance of ensuring continuity, a comprehensive approach and integration of the patient perspective in care trajectories of older, chronically ill patients. Although they adhered to these ideals, they rarely pursued them in practice. Hindering factors were: organisational values, episodic focus on patients and lack of time. They felt caught in a value conflict between nursing professional values and system values, which caused a feeling of powerlessness, maintaining status quo in their clinical practice.Conclusion: The prevailing episodic focus and the competing rationales on the ward constituted a barrier to continuity and integration of the patient perspective in a comprehensive way.Implications for practice: In order to change actual practice management and staff must demand and act on a practice based on professional nursing values, for instance by using PAR due to the empowered and innovative processes involved.

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