Towards patient‐centred communication in the management of older patients' medications across transitions of care: A focused ethnographic study

Transitional medication management, in which individual needs are balanced against organizational priorities, is crucial for safe discharge processes. The aim of this study was to explore hospital nurses’ transitional medication management in the discharge of older patients with multi-morbidity. Using an ethnographic approach the data were collected through participant observations at a mixed medical ward at a Danish university hospital for two weeks. The participants were five registered nurses, responsible for nursing care of 23 patients with multi-morbidity and planned for discharge. The data comprised field notes that were analysed using iterative processes of domain, taxonomic and component analysis. The reporting adhered to the COREQ checklist. Hospital nurses’ transitional medication management was characterized by unpredictability and inconsistency in patient situations, fragmentation and discontinuity in working processes and complexity in communication systems. Special attention to nurses’ needs assessment skills and clinical decision making in caring for patients with multi-morbidity in a single focused healthcare system is required.

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Successful care transitions for older people: a systematic review and meta-analysis of the effects of interventions that support medication continuity

Age and Ageing ◽

10.1093/ageing/afaa002 ◽

2020 ◽

Vol 49 (4) ◽

pp. 558-569 ◽

Cited By ~ 3

Author(s):

Justine Tomlinson ◽

V-Lin Cheong ◽

Beth Fylan ◽

Jonathan Silcock ◽

Heather Smith ◽

...

Keyword(s):

Hospital Readmission ◽

Older Patients ◽

Medication Reconciliation ◽

Meta Analysis ◽

Hospital Readmissions ◽

Transitions Of Care ◽

Self Management ◽

Multiple Time ◽

Post Discharge

Abstract Background medication-related problems occur frequently when older patients are discharged from hospital. Interventions to support medication use have been developed; however, their effectiveness in older populations are unknown. This review evaluates interventions that support successful transitions of care through enhanced medication continuity. Methods a database search for randomised controlled trials was conducted. Selection criteria included mean participant age of 65 years and older, intervention delivered during hospital stay or following recent discharge and including activities that support medication continuity. Primary outcome of interest was hospital readmission. Secondary outcomes related to the safe use of medication and quality of life. Outcomes were pooled by random-effects meta-analysis where possible. Results twenty-four studies (total participants = 17,664) describing activities delivered at multiple time points were included. Interventions that bridged the transition for up to 90 days were more likely to support successful transitions. The meta-analysis, stratified by intervention component, demonstrated that self-management activities (RR 0.81 [0.74, 0.89]), telephone follow-up (RR 0.84 [0.73, 0.97]) and medication reconciliation (RR 0.88 [0.81, 0.96]) were statistically associated with reduced hospital readmissions. Conclusion our results suggest that interventions that best support older patients’ medication continuity are those that bridge transitions; these also have the greatest impact on reducing hospital readmission. Interventions that included self-management, telephone follow-up and medication reconciliation activities were most likely to be effective; however, further research needs to identify how to meaningfully engage with patients and caregivers to best support post-discharge medication continuity. Limitations included high subjectivity of intervention coding, study heterogeneity and resource restrictions.

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The challenge of involving old patients with polypharmacy in their medication during hospitalization in a medical emergency department: An ethnographic study

PLoS ONE ◽

10.1371/journal.pone.0261525 ◽

2021 ◽

Vol 16 (12) ◽

pp. e0261525

Author(s):

Pia Keinicke Fabricius ◽

Ove Andersen ◽

Karina Dahl Steffensen ◽

Jeanette Wassar Kirk

Keyword(s):

Older Patients ◽

Patient Involvement ◽

Healthcare Professionals ◽

Structured Interview ◽

Ethnographic Study ◽

Boundary Object ◽

Medical Emergency ◽

Structured Interviews ◽

Old Patients ◽

It Systems

Background More than 70% of patients admitted to emergency departments (EDs) in Denmark are older patients with multimorbidity and polypharmacy vulnerable to adverse events and poor outcomes. Research suggests that patient involvement and shared decision-making (SDM) could optimize the treatment of older patients with polypharmacy. The patients become more aware of potential outcomes and, therefore, often tend to choose less medication. However, implementing SDM in clinical practice is challenging if it does not fit into existing workflows and healthcare systems. Aim The aim was to explore the determinants of patient involvement in decisions made in the ED about the patient’s medication. Methods The design was a qualitative ethnographic study. We observed forty-eight multidisciplinary healthcare professionals in two medical EDs focusing on medication processes and patient involvement in medication. Based on field notes, we developed a semi-structured interview guide. We conducted 20 semi-structured interviews with healthcare professionals to elaborate on the findings. Data were analyzed with thematic analyses. Findings We found five themes (determinants) which affected patient involvement in decisions about medicine in the ED: 1) blurred roles among multidisciplinary healthcare professionals, 2) older patients with polypharmacy increase complexity, 3) time pressure, 4) faulty IT- systems, and 5) the medicine list as a missed enabler of patient involvement. Conclusion There are several barriers to patient involvement in decisions about medicine in the ED and some facilitators. A tailored medication conversation guide based on the SDM methodology combined with the patient’s printed medicine list and well-functioning IT- systems can function as a boundary object, ensuring the treatment is optimized and aligned with the patient’s preferences and goals.

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Knowledge and Power Relations in Older Patients’ Communication About Medications Across Transitions of Care

Qualitative Health Research ◽

10.1177/10497323211043494 ◽

2021 ◽

pp. 104973232110434

Author(s):

Guncag Ozavci ◽

Tracey Bucknall ◽

Robyn Woodward-Kron ◽

Carmel Hughes ◽

Christine Jorm ◽

...

Keyword(s):

Critical Discourse Analysis ◽

Health Professionals ◽

Older Patients ◽

Power Relations ◽

Family Members ◽

Analysis Data ◽

Transitions Of Care ◽

Communication Model ◽

Medication Knowledge ◽

Communication Processes

Communicating about medications across transitions of care is a challenging process for older patients. In this article, we examined communication processes between older patients, family members, and health professionals about managing medications across transitions of care, focusing on older patients’ experiences. A focused ethnographic design was employed across two metropolitan hospitals. Data collection methods included interviews, observations, and focus groups. Following thematic analysis, data were analyzed using Fairclough’s Critical Discourse Analysis and Medication Communication Model. Older patients’ medication knowledge and family members’ advocacy challenged unequal power relations between clinicians and patients and families. Doctors’ use of authoritative discourse impeded older patients’ participation in the medication communication. Older patients perceived that nurses’ involvement in medication communication was limited due to their task-related routines. To reduce the unequal power relations, health professionals should be more proactive in sharing information about medications with older patients across transitions of care.

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Family involvement in managing medications of older patients across transitions of care: a systematic review

BMC Geriatrics ◽

10.1186/s12877-019-1102-6 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 10

Author(s):

Elizabeth Manias ◽

Tracey Bucknall ◽

Carmel Hughes ◽

Christine Jorm ◽

Robyn Woodward-Kron

Keyword(s):

Systematic Review ◽

Family Involvement ◽

Older Patients ◽

Transitions Of Care

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A systematic review of older patients’ experiences and perceptions of communication about managing medication across transitions of care

Research in Social and Administrative Pharmacy ◽

10.1016/j.sapharm.2020.03.023 ◽

2021 ◽

Vol 17 (2) ◽

pp. 273-291 ◽

Cited By ~ 2

Author(s):

Guncag Ozavci ◽

Tracey Bucknall ◽

Robyn Woodward-Kron ◽

Carmel Hughes ◽

Christine Jorm ◽

...

Keyword(s):

Systematic Review ◽

Older Patients ◽

Transitions Of Care

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Do Not Resuscitate orders and older patients: findings from an ethnographic study of hospital wards for older people

Journal of Advanced Nursing ◽

10.1046/j.1365-2648.2002.02314.x ◽

2002 ◽

Vol 39 (5) ◽

pp. 491-499 ◽

Cited By ~ 11

Author(s):

John Costello

Keyword(s):

Older People ◽

Older Patients ◽

Ethnographic Study ◽

Do Not Resuscitate ◽

Do Not Resuscitate Orders ◽

Hospital Wards

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Geriatric patients in the emergency department

Oxford Textbook of Geriatric Medicine ◽

10.1093/med/9780198701590.003.0032 ◽

2017 ◽

pp. 229-236

Author(s):

Don Melady ◽

Barry J. Goldlist

Keyword(s):

Emergency Department ◽

Quality Improvement ◽

Older Patients ◽

Current System ◽

Transitions Of Care ◽

Education Policies ◽

Essential Components ◽

Life Issues ◽

End Of Life Issues ◽

Atypical Presentations

This chapter addresses strategies for closing the ‘quality gap’ between the needs of complex older patients presenting to an emergency department (ED) and what current EDs mostly provide. It reviews historical reasons that the current system often fails to address the multiple and multifactorial needs of an older person in the ED. It explores domains of care—complex and atypical presentations, an awareness of polymorbidity, polypharmacy, falls, cognitive impairment, and end-of-life issues—that are specific to the older ED patient. It suggests opportunities for quality improvement in the essential components of a senior-friendly ED, summarizing some of the changes to staffing, education, policies, procedures, and physical design that prioritize the needs of older patients. It identifies the importance of the ED’s role in the continuum of care and opportunities for improving transitions of care involving the ED.

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Manoeuvring between interplay and context- an ethnographic study of social interaction in encounters between registered nurses, older patients and their relatives

BMC Nursing ◽

10.1186/s12912-021-00754-5 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Anette Johnsson ◽

Åse Boman ◽

Petra Wagman ◽

Sandra Pennbrant

Keyword(s):

Social Interaction ◽

Registered Nurses ◽

Social Interactions ◽

Older Patients ◽

Social Situation ◽

Well Being ◽

Ethnographic Study ◽

Care Relationship ◽

The Social ◽

The Moment

Abstract Background Social interactions between registered nurses, older patients and their relatives are essential and play a central role in developing a successful care relationship in healthcare encounters. How nurses interact with patients affects the patient’s well-being. Limited time and demands for efficiency influence the encounter and complaints from patients and relatives often concern social interactions. Therefore, the aim of this study was to explore the social interaction in encounters between registered nurses, older patients and their relatives at a department of medicine for older people. Methods The study has an ethnographic approach including participatory observations (n = 21) and informal field conversations (n = 63), followed by a thematic analysis with an abductive approach reflecting Goffman’s interactional perspective. Result The result revealed a pattern where the participants manoeuvred between interplay and context. By manoeuvring, they defined roles but also created a common social situation. Nurses led the conversation; patients followed and described their health problems, while relatives captured the moment to receive and provide information. Finally, nurses summarised the encounter using ritual language, patients expressed gratitude through verbal and non-verbal expressions, while relatives verbally confirmed the agreements. Conclusion The social interaction between registered nurses, older patients and relatives was shaped by a pattern where the participants manoeuvred between interplay and context. When all participants assume responsibility for the social interaction, they become active and listen to each other. The approach adopted by nurses is crucial, thus training in communication and social interaction skills are important. When the asymmetry due to imbalance, is reduced, less misunderstanding and a satisfactory care relationship can be achieved.

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Aging and Autism

Perspectives on Gerontology ◽

10.1044/gero17.2.69 ◽

2012 ◽

Vol 17 (2) ◽

pp. 69-75 ◽

Cited By ~ 1

Author(s):

Pamela A. Smith

Keyword(s):

Health Care ◽

Autism Spectrum Disorders ◽

Patient Group ◽

Older Patients ◽

Geriatric Patients ◽

Recent Literature ◽

Communication Disorders ◽

Autism Spectrum ◽

Need For Support ◽

Spectrum Disorders

In this article, I will review the available recent literature about the aging population with autism, a patient group that researchers know little about and a group that is experiencing a growing need for support from communication disorders professionals. Speech-language pathologists working with geriatric patients should become familiar with this issue, as the numbers of older patients with autism spectrum disorders is likely to increase. Our profession and our health care system must prepare to meet the challenge these patients and residents will present as they age.

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