1 University Health Care Research Centre, Region Örebro County and School of Medical Sciences, Örebro University, Sweden.
2 Academy of Sahlgrenska, Institute of Medicine, University of Gothenburg, Sweden.
Scand J Public Health. 2018 Nov;46(7):680-689. doi: 10.1177/1403494817716001. Epub 2017 Jul 12.
Frail elderly patients who have multiple illnesses do not fare well in modern health care systems, mainly due to a lack of care planning and flawed communication between health professionals in different care organisations. This is especially noticeable when patients are discharged from hospital. The aim of this study was to explore health care professionals' experience of obstacles and opportunities for collaboration.
Health professionals were invited to participate in three focus groups, each consisting of a hospital physician, a primary care physician, a hospital nurse, a primary care nurse, a municipal home care nurse or an assistant officer, a physical or occupational therapist and a patient or a family member representative. These individual people were then asked to discuss the obstacles and opportunities for communication between themselves and with the patients and their relatives when presented with the case report of a fictitious patient. Content analysis was used to identify categories.
Several obstacles were identified for effective communication and care planning: insufficient communication with patients and relatives; delayed collaboration between care-givers; the lack of an adequate responsible person for care planning; and resources not being distributed according to the actual needs of patients. The absence of an overarching responsibility for the patient, beyond organisational borders, was a recurring theme. These obstacles could also be seen as opportunities.
Obstacles for collaboration were found on three levels: societal, organisational and individual. As health care professionals are well aware of the problems and also see solutions, management for health care should support employees' own initiatives for changes that are of benefit in the care of frail elderly patients with multiple illnesses.
患有多种疾病的体弱老年患者在现代医疗保健系统中表现不佳，主要是由于缺乏护理计划以及不同护理机构的卫生专业人员之间沟通不畅。当患者从医院出院时，这种情况尤其明显。本研究旨在探讨卫生保健专业人员在协作方面面临的障碍和机遇。
邀请卫生保健专业人员参加三个焦点小组，每组由一名医院医生、一名初级保健医生、一名医院护士、一名初级保健护士、一名市家庭护理护士或助理官员、一名物理治疗师或职业治疗师以及一名患者或患者家属代表组成。然后，要求这些个人根据虚构患者的病例报告，讨论他们之间以及与患者及其家属进行沟通的障碍和机遇。采用内容分析法来识别类别。
确定了一些有效的沟通和护理计划障碍：与患者和家属沟通不足；护理人员之间协作延迟；缺乏负责护理计划的合适人员；资源分配不符合患者的实际需求。超越组织边界对患者缺乏全面的责任，这是一个反复出现的主题。这些障碍也可以被视为机遇。
协作障碍存在于三个层面：社会、组织和个人。由于卫生保健专业人员非常清楚这些问题，并且也看到了解决方案，因此医疗保健管理部门应该支持员工为改善患有多种疾病的体弱老年患者的护理而采取的有益的主动行动。
