Faculdade de Medicina de São José do Rio Preto, Programa de Pós-graduação em Enfermagem, São José do Rio Preto, SP, Brazil.
Pontifícia Universidade Católica de Campinas, Programa de Pós-graduação, Campinas, SP, Brazil.
Rev Esc Enferm USP. 2021 Sep 17;55:e20210145. doi: 10.1590/1980-220X-REEUSP-2021-0145. eCollection 2021.
To analyze how the articulation between hospital and primary health care related to patient discharge and continuity of care after hospitalization takes place.
Qualitative study, using the focus group technique to explore the experience of 21 nurses in hospitals (n = 10) and at primary care (n = 11) in a municipality in the northwest area of the State of São Paulo. Data collection took place between December 2019 and April 2020. Four focus groups were carried out (two in the hospital and two in the health units) and the findings underwent thematic analysis.
The categories identified were: Patient inclusion flow in the responsible discharge planning, Patient/family member/caregiver participation, Care planning, Communication between services, and Challenges in the discharge process. According to reports, the discharge process is centered on bureaucratic aspects with gaps in communication and coordination of care.
This research allowed understanding how nurses from different points of health care experience the discharge and (dis)articulation of the team work. The findings can equip managers in the (re)agreement of practices and integration of services to promote continuity of care.
分析医院和初级卫生保健之间在患者出院和住院后护理连续性方面的衔接情况。
这是一项定性研究，采用焦点小组技术，探索了来自圣保罗州西北部一个市的 21 名护士在医院（n=10）和初级保健（n=11）的经验。数据收集于 2019 年 12 月至 2020 年 4 月之间进行。共进行了 4 次焦点小组（医院 2 次，卫生单位 2 次），并对研究结果进行了主题分析。
确定的类别包括：负责出院计划的患者纳入流程、患者/家属/照顾者的参与、护理计划、服务之间的沟通以及出院过程中的挑战。据报告，出院过程以官僚主义为中心，存在沟通和护理协调方面的差距。
这项研究使我们能够了解来自不同医疗保健点的护士在出院和（不）团队协作方面的体验。研究结果可以为管理者提供实践协议和服务整合的依据，以促进护理的连续性。
