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A Study to Explore the Barriers and Facilitators

Introduction

The delivery of quality healthcare depends on how the care is patient-centered (PCC) (Winefield et al, 1996). Consequently, researchers and practitioners in the field of medicine have endorsed PCC as an essential element of practice which ensures quality delivery of care by giving attention to patients’ needs, values, and preferences and desires (Garvey et al, 2016). Whereas different scholars define PCC differently depending on the context within which they intend to use the term, most studies focus on the idea of identifying and responding to the patients’ desires, values and needs; involving the patients and their family members in decision-making regarding the care, creating an atmosphere of shared knowledge and educating the patient of various aspects of their care (Groves, 2016). In this context, Liang et al (2019) came up with three significant characteristics of PCC, namely putting the patients’ needs first, acknowledging that the care is never in the patient’s interest if they are not involved in the decision-making process, and customizing the care to the individual patient’s needs.

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Patient-centered care is especially important in critical situations such as when the patient is discharged from the hospital. With the growing interest in shorter hospital stay, more emphasis is put on post-discharge care, as well as the important role played with community caregivers and family members in coordinating patient post-discharge care (Hakansson et al, 2019). In most cases, patients and their families are the links between the hospital and community caregivers (Kogan et al, 2016). Therefore, family members, apart from the community caregivers, require the necessary skills and ability to continue with caring for the patients. Based on the assertions by (Schottenfield et al, 2016), this is especially true when the patients suffer from mental illnesses such as dementia that interferes with their cognition abilities. Moreover, according to Sanger et al (2016) and Narva et al (2016), dementia patients discharged from the hospitals are mostly in the state of anxiety, may have a cognitive impairment, or maybe under the influence of medication side effects. Besides, the discharge process may be a challenging affair because family and other relatives may not be ready to take care of the patient at home especially because of the difficult financial and emotional decisions that they may have to make in the process.

Despite an increasing interest in patient-centeredness, patients are sometimes being discharged before being ready to face the care demands that come along with the discharge (Smith, 2018). In a study by Ross (2019) on patients with complex needs, the researchers found that one out of four patients did not receive clear medication instruction; neither did they adhere to the given instructions post-discharge. Other studies by Milling et al (2017) and Acher et al (2017) indicate that patients and their family members develop a sense of abandonment and anxiety after discharge. Yet, the unpreparedness for discharge, together with misunderstanding and anxiety over their situation during discharge increases the chances of adverse events and hospital readmission, especially in the case with the elderly with chronic illnesses such as dementia, which require a proper transition between home and hospital care (Hakansson et al, 2019).

Little is known about patient-centered care during hospital discharge, or whether the availability or community and family caregivers can lead to a successful discharge by ensuring that the patient receives post-discharge care. Identifying such barriers and facilitators of patient-centered care port-discharge can enable the development of effective discharge processes and promote shorter hospital stay. Moreover, the development of effective discharge processes can help in reducing patient anxiety while avoiding costly hospital readmissions.

The Aim of the Study

The main aim of the proposed study is to explore the barriers and facilitators of PCC during the discharge process. The study will evaluate the experiences and perceptions of caregivers about the discharge process, identifying some of the factors that make them agree or decline to discharge dementia patients from hospital care.

Research Objectives

To identify the barriers and facilitators of PCC during the discharge process of dementia patients

To identify whether the availability of community care can facilitate faster discharge of dementia patients

To identify whether the availability of family care can facilitate faster discharge or dementia patients

Literature Review

The availability of professional support provides an opportunity for patients to actively participate in their care (Makoul & Clayman, 2006), from which they benefit by acquiring quality care. However, whereas the concept of PCC has seen a huge development in the recent past, little action has been taken to enhance PCC in various care settings and situations (Frosch et al, 2012). Particularly, the development of PCC in hospital care settings has been curtailed by the availability of cultural barriers, and therefore eliminating these barriers require patients, their families and healthcare professionals to feel engaged and treated as equal stakeholders (Gravel et al, 2006).

Hakansson et al, (2019) argue that patients can only be discharged when there is enough evidence that they will receive a continuity of care from families and community caregivers post-discharge. This implies that the discharging practitioner must ascertain that both the community caregivers and the family will maintain the level of person-centeredness when the patient is discharged, otherwise the patient might be readmitted soon as a result of poor care (Ross, 2019).

Existing literature and practice guidelines have documented some of the reason why it is important to ascertain that dementia patients will receive patient-centered care from families and community caregivers after discharge. For instance, Alzheimer Society (2011) recommends that dementia patients need interactions that promote personhood and respectful relationships that are characterized by proactive interventions. Furthermore, family members and community caregivers must be able to maintain, support or restore the dementia patient’s independence (Hakansson et al, 2019). Therefore, the inability of families and community caregivers to adhere to these elements of PCC acts as a barrier to the discharge process because the patient would not have a positive care experience without these elements post-discharge.

Research methodology

Research Design

The researcher will conduct a qualitative study of dementia patient discharge in two hospitals together with their respective community care settings. There are several theoretical underpinnings for the selection of qualitative research design for the proposed study. First, qualitative research design allows for an examination of subjective human experience using non-statistical methods of data analysis (Hennink et al, 2020). The main aim of the proposed study is to explore the barriers and facilitators PCC in the hospital discharge process. This can be associated with a naturalistic enquiry (Glesne, 2016) where the complex experiences of the dementia patients are explored. Therefore, taking the qualitative research design will allow for an exploration of the patients’ holistic pathway, enabling the development of theories regarding what hinders or facilitates PCC among dementia patients during the discharge process. More importantly, the qualitative research design is considered appropriate for the proposed study because it maintains the focus on the experiences and perceptions of families and health professionals involved in dementia patients’ discharge process. Therefore this approach will not require any oversimplification of the reality of the perceptions and experiences of the target population.

Data Collection

While the study targets 80-year-old dementia patients, it will collect data through individual interviews with family and community caregivers of those patients considering that the patients will be too old to engage in a meaningful interview. Therefore, interviews will be conducted with family members and community caregivers of 80-year-old patients recently discharged from hospital into either nursing homes or their homes. Furthermore, interview data will be collected from nurses, general practitioners and physicians involved with the patients before discharge. Meanwhile, the researcher will approach patients who are capable of engaging in an interview before discharge, and the interviews will be conducted within 2-3 weeks before and after discharge. All the interviews will e recorded and transcribed verbatim for analysis.

Data Analysis

The researcher will use thematic analysis and grounded theory to analyse the transcribed data. The grounded theory is a qualitative data analysis approach that relies on identifying concepts emerging from interview and observation data (Lune & Berg, 2016). Fundamentally, according to Quinlan et al (2019), thematic analysis is a data analysis approach useful when the researcher intends to explore something regarding the respondents’ views, experiences, opinions, values or perceptions. In doing so, the researcher will take a deductive approach, whereby the researcher will begin the study with some preconceived themes that are expected to be realised based on existing knowledge. Meanwhile, the thematic analysis process will begin with data familiarization, where the researcher will read through the transcripts to better understand the data. The process will then move to the coding step, which involves highlighting sections of the texts to identify words and sentences that give explicit information useful in answering the research questions (Tracy, 2019).

Ethical Considerations

Being a study that involves human participants, the researcher will make several ethical considerations to maintain the integrity and validity of the study. For instance, the researcher will respect the confidentiality and anonymity of the participants by not mentioning their names or any other personal identification information within the study. Besides, all the participants will be required to fill and sign an informed consent form to ensure that they participate voluntarily.

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References

Alzheimer Society 2011. Person-centered care for people with dementia living in care homes, Framework.

Acher, A.W., Campbell-Flohr, S.A., Brenny-Fitzpatrick, M., Leahy-Gross, K.M., Fernandes-Taylor, S., Fisher, A.V., Agarwal, S., Kind, A.J., Greenberg, C.C., Carayon, P. and Weber, S.M., 2017. Improving patient-centered transitional care after complex abdominal surgery. Journal of the American College of Surgeons, 225(2), pp.259-265.

Bresler, L. and Stake, R.E., 2017. Qualitative research methodology in music education. In Critical Essays in Music Education (pp. 113-128). Routledge.

Frosch L, May G, Rendle KA, et al. 2012. Authoritarian physicians and patients' fear of being labeled 'difficult' among key obstacles to shared decision making. Health Aff;31:1030–8. 10.1377/hlthaff.2011.0576

Garvey, W.T., Hurley, D.L. and Kushner, R.F., 2016. Patient-Centered care of the patient with obesity. Endocrine Practice, 22, p.9.

Groves, J., 2016. Person-Centered Patient Perspectives. In Person Centered Psychiatry (pp. 113-125). Springer, Cham.

Glesne, C., 2016. Becoming qualitative researchers: An introduction. Pearson. One Lake Street, Upper Saddle River, New Jersey 07458.

Hennink, M., Hutter, I. and Bailey, A., 2020. Qualitative research methods. SAGE Publications Limited.

Håkansson, J.E., Holmström, I.K., Kumlin, T., Kaminsky, E., Skoglund, K., Höglander, J., Sundler, A.J., Conden, E. and Summer, M.M., 2019. " Same same or different?" A review of reviews of person-centered and patient-centered care. Patient education and counseling, 102(1), pp.3-11.

Kogan, A.C., Wilber, K. and Mosqueda, L., 2016. Person‐centered care for older adults with chronic conditions and functional impairment: A systematic literature review. Journal of the American Geriatrics Society, 64(1), pp.e1-e7.

Liang, H., Tao, L., Ford, E.W., Beydoun, M.A. and Eid, S.M., 2019. The patient-centered oncology care on health care utilization and cost: A systematic review and meta-analysis. Health care management review.

Milling, T.J., Feronti, C., Clark, C.L., Fermann, G.J., Song, S.S., Torbati, S.S., Weiss, J., Patel, D. and Neuman, W.R., 2017. Treatment Patterns and Outcomes of Patients Receiving Direct Oral Anticoagulants or Low Molecular Weight Heparin who Experienced Life-threatening Intracranial Hemorrhage (P5. 053).

Makoul G, Clayman L. 2006. An integrative model of shared decision making in medical encounters. Patient Educ Couns;60:301–12. 10.1016/j.pec.2005.06.010

Narva, A.S., Norton, J.M. and Boulware, L.E., 2016. Educating patients about CKD: the path to self-management and patient-centered care. Clinical Journal of the American Society of Nephrology, 11(4), pp.694-703.

Quinlan, C., Babin, B., Carr, J. and Griffin, M., 2019. Business research methods. South Western Cengage.

Ross, L.F., 2019. Engaging family stakeholders in post-discharge NICU missions. The Journal of pediatrics, 207, p.2.

Schottenfeld, L., Petersen, D., Peikes, D., Ricciardi, R., Burak, H., McNellis, R. and Genevro, J., 2016. Creating patient-centered team-based primary care. Rockville: Agency for Healthcare Research and Quality.

Sanger, P.C., Hartzler, A., Lordon, R.J., Armstrong, C.A., Lober, W.B., Evans, H.L. and Pratt, W., 2016. A patient-centered system in a provider-centered world: challenges of incorporating post-discharge wound data into practice. Journal of the American Medical Informatics Association, 23(3), pp.514-525.

Smith, C., 2018. Patients’ Perceptions of Patient-Centered Care and the Hospital Experience Pre-and Post-Discharge.

Lune, H. and Berg, B.L., 2016. Qualitative research methods for the social sciences. Pearson Higher Ed.

Tracy, S.J., 2019. Qualitative research methods: Collecting evidence, crafting analysis, communicating impact. John Wiley & Sons.

Winefield H, Murrell T, Clifford J, et al 1996. The search for reliable and valid measures of patientcentredness. Psychol Health;11:811–24.

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