Sammenhæng i ældre kroniske syges patientforløb - idealer og realiteter. Et aktionsforskningsprojekt

Title: Continuity in care trajectories of older chronically ill patients – ideals and realities. An action research project. 

Project focus:
The focus of the PhD project is care trajectories of older chronically ill patients. Key areas are the nursing staff’s communication in relation to continuity and integration of the patient perspective in older, chronically ill patients’ care trajectories.

Background:
The number of older chronically ill patients worldwide and nationally is markedly increasing. In order to ensure these patients optimal trajectories research has shown that health professional communication is crucial to ensuring continuity in care trajectories. Studies have shown, however, that a number of problems with health professionals’ communication concerning older chronically ill patients exist, which for instance has become apparent in the lack of continuity and integration of the patient perspective in care trajectories. Further studies of the problem field are therefore required. 

The objective of the thesis:
The objective of the thesis is to study the conditions for continuity in patient care trajectories for older chronically ill patients in an acute medical ward, and implement actions in clinical practice according to ensuring continuity in care trajectories.

The research questions of the thesis are:
1. How are continuity and integration expressed in the nursing staff’s communication?
2. Can action research contribute to better continuity in patient care trajectories? 

Material and methods:
The project was a qualitative action research project. Action research was chosen as design with the aim of founding both problem identification and quality development on clinical practice, and with the aim of implementing the obtained knowledge during the process in nursing practice for the benefit of patients as well as nursing staff. 

The applied methods were field observations, interviews, audits of medical records and log book recordings in relation to the nursing staff’s communication about care trajectories of older chronically ill patients, both internally in a medical hospital ward and across sectors. The study was carried out in an acute general medical ward at a university hospital in Denmark. The participants were nursing staff employed at the ward and coordinating nurses from three of the municipalities in the hospital’s catchment area (n=29). Data underwent qualitative content analysis, both on a manifest and latent level. 

Results:
The staff knew how to ensure continuity in the care trajectories in an overall perspective, and they knew that action research as a design required their active participation, but they stated that they had neither the time to ensure this continuity nor the time to participate in the research process. They stated, that it was their leaders who were in charge of their time and thus also of what tasks they should attend to, as well as how the tasks should be solved. 

The themes “knowing-doing gap”, time and management thus seemed to be of vital importance to the nursing staff’s prioritization of tasks and their handling of them.

Conclusion and perspective:
The project results provide new knowledge about conditions and prerequisites for continuity of patient care trajectories, generally and specifically in relation to care trajectories of older chronically ill patients. The process results provide new knowledge about conditions and prerequisites for being able to implement and carry out action research in a medical hospital ward. In order to support continuity in an overall perspective it is necessary to change both the organizational frames and management’s and nursing staff’s attitudes to their clinical practice. This study can therefore open up a dialogue both among health professionals and politicians about ways to improve continuity in care trajectories of older, chronically ill patients in clinical everyday life, where integration of the patient perspective plays a central role.
Furthermore, the study also opens up for discussions in relation to what framework and conditions should be present in a given context, in order for action research to be successfully carried out. 
This study was carried out in a hospital ward in Denmark. It could therefore be of interest to conduct studies of continuity of patient trajectories in other contexts with a view to achieving a more many-facetted view of the problem field.