A Small-Scale Qualitative Study of Early Comprehensive Patient Engagement in Acute Clinical Settings: Is It Feasible?

Background: Patient-centered care (PCC) based on systematic and comprehensive patient engagement is important for patient satisfaction. However, ensuring PCC is dicult in emergency departments (ED) characterized by a high patient ow and a substantial proportion of older adults with multimorbidity and complex care needs. This small-scale qualitative study aimed to identify potentials and barriers for providing early PCC for older adults in Danish EDs using a novel user-engagement conversation tool. Methods: Participant observation, focus group interviews and individual semi-structured interviews with ED nurses and geriatric nurses were conducted between September and December 2019 in an ED at a hospital in the Capital Region of Denmark. Thematic network analysis with a focus on potentials and barriers for patient engagement was conducted. Results: Two key subthemes related to potentials emerged: 1) a positive attitude towards patient engagement in the context of PCC, and; 2) perceived benets of PCC overall and the engagement tool in particular. Additionally, two key subthemes related to barriers emerged: 1) time constraints and; 2) concerns related to the importance of cross-sectoral care coordination. Conclusion: This study contributes to mounting evidence in support of policies and practices that encourage PCC as a driver of unpacking patients’ needs and values leading to targeted follow-up care. However, barriers such as time constraints, and lack of cross-sectoral care collaboration should be acknowledged if the potentials of PCC is to be fullled in ED settings.


Background
The emphasis on providing patient-centered care (PCC) that is respectful of and responsive to individual patient preferences, needs, and values is ubiquitous in modern healthcare systems (1,2). Centering healthcare provision to individual needs promotes exibility of healthcare and leads to improved patient satisfaction (2). However, PCC is challenging in emergency departments (ED) due to the high patient ow (3), in particular of older, multimorbid patients with complex care needs (1,4,5). Identifying feasible PCC approaches in ED-contexts is necessary for patient outcomes and provider satisfaction (5).
User-engagement tools aim to empower individuals to improve their health, make informed decisions, and engage effectively with healthcare systems (6). Engagement facilitates patient-provider encounters that bring insight into the individual's multidimensional needs and identify relevant, individualized care strategies. This small-scale study was a part of a larger research program aimed at investigating approaches to patient engagement among older adults in different settings. The study aimed to identify potentials and barriers for providing early PCC for older adults in EDs using a novel user-engagement tool for structured conversations ( Table 1). The tool assesses multiple life domains of importance for older adults followed by the identi cation of relevant goals and actions needed (7). If proven feasible in daily clinical practice, the tool may positively affect the quality of life and possibly diminish the readmission rate (8). Table 1 The user-engagement tool • The tool entitled "Life And Vitality Assessment" was developed in the Netherlands by Leyden Academy on Vitality and Ageing and later adapted for a Danish context.
• The tool aims to guide a structured conversation between patients and healthcare professionals to gain insights into older adults' own needs, values, and preferences and to measure self-perceived wellbeing to provide appropriate care strategies.
• The older adults are asked to rank a variety of different life domains by how important they are to him or her; 1) very important, 2) important, and 3) not important.
• The tool contributes to a more holistic assessment by not focusing solely on health but also life satisfaction and engagement.

Methods
Data comprised of participant observation and interviews with ED nurses and geriatric nurses, respectively, at the ED of a hospital in the Capital Region of Denmark. Permission to conduct the eldwork was obtained from the nurse manager prior to the data collection. Observations were carried out between September-December 2019. ANJ conducted the eldwork over a period of three weeks where she accompanied different nurses for 5-6 hours during the day shifts to gain in-depth contextual insight into circumstances shaping the encounters between nurses and older patients. Approximately 60 patientnurse interactions were observed. An observation guide with a focus on organizational structures; everyday practice; work ow and; potentials and barriers for providing PCC using the tool in the ED were used to ensure that observations were systematic. Field notes were taken during observations and were expanded on after each eldwork.
An information letter regarding the study was sent to the ED nurses and the geriatric nurses inviting them to participate in a focus group or an individual interview. A semi-structured interview guide centered around patient engagement, PCC in the ED, and the engagement tool developed for this study was used (English version provided as Additional le 1). Two semi-structured focus group interviews with three ED nurses and three geriatric nurses, respectively, lasting from 12-52 minutes, and two individual semistructured interviews with ED nurses lasting from 19-23 minutes were conducted. Thus, 8 nurses participated in this study. The interviews were carried out in facilities near the ED. Before each interview nurses were informed about the study objective and their right to withdraw at any time. All nurses gave written informed consent. Each interview was audio-recorded, transcribed verbatim, and analyzed using thematic network. Observational data and preliminary ndings were discussed in the author group.

Results
The analysis revealed two main themes: Potentials for providing PCC (Table 2) and Barriers for providing PCC (Table 3). Each theme contained three subthemes. Overall nurses had a positive attitude towards PCC and emphasized the potentials of the tool. Observations revealed that most older patients in the ED had the physical and mental ability to be engaged and that the long hours of waiting enabled patient engagement. However, data also revealed barriers for providing PCC: time constraints and concerns related to unpacking the 'black box' of needs among older patients were raised. Nurses emphasized that challenges in care coordination across sectors was a key barrier for the uptake of the tool in EDs.

Discussion
This small-scale study highlights the potentials and barriers for providing PCC using patient engagement tools in ED settings. Nurses emphasized the potentials of using the tool, including the opportunity to gain insight into patients' individual needs. More in-depth conversations would unpack the 'black box' of older patients' needs and resources thus feeding into targeted and responsive follow-up care (1,4). Thus, our study adds to the body of research highlighting the potentials of systematically engaging patients in a more comprehensive manner than what is often the case (2,9), as the tool recognizes that life domains that extend beyond traditional disease management dimensions are of importance for care provision for older patients (7).
Not surprisingly, our study reveals that the circumstances for providing early PCC in the ED are challenged by barriers including time constraints and concerns related to unpacking the 'black box' of older patients' needs. The nurses emphasized the high-intensity work condition characterized by a constant uncertainty of what type of patient will arrive next and a need for rapid prioritizing between tasks and patients. This is in accordance with other studies highlighting barriers for PCC in acute care settings related to time constraints and low priority given to the implementation of new tools that do not support acute treatment to maintain a high patient ow (3,9). Another key barrier relates to cross-sectoral care coordination which is hampered by different organizational structures. In Denmark municipalities and general practitioners provide a variety of services covered by the tool. Thus, nurses feared that insu cient cross-sectoral communication would lead to uncoordinated and inadequate follow-up care. Effective cross-sectoral coordination and communication are important especially when designing individualized discharge plans, as the plans may reduce hospital length of stay and readmissions among older medical patients (8). Routinely engaging patients in decision-making remains a challenge. There is a need for approaching PCC in EDs more systematically and comprehensively to unlock the likely positive effect on the quality of care and more appropriate resource allocation for the growing population of older adults in EDs (4,5).
This study has some limitations in particular related to the lack of inclusion of patient perspectives.
Further, the study was conducted in a single ED and within a single geriatric team. However, we believe that the potentials and barriers identi ed are similar across EDs in different geographical contexts. Based on these preliminary ndings we suggest that the tool in the current format is too extensive for the setting of the ED. However, the development of a shortened version particularly for use in ED settings and conduction of a pilot validation study may result in a feasible tool to guide targeted PCC for older patients in EDs.

Conclusion
This study contributes to the increasing evidence in support of PCC. Ideally, older patient's preferences are assessed at an early stage and adequately recorded and made available for healthcare providers.
However, early PCC in EDs is challenging due to the high patient ow, the unpredictable tasks, and limited time available for unpacking the 'black box' of older patients' needs and following up on needs requiring cross-sectoral collaboration.  (10). Before beginning the interviews, each participant was provided with the necessary information about the study and the interview began after obtaining written informed consent.
Consent for publication: Not applicable.
Availability of data and materials: The data generated and/or analyzed during the current study are not publicly available due to the sensitive nature of the data.