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

doi:10.21203/rs.3.rs-78222/v1

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

https://doi.org/10.21203/rs.3.rs-78222/v1

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Background: Patient-centered care (PCC) based on systematic and comprehensive patient engagement is important for patient satisfaction. However, ensuring PCC is difficult in emergency departments (ED) characterized by a high patient flow 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 benefits 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 fulfilled in ED settings.

Health Economics & Outcomes Research

Health Policy

Patient-Centered Care

Emergency Department

Patient Engagement

Frail Older Adults

Qualitative Research

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 flexibility of healthcare and leads to improved patient satisfaction (2). However, PCC is challenging in emergency departments (ED) due to the high patient flow (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 identification 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.

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 fieldwork was obtained from the nurse manager prior to the data collection. Observations were carried out between September-December 2019. ANJ conducted the fieldwork 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 patient-nurse interactions were observed. An observation guide with a focus on organizational structures; everyday practice; workflow 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 fieldwork.

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 file 1). Two semi-structured focus group interviews with three ED nurses and three geriatric nurses, respectively, lasting from 12–52 minutes, and two individual semi-structured 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 findings were discussed in the author group.

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.

Table 2

Potentials for providing early PCC and implementing the user-engagement tool
Subtheme	Example
Nurses had a positive attitude towards patient engagement and considered engagement as valuable.	“(…) it is really important to try to engage them [patients] to uncover how we may accommodate the needs of the patients in the best possible way according to the resources currently available” (Nurse 2).
Nurses had a positive attitude towards initiatives focusing on PCC and emphasized that the specific innovative user-engagement tool could be beneficial.	“[Using the tool] One could get to know the patients in another way than usual. Our classic questions, which are not even so classic, differ from nurse to nurse: what you ask and what you respond to. (…) So, it could be beneficial if we were better at being, you know, becoming aware of the issues and pay attention to the older adults” (Nurse 6).
Nurses perceived the tool to be feasible.	“So, I believe that it [the tool] is more feasible for the patients. If some of the things that are the most important to them can be fulfilled – then I think it can create better care and maybe prevent some things, such as hospitalization. Maybe they [the patients] can better cater to some of the things that they are encouraged to during hospitalization (…)”. (Nurse 2)

Table 3

Barriers for providing early PCC and implementing the user-engagement tool
Subtheme	Example
The workflow is characterized by being fast and hectic. Nurses must prioritize among many different tasks.	“When we have a patient – we have six others as well and different emergency rooms we must run to. And we don’t know what we’ll receive in five minutes. We have no scheduled tasks. (…) For us, it’s about prioritizing. I can easily postpone a blood glucose test if another patient needs my help more. I can easily postpone giving medicine until noon if some of my colleagues need help with something. So, it [the tool] is not going to be prioritized – that’s what I’m trying to say.” (Nurse 4).
Nurses expressed concern for unpacking the ‘black box’ of needs among the older adults, as they are not familiar with the existing services provided by the municipality.	“Someone has to follow up on the needs that we uncover [using the tool]. And here [in the hospital] we do not know exactly that the municipality can offer and what the possibilities are (…)” (Nurse 3) “The municipality must also accommodate it [the needs], and again, it is the municipality that ultimately.. they’re the ones who have to provide some of the things that need to be accommodated for in these life domains. And there is a communicative path between us and them [the municipality] (…) that’s a lot of work, and there are also a lot of things that can go wrong. And if we open up something and say: ‘Well, we will pass this on to the municipality, if it’s okay with you?’, and then we pass it on, and the municipality cannot accommodate it. There might be some disappointment associated with it, I think, if things cannot be done” (Nurse 2)
Nurses underscored that the tool could be useful and relevant in other settings and by other professions.	Municipality: “(…) Isn’t there better conditions for a deeper dialogue there [in the municipality]?” (Nurse 1). Geriatric team: “If the gerontology-team should perform the task then I can see the point of using the tool, yes. Because I know that they have the time to follow up and get things done” (Nurse 4). Ward: “It might be different in the other hospital wards. Because you can easily plan and say: ‘Now I’ll spend 15 minutes sitting with the patient talking about things’. (…). There, I think, the workflow is completely different. You can easily incorporate it [the tool] as a part of the routine tasks (…).” (Nurse 4).

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 flow (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 insufficient 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 identified are similar across EDs in different geographical contexts. Based on these preliminary findings 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.

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 flow, 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.

PCC

Patient-centered care

Emergency department

Ethics approval and consent to participate: The Danish Data Protection Agency approved the study (journal number P-2019-823) performed in compliance with the Declaration of Helsinki and the General Data Protection Regulation. According to the Danish national research guidelines, no ethical review is needed for studies not involving biological material (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.

Competing interests: The authors declare that they have no competing interests.

Funding: This study was funded by the Strategic Research Fund, Amager and Hvidovre Hospital. The research in Center for Healthy Aging is supported by Nordea-Fonden. The funders had no role in the study design, data collection, analysis, and interpretation of data, or preparation of the manuscript.

Authors’ contributions: ANJ and MK designed the study. ANJ carried out the data collection and analysis. ANJ and MK drafted the manuscript. All authors contributed with critical feedback to drafts and read and approved the final manuscript.

Acknowledgments: The authors would like to thank all participants involved in the research and Leyden Academy on Vitality and Ageing for kindly providing the innovative user-engagement conversation tool and the researchers who developed the tool. This study was performed as a part of the Acute-CAG (Recovery Capacity After Acute Illness in an Aging Population (RECAP) nominated by Greater Copenhagen Health Science Partners (GCHSP).

Author’s information: The authors represent a multi-professional background (medicine, nursing, public health, and health services).

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

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