Lindblom Sebastian, Ytterberg Charlotte, Elf Marie, Flink Maria
Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, SE.
Function Area Occupational Therapy and Physiotherapy, Allied Health Professionals, Karolinska University Hospital, Stockholm, SE.
Int J Integr Care. 2020 Mar 25;20(1):11. doi: 10.5334/ijic.4689.
Care transitions are a complex set of actions that risk poor quality outcomes for patients and their significant others. This study explored the transition process between hospital and continued rehabilitation in the home. The process is explored from the perspectives of people with stroke, significant others and healthcare professionals in Stockholm, Sweden.
Focus group interviews (n = 10), semi-structured individual interviews (n = 23) and interviews in dyad (n = 4) were conducted with healthcare professionals, people with stroke and significant others, altogether 71 participants. Data was collected and analyzed using Grounded Theory.
One core category and emerged from the analysis. The transition consisted of several parallel processes which made it difficult for the stakeholders to get a common understanding of the transition as a whole. Enabling a perceptive dialogue was as a prerequisite for the creation of a common understanding of the care transition.
This study elucidates that a perceptive dialogue with patients/significant others as well as within and across organizations is part of a coordinated and person-centred transition. There is an extensive need for increased involvement of patients and significant others regarding dialogue about health conditions, procedures at the hospital and preparation for self-management after discharge.
护理过渡是一系列复杂的行为，可能会给患者及其重要他人带来质量不佳的后果。本研究探讨了从医院到家庭持续康复的过渡过程。该过程从瑞典斯德哥尔摩的中风患者、重要他人和医疗保健专业人员的角度进行了探讨。
对医疗保健专业人员、中风患者和重要他人进行了焦点小组访谈（n = 10）、半结构化个人访谈（n = 23）和双人访谈（n = 4），共有71名参与者。使用扎根理论收集和分析数据。
分析得出一个核心类别。过渡由几个并行过程组成，这使得利益相关者难以对整个过渡形成共同的理解。进行有洞察力的对话是对护理过渡形成共同理解的先决条件。
本研究阐明，与患者/重要他人以及组织内部和组织之间进行有洞察力的对话是协调的、以患者为中心的过渡的一部分。在关于健康状况、医院程序和出院后自我管理准备的对话中，患者和重要他人的参与度有广泛的提升需求。
