| 1. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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In pursuit of integrated care : Interprofessional collaboration in transitional care for older people with complex care needs
- 2023
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Ingår i: Presented at the Nordic Conference in Nursing Research, Reykjavik, Iceland, October 2-4, 2023.
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Konferensbidrag (refereegranskat)abstract
- Background:Contemporary healthcare systems are based on a reductionist, biomedical paradigm maladapted to meet the needs of an aging population with multimorbidity. Integrated care and interprofessional collaboration are suggested to connect the different parts of healthcare. However, how this can be realised is less understood.The aim of the study was to develop a deeper understanding of how interprofessional collaboration across care providers in transitional care is conducted to achieve integrated care for older people with complex care needs.Method:Using constructivist grounded theory, observations and interviews were conducted with healthcare and social care professionals (n=86) from a multidisciplinary and cross-stakeholder perspective in a region in Sweden.Results:Interprofessional collaboration in transitional care emerges as a continuum of "Moving from fragmentation to coupling and integration through collaborative efforts". On the lowest level of integration, professionals are working in organisational “silos” that are difficult to cross, as each specialist's expert knowledge is necessary for the vulnerable patient´s wellbeing. Patients´ perception of seamless care is facilitated by the mutual sharing of patient data across organizations through integrated information systems. The highest level of integration is consolidated as the interprofessional team collaborates on a pronounced common ground with a shared mental map of the goals of care, constructing unity for the older person and their family.Conclusion:To achieve seamless transitional care for older people with complex care needs, clear boundaries and liability areas are necessary, and actors in interprofessional teams are required to assume responsibility across conceivable gaps across organizations.
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| 2. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Interlacing the threads of seamless care : Interprofessional collaboration in care transitions for older people with complex care needs
- 2022
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Ingår i: International Journal of Integrated Care. - : Ubiquity Press. ; , s. 360-360
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Konferensbidrag (refereegranskat)abstract
- Introduction: Current healthcare systems are not optimally designed to meet the needs of aging populations. With shorter hospital stays, fewer hospital beds, and fragmentation of the healthcare system, older people with complex care needs are recognised as particularly vulnerable. This development further increases the demands on older people and their family to assume responsibility of own health, and to navigate through the healthcare system, knowing of when and where to seek help. In care transitions, an interprofessional collaboration across care providers is considered as a path to deliver seamless care. Still, it seems hard to achieve.Aim and Method: The aim of the study is to explore interprofessional collaboration in care transitions from inpatient care to home healthcare for older people with complex care needs.Care transitions involve a variety of healthcare teams across stakeholder boundaries. Hence, to study this extensive process, an explorative qualitative methodology was chosen, using Constructivist Grounded Theory. The sampling approach was guided by the continuous analysis of the collected data, utilizing a theoretical sampling. Fifty-nine multidisciplinary healthcare and social care professionals (HSCP) from different stakeholders were recruited. Document analysis, participatory observations and semi-structured interviews were conducted and analysed according to Charmaz.Results: Collaborating for a comprehensive care of older people with complex care needs emerges as interlacing the different threads of care to construct seamless care. Organizational gaps and legislations divide the HSCP as they strive to perform safe care within system boundaries, limited by interdependencies and communication organized in silos. Care is integrated as HSCP assumes accountability by going above and beyond their responsibility, constructing unity for the older person and their family. Seamless care is facilitated when information systems are integrated and by mutual sharing of patient data across organizations. To achieve seamless care for older people with complex care needs, HSCP need to adapt the delivery of care to the older person’s needs and resources instead of performing care as per organizational boundaries and conditions. Further, the autonomy of older people and their families need to be strengthened, including them as partners in the collaboration and coordination of care.Conclusions: Care efforts for older people with complex care needs are visualized as threads that together create a comprehensive care. To weave the threads together, a collaborative effort is required, strengthening the autonomy of the older person and their family, supported by integrated information systems that coordinate the care seamlessly.Implications and limitations: This study contributes to the understanding of interprofessional collaboration in care transitions of older people with complex care needs. Key strengths include the rich data and multidisciplinary perspective on providing integrated care. Limitations concern the absence of patient, family and informal caregivers’ involvement which should be included in further studies.
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| 3. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Nurses' experiences of person-centred care planning using video-conferencing.
- 2023
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Ingår i: Nursing Open. - : Wiley-Blackwell Publishing Inc.. - 2054-1058. ; :3, s. 1163-1937
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Tidskriftsartikel (refereegranskat)abstract
- AIM: The aim was to illuminate how nurses experience person-centred care planning using video conferencing upon hospital discharge of frail older persons.DESIGN: Care planning via video conferencing requires collaboration, communication and information transfer between involved parties, both with regard to preparing and conducting meetings. Participation of involved parties is required to achieve a collaborative effort, but the responsibilities and roles of the involved professions are unclear, despite the existence of regulations.METHOD: A qualitative content analysis was conducted based on 11 individual semi-structured interviews with nurses from hospitals, municipalities and primary care in Sweden.RESULTS: This study provides valuable insights into challenges associated with care planning via video conferencing. The meeting format, that is video conferencing, is perceived as a barrier that makes the interaction challenging. Shortcomings in video technology make a person-centred approach difficult. The person-centred approach is also difficult for nurses to maintain when the older person or relatives are not involved in the planning.
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| 4. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Person-centered healthcare in coordinated care planning with video conference : Nurses’ perspective
- 2019
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Ingår i: Proceedings of the European Conference on Knowledge Management, ECKM 2019. - : Academic Conferences and Publishing International Limited. - 9781912764327 ; 1, s. 514-520
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Konferensbidrag (refereegranskat)abstract
- We are becoming older and more people remain in their home with the need for care, as well as these persons for some reasons be hospitalized. This imply for the need of coordinated care planning in hospitals, as the person would be able to leave the ward in a safe manner. With an increasing number of elderly persons in need of care interventions in their home, the need for coordinated care planning in hospitals will also increase. Such planning is today being performed increasingly often via video conferencing. This form of digital encounters poses new challenges for the nurse in creating and maintaining a mutuality. The aim of this paper is to shed light on how coordinated care planning via video conferencing affects the ability of health care professionals to understand and interpret the patient’s situation from a holistic perspective, thus performing a person-centered meeting at a distance. A qualitative research approach was used to gain an understanding of nurses’ experience of coordinated care planning via video conferencing, where seven semi-structured interviews have been conducted. The result shows that the communication is affected and that meetings via video technology lose proximity and thus a part of the human contact. This can disrupt the possibility of seeing each other as persons but can be compensated by a person-centered approach. The technology can act as a means of human interaction, but not as a compensation for it. Coordinated care planning via video conferencing involves challenges in conveying presence and genuine interest that compensates for the loss of physical presence. The nurses need to be well acquainted with person-centered care in order to meet the patient despite the barrier that the screen may create. Proper technology can be used with great time gains to access each other regardless of geographical location and can contribute to human interaction but not replace it.
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| 5. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Bracing for the next wave: A critical incident study of frontline decision‐making, adaptation and learning in ambulance care during COVID‐19
- 2024
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Ingår i: Journal of Advanced Nursing. - 0309-2402 .- 1365-2648. ; 00, s. 1-16
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Tidskriftsartikel (refereegranskat)abstract
- Aim: To explore frontline decision-making, adaptation, and learning in ambulance care during the evolving COVID-19 pandemic.Design: Descriptive and interpretative qualitative study.MethodsTwenty-eight registered nurses from the Swedish ambulance services described 56 critical incidents during the COVID-19 pandemic through free-text questionnaires. The material was analysed using the Critical Incident Technique and Interpretive Description through the lens of potential for resilient performance.Results: The findings were synthesized into four themes: ‘Navigating uncharted waters under never-ending pressure’, ‘Balancing on the brink of an abyss’, ‘Sacrificing the few to save the many’ and ‘Bracing for the next wave’. Frontline decision-making during a pandemic contribute to ethical dilemmas while necessitating difficult prioritizations to adapt and respond to limited resources. Learning was manifested through effective information sharing and the identification of successful adaptations as compared to maladaptations.Conclusions: During pandemics or under other extreme conditions, decisions must be made promptly, even amidst emerging chaos, potentially necessitating the use of untested methods and ad-hoc solutions due to initial lack of knowledge and guidelines. Within ambulance care, dynamic leadership becomes imperative, combining autonomous frontline decision-making with support from management. Strengthening ethical competence and fostering ethical discourse may enhance confidence in decision-making, particularly under ethically challenging circumstances.Impact: Performance under extreme conditions can elevate the risk of suboptimal decision-making and adverse outcomes, with older adults being especially vulnerable. Thus, requiring targeted decision support and interventions. Enhancing patient safety in ambulance care during such conditions demands active participation and governance from management, along with decision support and guidelines. Vertical communication and collaboration between management and frontline professionals are essential to ensure that critical information, guidelines, and resources are effectively disseminated and implemented. Further research is needed into management and leadership in ambulance care, alongside the ethical challenges in frontline decision-making under extreme conditions.
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| 6. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Bridging Boundaries for Integrated Care : Constructing Interprofessional Collaboration Pathways for Complex Care Needs
- 2024
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Ingår i: The First Global Conference on Person-Centred Care: Knowledge(s) and Innovations for Health in Changing Societies. - Göteborg : University of Gothenburg. - 9789153106708 ; , s. 255-256
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Konferensbidrag (refereegranskat)abstract
- Background: Amid the increasing prevalence of chronic diseases and multimorbidity globally, the quest for integrated care models has intensified. However, empirical evidence on their implementation remains limited. Understanding the intricacies of effective interprofessional collaboration is crucial for achieving seamless integration of care.Aim: This study seeks to construct a grounded theory elucidating the dynamics of interprofessional collaboration across care providers to support integrated care for persons with complex needs.Design: A constructivist grounded theory approach guided the research.Methods: Observational and interview data were collected and analyzed using constant comparative methods to reach theoretical saturation. The sample consisted of 86 participants from diverse professional backgrounds within health and social care sectors, including hospital, ambulance services, primary care, and community care settings.Results: The theory titled “Negotiating Care in Organizational Borderlands” conceptualizes interprofessional collaboration as a complex and layered process. The process encompasses three distinct levels, influenced by how effectively organizational and professional boundaries are navigated. At the fragmentation level, care is disjointed, leading to a lack of cohesion among providers. The dependence level sees professionals relying on each other yet struggling with boundary issues. Ultimately, integration is possible when care providers collaboratively transcend organizational divides, leveraging their collective expertise while maintaining clearly defined accountability lines.Conclusion: Establishing clear pathways for robust collaboration is pivotal for care integration. However, care integration from the patient's perspective does not prevent healthcare professionals from encountering fragmented roles. This underscores the importance of clearly defined accountability lines to support shared responsibility and to bridge gaps across professional and organizational boundaries.Relevance to Clinical Practice: This research emphasizes the need for adaptive collaboration to support integrated care for persons with complex needs. It underscores the importance of clear accountability and communication pathways in organizational borderlands to provide person-centered care and meet individual patient needs.
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| 7. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Entangled in complexity: An ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs
- 2024
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Ingår i: Journal of Advanced Nursing. - : John Wiley & Sons. - 0309-2402 .- 1365-2648. ; 00, s. 1-18
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Tidskriftsartikel (refereegranskat)abstract
- Aim: The aim of this study was to visualize vulnerabilities and explore the dynamics of inter-professional collaboration and organizational adaptability in the context of care transitions for patients with complex care needs.Design: An ethnographic design using multiple convergent data collection techniques.Methods: Data collection involved document review, participant observations and interviews with healthcare and social care professionals (HSCPs). Narrative analysis was employed to construct two illustrative patient scenarios, which were then examined using the Functional Resonance Analysis Method (FRAM). Thematic analysis was subsequently applied to synthesize the findings.Results: Inconsistencies in timing and precision during care transitions pose risks for patients with complex care needs as they force healthcare systems to prioritize structural constraints over individualized care, especially during unforeseen events outside regular hours. Such systemic inflexibility can compromise patient safety, increase the workload for HSCPs and strain resources. Organizational adaptability is crucial to managing the inherent variability of patient needs. Our proposed ‘safe care transition pathway’ addresses these issues, providing proactive strategies such as sharing knowledge and increasing patient participation, and strengthening the capacity of professionals to meet dynamic care needs, promoting safer care transitions.Conclusion: To promote patient safety in care transitions, strategies must go beyond inter-professional collaboration, incorporating adaptability and flexible resource planning. The implementation of standardized safe care transition pathways, coupled with the active participation of patients and families, is crucial. These measures aim to create a resilient, person-centred approach that may effectively manage the complexities in care transitions.Implications: The recommendations of this study span the spectrum from policy-level changes aimed at strategic resource allocation and fostering inter-professional collaboration to practical measures like effective communication, information technology integration, patient participation and family involvement. Together, the recommendations offer a holistic approach to enhance care transitions and, ultimately, patient outcomes.
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| 8. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method
- 2023
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Ingår i: BMC Health Services Research. - : BioMed Central (BMC). - 1472-6963. ; 23:1
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundHospital discharge is a complex process encompassing multiple interactions and requiring coordination. To identify potential improvement measures in care transitions for people with complex care needs, intra- and inter-organisational everyday work needs to be properly understood, including its interdependencies, vulnerabilities and gaps. The aims of this study were to 1) map coordination and team collaboration across healthcare and social care organisations, 2) describe interdependencies and system variability in the discharge process for older people with complex care needs, and 3) evaluate the alignment between discharge planning and the needs in the home.MethodsData were collected through participant observations, interviews, and document review in a region of southern Sweden. The Functional Resonance Analysis Method (FRAM) was used to model the discharge process and visualise and analyse coordination of care across healthcare and social care organisations.ResultsHospital discharge is a time-sensitive process with numerous couplings and interdependencies where healthcare professionals’ performance is constrained by system design and organisational boundaries. The greatest vulnerability can be found when the patient arrives at home, as maladaptation earlier in the care chain can lead to an accumulation of issues for the municipal personnel in health and social care working closest to the patient. The possibilities for the personnel to adapt are limited, especially at certain times of day, pushing them to make trade-offs to ensure patient safety. Flexibility and appropriate resources enable for handling variability and responding to uncertainties in care after discharge.ConclusionsMapping hospital discharge using the FRAM reveals couplings and interdependencies between various individuals, teams, and organisations and the most vulnerable point, when the patient arrives at home. Resilient performance in responding to unexpected events and variations during the first days after the return home requires a system allowing flexibility and facilitating successful adaptation of discharge planning.
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| 9. |
- Hedqvist, Ann-Therese, Doktorand
(författare)
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In transition to a closer care : ambulance clinicians experiences of caring for older people with complex care needs
- 2022
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Ingår i: Presented at Caring in a Changing World - The 4th International NCCS & EACS Conference, Mälardalen University, Eskilstuna, Sweden, April 27-28, 2022.
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Konferensbidrag (refereegranskat)abstract
- Background: Multimorbidity in the elderly is associated with increased need of emergency care and the use of ambulance care increases with age. To maintain a sustainable care of high quality while at the same time effectively meeting the demographic change with an aging population, a major restructuring of Swedish healthcare is underway. However, there is limited knowledge about prehospital care of older people with complex care needs and the role of the ambulance service in the concept of a care closer to the patient. Aim: To describe ambulance clinicians’ experiences of caring for older people with complex care needs.Method: A qualitative interview study with a strategic sample consisting of 18 ambulance clinicians in two different Swedish regions. The material was analyzed with thematic content analysis.Results:Caring for older people with complex care needs is a common undertaking for the ambulance service that at the same time involves numerous challenges. The analysis of the experiences from ambulance clinicians revealed four themes: Relating to a common but multifaceted patient, Transferring knowledge and information at all levels, Striving for optimal level of care for the patient as a person and Lacking clarity about the role and mission. Ambulance care has an important role in the transition to a care closer to the patient, however, the assignment needs to be defined and the responsibility in relation to other actors clarified. Conclusion: A well-developed collaboration between ambulance care, inpatient care, primary care, and home care through a person-centered approach could promote that the right person be offered the right care, in the right place, at the right time.Implication for caring in a changing world: To provide equal and efficient ambulance care adapted to a changing world, a collaborative approach is required, bridging organizational boundaries to focus on the patient as a person.
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| 10. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Integrating the FRAM and ethnography in nursing research : Insights from a project on complex care transitions
- 2024
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Ingår i: Presented at the 16th FRAMily meeting/workshop, Lund, Sweden, June 3-6, 2024.
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Konferensbidrag (refereegranskat)abstract
- The challenge of ensuring patient safety and continuity of care during complex care transitions necessitates a deeper understanding beyond what traditional research methodologies typically offer. This study explores the integration of the Functional Resonance Analysis Method (FRAM) with ethnographically derived patient scenarios to thoroughly investigate the complexities, variabilities, and unforeseen dynamics within these transitions.Adopting an ethnographic methodology, we have developed patient scenarios through comprehensive document reviews, participant observations and interviews with 37 healthcare professionals across multiple healthcare environments. These scenarios set the stage for applying the FRAM analysis, enabling an in-depth analysis of the care transition process. This approach is pivotal for identifying critical moments and decisions that significantly affect patient safety and for revealing potential system vulnerabilities.Our research sheds light on the daily practices and challenges healthcare professionals face during complex care transitions. It highlights systemic vulnerabilities and areas prone to risks while emphasizing effective practices. It underscores the importance of patient and family participation in facilitating safe and seamless transitions. From our findings, we present a "safe care transition pathway," offering a structured approach that encapsulates strategies for patient and family participation, and recommendations for overcoming identified vulnerabilities.Our study demonstrates that combining the FRAM with ethnographic research and patient scenarios offers a comprehensive and nuanced methodology for analyzing complex healthcare processes. This approach is particularly valuable for uncovering the variabilities and emergent behaviors that can affect care transitions. It provides a scaffold for future nursing research and practice to improve understanding and management of complex care transitions in healthcare environments.
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| 11. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Optimizing resilient care transitions: The synergy of interprofessional collaboration and organizational adaptability
- 2024
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Ingår i: Presented at the Resilient Health Care Society Summer Meeting 2024, Stavanger, Norway, June 9-12, 2024.
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Konferensbidrag (refereegranskat)abstract
- BackgroundNavigating care transitions for patients with complex care needs represent a formidable challenge, where resilience becomes a crucial benchmark for quality and safety. There is a need to develop a healthcare infrastructure that not only reacts to disruptions but also proactively strengthens its capacity for continuity and patient safety. By addressing vulnerabilities and enhancing systemic responsiveness, the study illustrates how a coordinated, patient-centered approach is pivotal in building a healthcare infrastructure that can effectively navigate and adapt to challenges, thereby embodying the essence of resilient healthcare.ObjectiveThe aim of the study was to visualize vulnerabilities inherent in care transitions and to demonstrate how resilience—manifested through interprofessional collaboration and organizational adaptability—can fortify these critical junctures for patients with complex care needs.MethodsEmploying an ethnographic methodology, we engaged in document review, participant observations, and interviews with an array of healthcare and social care professionals involved in the care trajectory of patients with complex care needs. Narrative analysis was employed to construct two illustrative patient scenarios, which were then examined using the Functional Resonance Analysis Method (FRAM). Thematic analysis was subsequently applied to synthesize the findings.ResultsOur findings reveal that timing and precision variability during care transitions not only exacerbate vulnerabilities but also jeopardize patient safety. The inherent systemic rigidity, particularly during non-standard hours, amplifies the strain on resources and escalates the demands placed on care providers. In the face of patient needs' inherent unpredictability, the capacity of an organization to adapt is not just advantageous but essential. The crux of resilience in this context is interprofessional collaboration, which empowers healthcare teams to manage care proactively and navigate transitions more securely. Through collaborative practices, professionals are equipped to pool knowledge, predict fluctuations in patient conditions, and proactively coordinate responses to unexpected situations.ConclusionsWe advocate for a resilient model of care transition that is anchored in the collaborative synergy of healthcare teams, strategic resource management, and robust communication infrastructures. This model advocates for the vital contributions of frontline workers, patients, and their families, suggesting that their involvement is key in overcoming systemic obstacles and championing integrated, person-centered care. Our proposed pathway seeks to foster a healthcare environment where resilience is ingrained in the culture and practices, thereby ensuring safe, continuous, and responsive care transitions for all patients, particularly those with complex care needs.
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| 12. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Resilience in Action: Frontline Decision-Making in Swedish Ambulance Services During COVID-19
- 2024
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Ingår i: Presented at the Resilient Health Care Society Summer Meeting 2024, Stavanger, Norway, June 9-12, 2024.
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Konferensbidrag (refereegranskat)abstract
- BackgroundThe COVID-19 pandemic has significantly tested the resilience of global healthcare systems, particularly in emergency medical services. This study delves into the Swedish ambulance services' response to the pandemic, focusing on the dynamics of resilient performance and decision-making processes under extreme pressure. Understanding these responses is crucial for strengthening system-wide preparedness for future healthcare crises. ObjectiveThe aim of the study was to explore frontline decision-making, adaptation, and learning over time in ambulance care during the COVID-19 pandemic.MethodsWe gathered data from twenty-eight registered nurses in the Swedish ambulance services, who reported on 56 critical incidents during the pandemic using free-text questionnaires. The Critical Incident Technique, supplemented by Interpretive Description, was employed to analyze these incidents, concentrating on aspects of resilience in the context of emergency healthcare practice.ResultsAnalysis of the data revealed four main themes: ‘Navigating uncharted waters under never-ending pressure’ which underscores the continuous adaptation to evolving care challenges; ‘Balancing on the brink of an abyss’ reflecting the critical nature of decision-making amidst limited resources; ‘Sacrificing the few to save the many’ addressing the ethical complexities in prioritization and resource allocation; and ‘Bracing for the next wave’ indicating the importance of proactive planning for future resilience. These themes highlight a healthcare system's capacity to not only endure disruptions but to also evolve through them. Key to resilient practices were effective information sharing and the ability to discern between beneficial and harmful adaptations.ConclusionsThe study emphasizes the crucial role of dynamic leadership in crisis scenarios. It highlights the need for a balance between autonomous decision-making by frontline workers and structured guidance from management. Building ethical competence through situational awareness, reflective practices, and participation in ethical discourse is vital. These practices empower frontline workers to confidently manage ethical decision-making in crisis situations, thereby enhancing the adaptive capacity of healthcare systems in the face of future challenges.
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| 13. |
- Hedqvist, Ann-Therese, Doktorand
(författare)
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Safe care transitions for elderly people with complex care needs
- 2021
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Ingår i: Presented at the 15th Conference on Naturalistic Decision Making and 9th Symposium on Resilience Engineering (Emerging talents program, resilience engineering), Toulouse, France, June 21–24, 2021.
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Konferensbidrag (refereegranskat)
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| 14. |
- Hedqvist, Ann-Therese, Doktorand, et al.
(författare)
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Vulnerable patients in a complex system depend on interprofessional team adaptation at hospital discharge
- 2022
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Ingår i: International Society For Quality In Health Care (ISQua) 38th International Conference, Brisbane, Australia, October 17-20, 2022.
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Konferensbidrag (refereegranskat)abstract
- Objectives: The highly differentiated and specialized healthcare systems are not optimally designed to provide patients with chronic conditions in need of treatment from multi-professional teams with a smooth and seamless care trajectory. Care transitions, especially hospital discharge, tend to be critical for patients' safety and health outcomes. Interprofessional team collaboration across care providers is crucial for efficient and safe care transitions, depending on dynamic and adaptive teams in the unavoidable uncertainty characterizing today's healthcare systems. This study explores adaptation and maladaptations in horizontal team collaboration in care transitions of vulnerable patients with complex care needs at discharge from hospital to their private homes.Methods: The study was conducted in a southern region in Sweden using an ethnographic methodology with participatory observations, document review and interviews. A total of 77 professionals from hospital and primary care participated. A purposive sampling strategy was utilized to capture the interprofessional team collaboration across organizations in the patient's care transition from hospital to home. The comprehensive data was then applied to two patient cases and analysed with the Functional Resonance Analysis Method.Results: Successful team adaptations as well as maladaptations are revealed as homecare team and patients attempt to manage the uncontrolled conditions in the home after discharge. Maladaptations occur as the organizational capacity is insufficient to meet the needs of the patients in their home environment. The demands challenge the resources of the patient, his or her family, and the homecare team must anticipate and adapt to the unexpected to maintain patient safety. Whether the team adaptations of preparing discharge were successful or not will be revealed through adaptive outcomes or adverse events. Information sharing emerges as a central prerequisite for successful team collaboration in care transitions. Flawed or insufficient access to information affected the team performance by hindering anticipating and planning for the care at home. In exacerbations of the chronic illness, information access and communication are needed to obtain a holistic view and respond to the altered care needs. For the team to adapt to the new demands, each team member require a clear understanding of their own as well as other team member’s roles and responsibilities. Ambiguity or imprecision could lead to uncertainty of who does what and where lines are drawn between organizations. By interprofessional collaboration during the discharge planning, a shared understanding of treatment and care needed at home is distributed to the team as a collective cognitive mind. Through a shared mental model, the team may anticipate and prepare for the patient's arrival home. When the team collaboration failed or communication was insufficient, gaps appeared, which pressed the need for further adaptations. Successful adaptations could bridge the gaps, maintaining safe and secure care for the patient, while maladaptations posed a risk of patient harm or re-hospitalisation.Conclusion: To maintain patient safety in transitional care from hospital to home, adaptations to the variability of the system are not to be stifled. Instead, the system needs to allow for flexibility, promoting availability of all resources needed since these are hard to predict. Responding to unexpected events and variations requires allocated resources in the first few days of homecoming, allowing for flexibility and thus increasing patient safety.
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