EMPIRICAL STUDIES
doi: 10.1111/scs.12099
Continuity of care in day surgical care – perspective of patients Marja Renholm MNSc, RN, PhD-candidate (Nursing Director)1,2, Tarja Suominen PhD, RN (Docent, Professor)1,3, Ann-Marie Turtiainen PhD, RN (Service Manager)4, Pauli Puukka MSocSc (Senior Planning Officer)5 and Helena Leino-Kilpi PhD, RN (Professor, Nurse Director)1,6 1
University of Turku, Department of Nursing Science, Turku, Finland, 2Hospital District of Helsinki and Uusimaa, Helsinki, Finland, University of Tampere, Tampere, Finland, 4City of Helsinki Health Centre, Helsinki, Finland, 5National Institute for Health and Welfare, Turku, Finland and 6Hospital District of Southwest Finland, Turku, Finland
3
Scand J Caring Sci; 2014; 28; 706–715 Continuity of care in day surgical care – perspective of patients
Background: The realisation of continuity in day surgical care is analysed in this study. The term ‘continuity of care’ is used to refer to healthcare processes that take place in time (time flow) and require coordination (coordination flow), rapport (caring relationship flow) and information (information flow). Patients undergoing laparoscopic cholecystectomy or inguinal hernia day surgery are ideal candidates for studying the continuity of care, as the diseases are very common and the treatment protocol is mainly the same in different institutions, in addition to which the procedure is elective and most patients have a predictable clinical course. Aim: The aim of the study was to describe, from the day surgery patients’ own perspective, how continuity of care was realised at different phases of the treatment, prior to the day of surgery, on the day of surgery and after it. Method: The study population consisted of 203 day surgical patients 10/2009–12/2010 (N = 350, response rate 58%). A questionnaire was developed for this study.
Introduction Day surgical treatment has increased significantly in Europe and in Scandinavia in the last 20 years (1). For example, day surgery accounted for 50% of all nonacute surgery in municipal hospitals in Finland in 2010, compared to 37% in 2003 (2); the corresponding numbers in Sweden are 60% in 2010, compared to 50% in 2005 (3). The rapid increase in the number of day surgical Correspondence to: Marja Renholm, PO Box 340, FI- HUS, Finland. E-mail: [email protected]
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Results: Based on the results, the continuity of care was well realised as a rule. Continuity is improved by the fact that patients know the nurse who will look after them in the hospital before the day of surgery and have a chance to meet the nurse even after the operation. Meeting the surgeon who performed the operation afterwards also improves patients’ perception of continuation of care. Conclusions: Continuity of care may be improved by ensuring that the patient meets caring staff prior to the day of operation and after the procedure. An important topic for further research would be how continuation of care is realised in the case of other patient groups (e.g. in internal medicine). On the other hand, realisation of continuation of care should also be studied from the viewpoint of those taking part in patient care in order to find similarities/differences between patients’ perceptions and professionals’ views. Studying interventions aimed to promote continuity of care, for example in patient guidance, would also be of great importance. Keywords: continuity of care, day surgery, day surgical care, patient perspectives. Submitted 22 May 2013, Accepted 11 October 2013
procedures is a result of short-acting anaesthetics and new surgical techniques (4). In Finland, there are guaranteed statutory time frames within which treatment has to be made available. Nonemergency healthcare examinations by a nurse or physician are available at health centres within 3 days of making an appointment. Treatment has to be arranged within 3 months and specialist treatment within 6 months (5). The time limits are based on three factors: the Lisbon strategy, the Stability and Growth Pact and decisions by the European Court of Justice (6). According to earlier studies, patients have been mostly satisfied with the day surgical treatment (2). © 2013 Nordic College of Caring Science
Patient care continuity There are different definitions of continuity of care (7– 11). Continuity of care has been described as treatment relationship-related, treatment organisation-focused individual care and as being associated with the time course of treatment. One definition is that continuity of care is idealised in the patients’ experience of continuous caring relationship with healthcare professionals (7). The contrasting definition of continuity of care is that in vertically integrated systems providers deliver seamless service through integration, coordination and the sharing of information between professionals (7). According to Haggerty et al. (8), two elements must be present for continuity of care to exist: the care of individual patient and care delivered over time. The widest conceptual framework of continuity of care is that of a patient experiencing care over time as coherent and linked (9). Continuity of care may also be examined from different viewpoints as follows: between the patient and the treatment unit (10), between treatment units (11) and between professionals (7). In this study, the purpose is to evaluate the realisation of continuity based on day surgical patients’ perceptions. Continuity of care is defined as a healthcare process that takes place in time (time flow) and requires coordination (coordination flow), rapport (caring relationship flow) and information (information flow) (12). Time flow describes treatment over time; it is a process carried out within a certain time frame. Time dominates the day surgical process, reducing it to the equivalent of a production line (13). Coordination flow describes the fluency of treatment. It refers to care that works fluently between patients, healthcare professionals and the organisation. Coordination is about making different people or things work together towards a common goal (14). Caring relationship flow describes the course of the caring relationship; it is about patients and healthcare professionals having a rapport in different phases of care. Care relationship occurs between the person providing care and the person receiving care (15). Information flow describes the flow of information, that is, how patients receive information in a fluent manner in different phases of care. In an ideal case, the above-mentioned patient care processes follow patients through the health care system seamlessly, giving them the experience of continuity. The ultimate goal is to find out how the continuity of care is realised and what areas are in need of further improvement.
Literature review A search for relevant literature was conducted by means of the databases Ovid Medline, CINAHL and Cochrane with the search words ‘continuity of care, day surgery/ ambulatory surgery/day surgical procedures, patient perspectives/experiences, time-, coordination-, caring© 2013 Nordic College of Caring Science
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relationship- and information flow’. The inclusion criteria for the articles were based on the aspects of continuity of care in surgical/ambulatory surgery/day surgical care, time, coordination, caring relationship and information flow. The included articles had to be written in English, focus on adult patients and be published in the period 1996–2012. In time flow, the critical things for patients are punctuated by waiting time variables and delays (16, 17). Day surgical patients have emphasised the importance of time planning before admission, during their period of hospitalisation, and in their discharge plan (18). Patients who are already feeling anxious can experience added stress if the waiting times in day surgical units are long (19, 20). A Finnish study examining the quality of perioperative care found that the longer the patients had to wait for the operation the less satisfied they were (21). In coordination flow, the critical things for patients are collaboration and self-care. Collaboration between actors in different organisations is emphasised in the coordination of day surgical treatment. For example, collaboration between general practitioners in healthcare centres and the hospital is of importance at boundaries of organisations in order to achieve preoperative evaluation of patients admitted for day surgery, thus improving patients’ perception of care coordination (22, 23). Selfcare has become a more significant part of preparation for and recovery from day surgery due to the shorter stay in hospital (24–26). The lack of a model of continuity of care can also require that patients are sufficiently independent in order to be able to coordinate their own care (27, 28); in addition, day surgery also seems to rely heavily on the care provided by relatives (28, 29). In caring relationship flow, critical things for the patients are the relationship with nurses and physicians. Based on earlier research findings, the care relationship between a surgical patient and nurse may be improved by arranging a meeting between the nurse and patient prior to the operation and after it, which improves the patient’s perception of continuation of care (30, 31). According to nurses working in day surgical units, patients’ and family members’ expectations of the day surgical nursing relationships are not always met (32). Another critically important thing in terms of the caring relationship is the patient’s relationship with the treating physician. Patients value highly the relationship with their physician (33). Patients have expressed the need to meet the surgeon who is operating them both before (16, 22) and after the operation (22). Patients have also experienced the need for closer postoperative follow-up by the staff directly involved in their care (30). In information flow, it is critical for patients that they get information so that they can prepare themselves at home before the operation and take care of themselves after the operation. According to the study by Kanerva
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(34), as a rule day surgical patients who had undergone a vein operation received information on how to prepare for the operation and on postsurgical care that was understandable and sufficient. Sufficient provision of information to patients is associated with knowledge of the caring staff and meeting them prior to the operation (34). Patients have reported information about the operation, particularly anaesthesia, to be lacking (34), while written information has lacked clarity and been constructed using difficult medical language (35). Patients have also reported being unable to understand (36) and remember information received prior to discharge from the day surgical unit (22). According to earlier research findings, a timely and appropriate provision of different levels of information tailored to patients’ coping styles and preferences is strongly recommended (25, 36–38). Information and psychological aspects are areas that need to be taken into account in the development of elective ambulatory surgical nursing (24, 26, 39). Patients who have undergone a day surgical operation must bear responsibility for their self-care before the procedure and after it (40, 41). That is why it is important for day surgical patients to have access to follow-up information and support. According to Gilmartin (20), it is also essential that healthcare professionals recognise that all patients, regardless of their professional background, must be treated as individuals and their right to information be taken into consideration (20).
Aim The purpose of this study was to analyse the realisation of continuity of care of day surgical patients’ care and to identify potential areas of development. Ultimately, the goal is to improve the continuity of day surgical care. The research questions were as follows: 1 How is the continuity of care realised in day surgical care, as perceived by the patients? 2 Which background factors are related to the realisation of the continuity of care from patients’ point of view?
Sample and data collection The study population (N = 350) consisted of Finnish day surgery laparoscopic cholecystectomy and hernia patients, both being the most frequent procedures in day surgery in the country. Finland has a total of 20 hospital districts. The data were gathered from the largest hospital district in Finland in 10/2009–12/2010. Permission to carry out the study was obtained from relevant authorities, and the study was approved by an ethics committee. The inclusion criteria for patients were age over 18 years, Finnish-speaking and capable of self-administering the questionnaire. Nurses in the day surgical unit enquired about patients’ willingness to take part in the study and handed out questionnaires to those willing to participate
before discharge from hospital on the day of operation. Nurses informed patients about the study and asked them to fill in the questionnaire at home 1 week after the operation. The patients were given the questionnaire and a return envelope if they agreed to participate in the study. The patients returned the questionnaire to the researcher by post. The final response rate for patients was 58% (n = 203). Ten patients refused to participate, 145 did not return the questionnaire, and one questionnaire was excluded due to missing data. Sample size was based on power analysis indicating a sample size of 216. The calculations were based on data from a pilot study, with a medium effect size of 0.5 and power of 0.80. Significance level 0.01 was used because of multiple comparisons.
Instrument The questionnaire was developed for this study based on a literature review (42), interview study (12) and a pilot study. The pilot study was conducted in one Finnish hospital (not the same hospital district where the data were gathered) on 20 purposefully selected day surgically operated patients. No changes to the questionnaire were needed. The questionnaire consists of 41 Likert scale items (a five-point Likert scale was used, 1 = strongly disagree, 5 = strongly agree). The realisation of continuity of care was divided into four different categories: timing of care (nine items), coordination of care (nine items), caring relationship in care (nine items) and information in care (nine items). In timing of care, the items were waiting, scheduling and self-help. In coordination of care, the items were organisation of care, fluidity and own initiative. In caring relationship, the items were caring relationship with the nurse, with the physician and responsibility for care. In information, the items were receiving information, flow of information and documents and own initiative. References to before, during and after the procedure were repeated in individual questions. In addition, the questionnaire included 24 background factors [sociodemographic background six items (age, gender, civil status, education, education in health care, job situation), four items about the procedure (the procedure performed, operations performed before, day surgical procedure before, day following the procedure), seven items about preparing for the procedure (first visit to health care, who took care of the patient, care in outpatient clinic, the call preceding the procedure, the visit preceding the procedure, caring staff, change of procedure time), four items about timing of care (waiting time, expected waiting time, caring personnel in day surgery unit, call after the procedure) and three items about care after the procedure (convalescence time, more information, removal of stitches)]. © 2013 Nordic College of Caring Science
Patient care continuity
Data analysis The data were analysed statistically using SPSS software for Windows (version 17.0; SPSS Inc., Chicago, IL, USA) and SAS 9.1 Inc. (Cary, NC, USA). The data were described by using frequency tables and descriptive statistics. Four sum variables were formed by categories to describe the realisation of continuity of care in day surgical patients’ care. The sum variables were time flow, coordination flow, caring relationship flow and information flow. These four sum variables were finally combined into a total sum variable = total continuity of care. The consistency of these sum variables was estimated by calculating Cronbach’s alpha coefficients. The alpha coefficients ranged from 0.74 to 0.89: time flow 0.75, coordination flow 0.77, caring relationship flow 0.74 and information flow 0.78. Alpha of the total sum variable total continuity of care was 0.89. Due to some skewed distributions, comparisons were made between the sum variables by Wilcoxon signedrank test. Spearman’s correlations were used to examine the interdependencies between the sum variables. Multivariate analyses were done to identify the independent determinants of the continuity of care. All univariately significant background variables were first included in the multivariate linear model and then removed one by one until all determinants in the model were statistically significant. The level of significance was set at p < 0.05.
Ethical considerations The research adhered to the general principles of research ethics (43, 44). The study plan was approved by the ethics committee of the hospital district (§114/2009) involved in the study. Permission to collect the data was obtained from authorities at five hospitals. Nurses at the units taking part in the study handed out questionnaires to patients who consented to participate. The envelope containing the questionnaire offered to subjects also contained an information leaflet describing the study. Based on the information, subjects made a voluntary decision about whether to respond to the questionnaire. Responding to the questionnaire and returning it to the researcher by post was considered consent. The identity of the respondents was not revealed to the researcher; the questionnaires were completed anonymously, and the researcher did not meet the respondents.
Results
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Table 1 Sociodemographic patient data All patients N = 202 Sociodemographic variables
Mean
n
%
Age Gender Male Female Marital status Married/cohabiting Single Divorced Widowed Education No vocational education Vocational training course Secondary level qualifications College diploma University Healthcare education Job situation Student Working Entrepreneur Unemployed Retired Other
53.6
178 144 58
71 29
165 15 14 8
82 7 7 4
33 64
16 32
64 39 14
32 20 7
3 103 18 8 63 5
2 52 9 4 31 2
Range
SD
25–82
13.03
underwent hernia surgery while forty-eight (24%) underwent laparoscopic cholecystectomy. The patients answered the questionnaire at home on average on the 9th postsurgery day. Fifty-seven (29%) patients got an appointment with a physician within 3 days of the first symptoms of illness. Seventy-five (37%) patients did not visit a physician when they experienced the first symptoms of illness. Thirty-one (16%) patients got a treatment evaluation 3 weeks after visiting a physician. Almost half (44%) of the patients were contacted by phone by the day surgical unit prior to the procedure. Fifty-eight per cent of the patients visited the day surgical unit before the procedure. Most patients did not know who would be the nurse, surgeon or anaesthesiologist responsible for their care. Half of the patients (50%) were contacted by phone the day after the procedure. Over half of the patients fully agreed that they had recovered as expected from the procedure. Half of the respondents (50%) did not feel that they needed more guidance at home after the operation (See Table 2).
Description of the sample
Realisation of continuity of care
The patients were mainly male (71%), married, and their average age was 53.6 years (range 25–82 years) (See Table 1). One hundred and fifty-two (76%) participants
The mean value of the total continuity of care sum score was 4.23 (Md 4.33, SD = 0.47). In timing of the care, the mean value of the time flow sum score was 4.27 (Md
© 2013 Nordic College of Caring Science
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Table 2 Sociodemographic clinical data All patients N = 202 Variables
Mean
n
Postoperative day when answering Operation Hernia/laparoscopic cholecystectomy Operation done before Yes/no Examinations within 3 days after getting symptoms Yes/no/no try Patient visited first time Healthcare centre Private Occupational health Else Evaluation of the treatment 3 weeks after symptoms Yes/no later/none Preoperative call Yes/no Preoperative visit Yes/no Patient knew her/his nurse before the operation day Yes/no Patient knew her/his surgeon before the operation day Yes/no Patient knew her/his anaesthesiologist before operation day Yes/no Patient changed the operation time Yes/no Phone call postoperative Yes/no
%
203 152/48
76/24
40/159
20/80
57/67/75
29/34/37
85 22 75 17
42 11 38 9
31/134/32
16/68/16
89/112
44/56
117/84
58/42
36/162
18/82
72/127
36/64
55/135
29/71
41/160
20/80
99/98
50/49
4.44, SD = 0.65). It was significantly (p ≤ 0.001) higher than the caring relationship flow score and significantly lower than the information flow sum score. The mean value of the coordination flow sum score was 4.37 (Md 4.44, SD = 0.55). It was significantly (p ≤ 0.001) higher than the caring relationship flow score and significantly lower than the information flow sum score. The mean value of the caring relationship flow sum score was 3.73
Range
Mean (SD)
1–14
8.76 (8.63)
(Md 3.66, SD = 0.78). Caring relationship flow had the lowest mean score, being significantly (p < 0.001) lower than all the other sum scores. The mean of the coordination flow sum score was 4.37 (Md 4.44, SD = 0.55). This mean score was significantly (p < 0.001) higher than all the others (See Table 3). All four sum variables correlated with each other in a significant manner. The highest correlation was seen between the sum variables
Table 3 The sum variables of the continuity of care Spearman’s correlations rs between the sum variablesa Sum variable
n
Mean (SD)
Median
Range
Alpha
Time flow
Coordination flow
Caring relationship flow
Information flow Coordination flowb Time flowb Caring relationship flow Total continuity of care
202 200 202 200 199
4.53 4.37 4.27 3.73 4.23
4.67 4.44 4.44 3.67 4.33
2.22–5 2.67–5 2.37–5 1.78–5 2.78–5
0.78 0.77 0.75 0.74 0.89
0.37*** 0.59*** – 0.33***
0.60*** – – 0.43***
0.39***
(0.51) (0.55) (0.65) (0.79) (0.47)
a
All correlations are significant. Difference between Time flow and Coordination flow is not significant. All other pairwise differences between the four sum variables are significant (p < 0.001). ***p < 0.001.
b
© 2013 Nordic College of Caring Science
Patient care continuity coordination and information flow (rs = 0.60) and the lowest between time flow and caring relationship flow (rs = 0.33). As a whole, patients felt that continuity of care was well realised. In different categories, the best areas were identified, however. There were both aspects that were well realised and aspects in need of development in the following subcategories of continuity of care: time, coordination, caring relationship and information flow (See Table 4).
Continuity of care in relation to background variables Background variables were examined in relation to the total sum score of continuity of care (=total continuity of care). The realisation of continuity of care was
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statistically significantly associated with certain background factors. In patients’ opinion, total continuity of care was better realised when the patients knew the healthcare professionals who were caring for them (See Table 5). Statistically significant associations were also seen when looking at the subcategories time, coordination, caring relationship and information flow in relation to background factors. In more detail, significant associations were found in the subcategories of continuity of care with how rapidly the patient had been admitted to the procedure, the procedure the patient had undergone and the patient’s need for further guidance. Meeting healthcare professionals and the nurse and surgeon both before and after the procedure had a significant impact, as did preoperative discussion (See Table 6).
Table 4 Realisation of subcategories of continuity of care from patients’ viewpoint Subcategory of continuity of care
Well realised
Areas in need of development
Time flow
No unnecessary waiting on the day of the operation Clear schedule in all phases of treatment
Coordination flow
Preparation for the procedure, treatment on the day of operation and follow-up well organised Systematic cooperation between treatment units prior to and on the day of operation On the day of operation, treating nurse and physician took patient’s matters in hand
Wish for smoother preparation during the period leading up to the operation More rapid admittance to operation Systematic cooperation between different treatment units during the period following the operation
Caring relationship flow
Information flow
Sufficient information provided at different stages of treatment Information and documents related to patient’s care were systematically transferred from one unit to another prior to and on the day of the procedure
At home during the period leading up to the operation, the patient knows the treating nurse and physician, and they take the patient’s matter in hand Knowledge of who is responsible for the care of a day surgical patient at different phases Information about patient’s treatment and transfer of documents during the period following the operation
Table 5 Patients’ perception of the continuity of care, total sum score in relation to background variables The independent determinants of sum.total flow. Multivariate linear model. Model 100*R2 = 23.1% Model p < 0.0001 Determinant n Adjusted mean (SE)a Before the procedure, did the patient know who would care for him/her? Yes 33 4.30 (0.09) No 148 4.01 (0.05) After the procedure, did the patient meet the nurse who cared for him/her before the procedure? Yes 152 4.25 (0.05) No 29 4.06 (0.09) After the procedure, did the patient meet the operating surgeon? Yes 104 4.23 (0.06) No 77 4.07 (0.07) SE, standard error of estimate. a The adjusted mean is the mean value of the category adjusted by all other determinants in the model. b Significance of the determinant. © 2013 Nordic College of Caring Science
pb
0.0005
0.032
0.015
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Table 6 Association of subcategories of continuity of care with background variables from patients’ viewpoint Determinant
n
Adjusted mean (SE)a
The independent determinants of sum.time flow. Multivariate linear model. Model 100*R2 = 42.4% Model p < 0.0001 How long did it take for the patient to be admitted to the procedure? 3 months 115 4.27 (0.07) More than 3 months 76 3.96 (0.08) After the procedure, did the patient meet the nurse (same as before the procedure)? Yes 161 4.26 (0.05) No 30 3.97 (0.12) I had need for further guidance at homec I totally disagree 97 4.26 (0.09) I partly disagree or don’t agree or disagree 49 4.14 (0.10) I partly or totally agree 45 3.94 (0.10) The independent determinants of sum.coordination flow. Multivariate linear model. Model 100*R2 = 14.7% Model p < 0.0001 Before the procedure, did the patient know the nurse (who would care for him/her on the day of the operation) Yes 35 4.47 (0.10) No 158 4.20 (0.05) How long did it take for the patient to be admitted to the procedure? 3 months 116 4.43 (0.07) More than 3 months 77 4.25 (0.08) The independent determinants of sum.caring relationship Multivariate linear model. Model 100*R2 = 33.8% Model p < 0.0001 Procedure Hernia 1 134 3.74 (0.07) Cholecystectomy 2 45 4.04 (0.11) The patient came in to discuss the coming operation before being admitted Yes 74 4.03 (0.09) No 105 3.75 (0.09) Before the procedure, did the patient know the nurse (who would care for him/her on the day of the operation) Yes 33 4.05 (0.13) No 146 3.73 (0.07) Before the procedure, did the patient know the operating surgeon? Yes 63 4.10 (0.09) No 116 3.69 (0.10) After the procedure, did the patient meet the operating surgeon? Yes 103 4.05 (0.08) No 76 3.73 (0.09) I had need for further guidance at home I totally disagree 93 4.18 (0.09) I partly disagree or don’t agree or disagree 46 3.73 (0.11) I partly or totally agree 40 3.76 (0.11) The independent determinants of sum.information flow. Multivariate linear model. Model 100*R2 = 16.2% Model p < 0.0001 Before the procedure, did the patient know the nurse (who would care for him/her on the day of the operation) Yes 36 4.61 (0.08) No 160 4.35 (0.05)
pb
0.0008
0.028
0.024
0.007
0.020
0.009
0.004
0.028
0.0006
0.001
0.0001
0.003
SE, standard error of estimate. The adjusted mean is the mean value of the category adjusted by all other determinants in the model. b Significance of the determinant. c The only significant pairwise difference between categories I totally disagree and I partly or totally agree. In pairwise comparisons, the difference between the category I totally agree and the other two categories is significant. a
Discussion The purpose of this study was to describe how the continuity of care and the factors connected to it are realised in day surgical care from patients’ viewpoint. Based on patients experiences, continuity of care is well realised as
a rule. There is room for improvement in the subcategories of continuity of care, especially time flow and caring relationship flow. The perception of continuity of care is improved by patients knowing before the procedure who the nurse taking care of them is. The fact that after the operation, © 2013 Nordic College of Caring Science
Patient care continuity patients meet the operating surgeon and the nurse who took care of them before the operation also has a positive impact. The findings above also support earlier research. Patients have expressed a wish to meet the operating surgeon prior to the operation (22). The study of Kanerva (34) also showed that sufficient provision of information was associated with knowledge of caring staff and meeting them before the operation (34). Based on their findings, Fraczyk and Godfrey (45) recommended sending patients to preoperative assessment immediately following their outpatient consultation, which would also provide more seamless service and promote increased patient satisfaction levels (45). In their study, B€ackstr€ om et al. (30) stated that continuity of care can be improved by a postoperative meeting between patients and those who cared for them. Patients who were admitted to treatment in
doi: 10.1111/scs.12099
Continuity of care in day surgical care – perspective of patients Marja Renholm MNSc, RN, PhD-candidate (Nursing Director)1,2, Tarja Suominen PhD, RN (Docent, Professor)1,3, Ann-Marie Turtiainen PhD, RN (Service Manager)4, Pauli Puukka MSocSc (Senior Planning Officer)5 and Helena Leino-Kilpi PhD, RN (Professor, Nurse Director)1,6 1
University of Turku, Department of Nursing Science, Turku, Finland, 2Hospital District of Helsinki and Uusimaa, Helsinki, Finland, University of Tampere, Tampere, Finland, 4City of Helsinki Health Centre, Helsinki, Finland, 5National Institute for Health and Welfare, Turku, Finland and 6Hospital District of Southwest Finland, Turku, Finland
3
Scand J Caring Sci; 2014; 28; 706–715 Continuity of care in day surgical care – perspective of patients
Background: The realisation of continuity in day surgical care is analysed in this study. The term ‘continuity of care’ is used to refer to healthcare processes that take place in time (time flow) and require coordination (coordination flow), rapport (caring relationship flow) and information (information flow). Patients undergoing laparoscopic cholecystectomy or inguinal hernia day surgery are ideal candidates for studying the continuity of care, as the diseases are very common and the treatment protocol is mainly the same in different institutions, in addition to which the procedure is elective and most patients have a predictable clinical course. Aim: The aim of the study was to describe, from the day surgery patients’ own perspective, how continuity of care was realised at different phases of the treatment, prior to the day of surgery, on the day of surgery and after it. Method: The study population consisted of 203 day surgical patients 10/2009–12/2010 (N = 350, response rate 58%). A questionnaire was developed for this study.
Introduction Day surgical treatment has increased significantly in Europe and in Scandinavia in the last 20 years (1). For example, day surgery accounted for 50% of all nonacute surgery in municipal hospitals in Finland in 2010, compared to 37% in 2003 (2); the corresponding numbers in Sweden are 60% in 2010, compared to 50% in 2005 (3). The rapid increase in the number of day surgical Correspondence to: Marja Renholm, PO Box 340, FI- HUS, Finland. E-mail: [email protected]
706
Results: Based on the results, the continuity of care was well realised as a rule. Continuity is improved by the fact that patients know the nurse who will look after them in the hospital before the day of surgery and have a chance to meet the nurse even after the operation. Meeting the surgeon who performed the operation afterwards also improves patients’ perception of continuation of care. Conclusions: Continuity of care may be improved by ensuring that the patient meets caring staff prior to the day of operation and after the procedure. An important topic for further research would be how continuation of care is realised in the case of other patient groups (e.g. in internal medicine). On the other hand, realisation of continuation of care should also be studied from the viewpoint of those taking part in patient care in order to find similarities/differences between patients’ perceptions and professionals’ views. Studying interventions aimed to promote continuity of care, for example in patient guidance, would also be of great importance. Keywords: continuity of care, day surgery, day surgical care, patient perspectives. Submitted 22 May 2013, Accepted 11 October 2013
procedures is a result of short-acting anaesthetics and new surgical techniques (4). In Finland, there are guaranteed statutory time frames within which treatment has to be made available. Nonemergency healthcare examinations by a nurse or physician are available at health centres within 3 days of making an appointment. Treatment has to be arranged within 3 months and specialist treatment within 6 months (5). The time limits are based on three factors: the Lisbon strategy, the Stability and Growth Pact and decisions by the European Court of Justice (6). According to earlier studies, patients have been mostly satisfied with the day surgical treatment (2). © 2013 Nordic College of Caring Science
Patient care continuity There are different definitions of continuity of care (7– 11). Continuity of care has been described as treatment relationship-related, treatment organisation-focused individual care and as being associated with the time course of treatment. One definition is that continuity of care is idealised in the patients’ experience of continuous caring relationship with healthcare professionals (7). The contrasting definition of continuity of care is that in vertically integrated systems providers deliver seamless service through integration, coordination and the sharing of information between professionals (7). According to Haggerty et al. (8), two elements must be present for continuity of care to exist: the care of individual patient and care delivered over time. The widest conceptual framework of continuity of care is that of a patient experiencing care over time as coherent and linked (9). Continuity of care may also be examined from different viewpoints as follows: between the patient and the treatment unit (10), between treatment units (11) and between professionals (7). In this study, the purpose is to evaluate the realisation of continuity based on day surgical patients’ perceptions. Continuity of care is defined as a healthcare process that takes place in time (time flow) and requires coordination (coordination flow), rapport (caring relationship flow) and information (information flow) (12). Time flow describes treatment over time; it is a process carried out within a certain time frame. Time dominates the day surgical process, reducing it to the equivalent of a production line (13). Coordination flow describes the fluency of treatment. It refers to care that works fluently between patients, healthcare professionals and the organisation. Coordination is about making different people or things work together towards a common goal (14). Caring relationship flow describes the course of the caring relationship; it is about patients and healthcare professionals having a rapport in different phases of care. Care relationship occurs between the person providing care and the person receiving care (15). Information flow describes the flow of information, that is, how patients receive information in a fluent manner in different phases of care. In an ideal case, the above-mentioned patient care processes follow patients through the health care system seamlessly, giving them the experience of continuity. The ultimate goal is to find out how the continuity of care is realised and what areas are in need of further improvement.
Literature review A search for relevant literature was conducted by means of the databases Ovid Medline, CINAHL and Cochrane with the search words ‘continuity of care, day surgery/ ambulatory surgery/day surgical procedures, patient perspectives/experiences, time-, coordination-, caring© 2013 Nordic College of Caring Science
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relationship- and information flow’. The inclusion criteria for the articles were based on the aspects of continuity of care in surgical/ambulatory surgery/day surgical care, time, coordination, caring relationship and information flow. The included articles had to be written in English, focus on adult patients and be published in the period 1996–2012. In time flow, the critical things for patients are punctuated by waiting time variables and delays (16, 17). Day surgical patients have emphasised the importance of time planning before admission, during their period of hospitalisation, and in their discharge plan (18). Patients who are already feeling anxious can experience added stress if the waiting times in day surgical units are long (19, 20). A Finnish study examining the quality of perioperative care found that the longer the patients had to wait for the operation the less satisfied they were (21). In coordination flow, the critical things for patients are collaboration and self-care. Collaboration between actors in different organisations is emphasised in the coordination of day surgical treatment. For example, collaboration between general practitioners in healthcare centres and the hospital is of importance at boundaries of organisations in order to achieve preoperative evaluation of patients admitted for day surgery, thus improving patients’ perception of care coordination (22, 23). Selfcare has become a more significant part of preparation for and recovery from day surgery due to the shorter stay in hospital (24–26). The lack of a model of continuity of care can also require that patients are sufficiently independent in order to be able to coordinate their own care (27, 28); in addition, day surgery also seems to rely heavily on the care provided by relatives (28, 29). In caring relationship flow, critical things for the patients are the relationship with nurses and physicians. Based on earlier research findings, the care relationship between a surgical patient and nurse may be improved by arranging a meeting between the nurse and patient prior to the operation and after it, which improves the patient’s perception of continuation of care (30, 31). According to nurses working in day surgical units, patients’ and family members’ expectations of the day surgical nursing relationships are not always met (32). Another critically important thing in terms of the caring relationship is the patient’s relationship with the treating physician. Patients value highly the relationship with their physician (33). Patients have expressed the need to meet the surgeon who is operating them both before (16, 22) and after the operation (22). Patients have also experienced the need for closer postoperative follow-up by the staff directly involved in their care (30). In information flow, it is critical for patients that they get information so that they can prepare themselves at home before the operation and take care of themselves after the operation. According to the study by Kanerva
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(34), as a rule day surgical patients who had undergone a vein operation received information on how to prepare for the operation and on postsurgical care that was understandable and sufficient. Sufficient provision of information to patients is associated with knowledge of the caring staff and meeting them prior to the operation (34). Patients have reported information about the operation, particularly anaesthesia, to be lacking (34), while written information has lacked clarity and been constructed using difficult medical language (35). Patients have also reported being unable to understand (36) and remember information received prior to discharge from the day surgical unit (22). According to earlier research findings, a timely and appropriate provision of different levels of information tailored to patients’ coping styles and preferences is strongly recommended (25, 36–38). Information and psychological aspects are areas that need to be taken into account in the development of elective ambulatory surgical nursing (24, 26, 39). Patients who have undergone a day surgical operation must bear responsibility for their self-care before the procedure and after it (40, 41). That is why it is important for day surgical patients to have access to follow-up information and support. According to Gilmartin (20), it is also essential that healthcare professionals recognise that all patients, regardless of their professional background, must be treated as individuals and their right to information be taken into consideration (20).
Aim The purpose of this study was to analyse the realisation of continuity of care of day surgical patients’ care and to identify potential areas of development. Ultimately, the goal is to improve the continuity of day surgical care. The research questions were as follows: 1 How is the continuity of care realised in day surgical care, as perceived by the patients? 2 Which background factors are related to the realisation of the continuity of care from patients’ point of view?
Sample and data collection The study population (N = 350) consisted of Finnish day surgery laparoscopic cholecystectomy and hernia patients, both being the most frequent procedures in day surgery in the country. Finland has a total of 20 hospital districts. The data were gathered from the largest hospital district in Finland in 10/2009–12/2010. Permission to carry out the study was obtained from relevant authorities, and the study was approved by an ethics committee. The inclusion criteria for patients were age over 18 years, Finnish-speaking and capable of self-administering the questionnaire. Nurses in the day surgical unit enquired about patients’ willingness to take part in the study and handed out questionnaires to those willing to participate
before discharge from hospital on the day of operation. Nurses informed patients about the study and asked them to fill in the questionnaire at home 1 week after the operation. The patients were given the questionnaire and a return envelope if they agreed to participate in the study. The patients returned the questionnaire to the researcher by post. The final response rate for patients was 58% (n = 203). Ten patients refused to participate, 145 did not return the questionnaire, and one questionnaire was excluded due to missing data. Sample size was based on power analysis indicating a sample size of 216. The calculations were based on data from a pilot study, with a medium effect size of 0.5 and power of 0.80. Significance level 0.01 was used because of multiple comparisons.
Instrument The questionnaire was developed for this study based on a literature review (42), interview study (12) and a pilot study. The pilot study was conducted in one Finnish hospital (not the same hospital district where the data were gathered) on 20 purposefully selected day surgically operated patients. No changes to the questionnaire were needed. The questionnaire consists of 41 Likert scale items (a five-point Likert scale was used, 1 = strongly disagree, 5 = strongly agree). The realisation of continuity of care was divided into four different categories: timing of care (nine items), coordination of care (nine items), caring relationship in care (nine items) and information in care (nine items). In timing of care, the items were waiting, scheduling and self-help. In coordination of care, the items were organisation of care, fluidity and own initiative. In caring relationship, the items were caring relationship with the nurse, with the physician and responsibility for care. In information, the items were receiving information, flow of information and documents and own initiative. References to before, during and after the procedure were repeated in individual questions. In addition, the questionnaire included 24 background factors [sociodemographic background six items (age, gender, civil status, education, education in health care, job situation), four items about the procedure (the procedure performed, operations performed before, day surgical procedure before, day following the procedure), seven items about preparing for the procedure (first visit to health care, who took care of the patient, care in outpatient clinic, the call preceding the procedure, the visit preceding the procedure, caring staff, change of procedure time), four items about timing of care (waiting time, expected waiting time, caring personnel in day surgery unit, call after the procedure) and three items about care after the procedure (convalescence time, more information, removal of stitches)]. © 2013 Nordic College of Caring Science
Patient care continuity
Data analysis The data were analysed statistically using SPSS software for Windows (version 17.0; SPSS Inc., Chicago, IL, USA) and SAS 9.1 Inc. (Cary, NC, USA). The data were described by using frequency tables and descriptive statistics. Four sum variables were formed by categories to describe the realisation of continuity of care in day surgical patients’ care. The sum variables were time flow, coordination flow, caring relationship flow and information flow. These four sum variables were finally combined into a total sum variable = total continuity of care. The consistency of these sum variables was estimated by calculating Cronbach’s alpha coefficients. The alpha coefficients ranged from 0.74 to 0.89: time flow 0.75, coordination flow 0.77, caring relationship flow 0.74 and information flow 0.78. Alpha of the total sum variable total continuity of care was 0.89. Due to some skewed distributions, comparisons were made between the sum variables by Wilcoxon signedrank test. Spearman’s correlations were used to examine the interdependencies between the sum variables. Multivariate analyses were done to identify the independent determinants of the continuity of care. All univariately significant background variables were first included in the multivariate linear model and then removed one by one until all determinants in the model were statistically significant. The level of significance was set at p < 0.05.
Ethical considerations The research adhered to the general principles of research ethics (43, 44). The study plan was approved by the ethics committee of the hospital district (§114/2009) involved in the study. Permission to collect the data was obtained from authorities at five hospitals. Nurses at the units taking part in the study handed out questionnaires to patients who consented to participate. The envelope containing the questionnaire offered to subjects also contained an information leaflet describing the study. Based on the information, subjects made a voluntary decision about whether to respond to the questionnaire. Responding to the questionnaire and returning it to the researcher by post was considered consent. The identity of the respondents was not revealed to the researcher; the questionnaires were completed anonymously, and the researcher did not meet the respondents.
Results
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Table 1 Sociodemographic patient data All patients N = 202 Sociodemographic variables
Mean
n
%
Age Gender Male Female Marital status Married/cohabiting Single Divorced Widowed Education No vocational education Vocational training course Secondary level qualifications College diploma University Healthcare education Job situation Student Working Entrepreneur Unemployed Retired Other
53.6
178 144 58
71 29
165 15 14 8
82 7 7 4
33 64
16 32
64 39 14
32 20 7
3 103 18 8 63 5
2 52 9 4 31 2
Range
SD
25–82
13.03
underwent hernia surgery while forty-eight (24%) underwent laparoscopic cholecystectomy. The patients answered the questionnaire at home on average on the 9th postsurgery day. Fifty-seven (29%) patients got an appointment with a physician within 3 days of the first symptoms of illness. Seventy-five (37%) patients did not visit a physician when they experienced the first symptoms of illness. Thirty-one (16%) patients got a treatment evaluation 3 weeks after visiting a physician. Almost half (44%) of the patients were contacted by phone by the day surgical unit prior to the procedure. Fifty-eight per cent of the patients visited the day surgical unit before the procedure. Most patients did not know who would be the nurse, surgeon or anaesthesiologist responsible for their care. Half of the patients (50%) were contacted by phone the day after the procedure. Over half of the patients fully agreed that they had recovered as expected from the procedure. Half of the respondents (50%) did not feel that they needed more guidance at home after the operation (See Table 2).
Description of the sample
Realisation of continuity of care
The patients were mainly male (71%), married, and their average age was 53.6 years (range 25–82 years) (See Table 1). One hundred and fifty-two (76%) participants
The mean value of the total continuity of care sum score was 4.23 (Md 4.33, SD = 0.47). In timing of the care, the mean value of the time flow sum score was 4.27 (Md
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Table 2 Sociodemographic clinical data All patients N = 202 Variables
Mean
n
Postoperative day when answering Operation Hernia/laparoscopic cholecystectomy Operation done before Yes/no Examinations within 3 days after getting symptoms Yes/no/no try Patient visited first time Healthcare centre Private Occupational health Else Evaluation of the treatment 3 weeks after symptoms Yes/no later/none Preoperative call Yes/no Preoperative visit Yes/no Patient knew her/his nurse before the operation day Yes/no Patient knew her/his surgeon before the operation day Yes/no Patient knew her/his anaesthesiologist before operation day Yes/no Patient changed the operation time Yes/no Phone call postoperative Yes/no
%
203 152/48
76/24
40/159
20/80
57/67/75
29/34/37
85 22 75 17
42 11 38 9
31/134/32
16/68/16
89/112
44/56
117/84
58/42
36/162
18/82
72/127
36/64
55/135
29/71
41/160
20/80
99/98
50/49
4.44, SD = 0.65). It was significantly (p ≤ 0.001) higher than the caring relationship flow score and significantly lower than the information flow sum score. The mean value of the coordination flow sum score was 4.37 (Md 4.44, SD = 0.55). It was significantly (p ≤ 0.001) higher than the caring relationship flow score and significantly lower than the information flow sum score. The mean value of the caring relationship flow sum score was 3.73
Range
Mean (SD)
1–14
8.76 (8.63)
(Md 3.66, SD = 0.78). Caring relationship flow had the lowest mean score, being significantly (p < 0.001) lower than all the other sum scores. The mean of the coordination flow sum score was 4.37 (Md 4.44, SD = 0.55). This mean score was significantly (p < 0.001) higher than all the others (See Table 3). All four sum variables correlated with each other in a significant manner. The highest correlation was seen between the sum variables
Table 3 The sum variables of the continuity of care Spearman’s correlations rs between the sum variablesa Sum variable
n
Mean (SD)
Median
Range
Alpha
Time flow
Coordination flow
Caring relationship flow
Information flow Coordination flowb Time flowb Caring relationship flow Total continuity of care
202 200 202 200 199
4.53 4.37 4.27 3.73 4.23
4.67 4.44 4.44 3.67 4.33
2.22–5 2.67–5 2.37–5 1.78–5 2.78–5
0.78 0.77 0.75 0.74 0.89
0.37*** 0.59*** – 0.33***
0.60*** – – 0.43***
0.39***
(0.51) (0.55) (0.65) (0.79) (0.47)
a
All correlations are significant. Difference between Time flow and Coordination flow is not significant. All other pairwise differences between the four sum variables are significant (p < 0.001). ***p < 0.001.
b
© 2013 Nordic College of Caring Science
Patient care continuity coordination and information flow (rs = 0.60) and the lowest between time flow and caring relationship flow (rs = 0.33). As a whole, patients felt that continuity of care was well realised. In different categories, the best areas were identified, however. There were both aspects that were well realised and aspects in need of development in the following subcategories of continuity of care: time, coordination, caring relationship and information flow (See Table 4).
Continuity of care in relation to background variables Background variables were examined in relation to the total sum score of continuity of care (=total continuity of care). The realisation of continuity of care was
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statistically significantly associated with certain background factors. In patients’ opinion, total continuity of care was better realised when the patients knew the healthcare professionals who were caring for them (See Table 5). Statistically significant associations were also seen when looking at the subcategories time, coordination, caring relationship and information flow in relation to background factors. In more detail, significant associations were found in the subcategories of continuity of care with how rapidly the patient had been admitted to the procedure, the procedure the patient had undergone and the patient’s need for further guidance. Meeting healthcare professionals and the nurse and surgeon both before and after the procedure had a significant impact, as did preoperative discussion (See Table 6).
Table 4 Realisation of subcategories of continuity of care from patients’ viewpoint Subcategory of continuity of care
Well realised
Areas in need of development
Time flow
No unnecessary waiting on the day of the operation Clear schedule in all phases of treatment
Coordination flow
Preparation for the procedure, treatment on the day of operation and follow-up well organised Systematic cooperation between treatment units prior to and on the day of operation On the day of operation, treating nurse and physician took patient’s matters in hand
Wish for smoother preparation during the period leading up to the operation More rapid admittance to operation Systematic cooperation between different treatment units during the period following the operation
Caring relationship flow
Information flow
Sufficient information provided at different stages of treatment Information and documents related to patient’s care were systematically transferred from one unit to another prior to and on the day of the procedure
At home during the period leading up to the operation, the patient knows the treating nurse and physician, and they take the patient’s matter in hand Knowledge of who is responsible for the care of a day surgical patient at different phases Information about patient’s treatment and transfer of documents during the period following the operation
Table 5 Patients’ perception of the continuity of care, total sum score in relation to background variables The independent determinants of sum.total flow. Multivariate linear model. Model 100*R2 = 23.1% Model p < 0.0001 Determinant n Adjusted mean (SE)a Before the procedure, did the patient know who would care for him/her? Yes 33 4.30 (0.09) No 148 4.01 (0.05) After the procedure, did the patient meet the nurse who cared for him/her before the procedure? Yes 152 4.25 (0.05) No 29 4.06 (0.09) After the procedure, did the patient meet the operating surgeon? Yes 104 4.23 (0.06) No 77 4.07 (0.07) SE, standard error of estimate. a The adjusted mean is the mean value of the category adjusted by all other determinants in the model. b Significance of the determinant. © 2013 Nordic College of Caring Science
pb
0.0005
0.032
0.015
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Table 6 Association of subcategories of continuity of care with background variables from patients’ viewpoint Determinant
n
Adjusted mean (SE)a
The independent determinants of sum.time flow. Multivariate linear model. Model 100*R2 = 42.4% Model p < 0.0001 How long did it take for the patient to be admitted to the procedure? 3 months 115 4.27 (0.07) More than 3 months 76 3.96 (0.08) After the procedure, did the patient meet the nurse (same as before the procedure)? Yes 161 4.26 (0.05) No 30 3.97 (0.12) I had need for further guidance at homec I totally disagree 97 4.26 (0.09) I partly disagree or don’t agree or disagree 49 4.14 (0.10) I partly or totally agree 45 3.94 (0.10) The independent determinants of sum.coordination flow. Multivariate linear model. Model 100*R2 = 14.7% Model p < 0.0001 Before the procedure, did the patient know the nurse (who would care for him/her on the day of the operation) Yes 35 4.47 (0.10) No 158 4.20 (0.05) How long did it take for the patient to be admitted to the procedure? 3 months 116 4.43 (0.07) More than 3 months 77 4.25 (0.08) The independent determinants of sum.caring relationship Multivariate linear model. Model 100*R2 = 33.8% Model p < 0.0001 Procedure Hernia 1 134 3.74 (0.07) Cholecystectomy 2 45 4.04 (0.11) The patient came in to discuss the coming operation before being admitted Yes 74 4.03 (0.09) No 105 3.75 (0.09) Before the procedure, did the patient know the nurse (who would care for him/her on the day of the operation) Yes 33 4.05 (0.13) No 146 3.73 (0.07) Before the procedure, did the patient know the operating surgeon? Yes 63 4.10 (0.09) No 116 3.69 (0.10) After the procedure, did the patient meet the operating surgeon? Yes 103 4.05 (0.08) No 76 3.73 (0.09) I had need for further guidance at home I totally disagree 93 4.18 (0.09) I partly disagree or don’t agree or disagree 46 3.73 (0.11) I partly or totally agree 40 3.76 (0.11) The independent determinants of sum.information flow. Multivariate linear model. Model 100*R2 = 16.2% Model p < 0.0001 Before the procedure, did the patient know the nurse (who would care for him/her on the day of the operation) Yes 36 4.61 (0.08) No 160 4.35 (0.05)
pb
0.0008
0.028
0.024
0.007
0.020
0.009
0.004
0.028
0.0006
0.001
0.0001
0.003
SE, standard error of estimate. The adjusted mean is the mean value of the category adjusted by all other determinants in the model. b Significance of the determinant. c The only significant pairwise difference between categories I totally disagree and I partly or totally agree. In pairwise comparisons, the difference between the category I totally agree and the other two categories is significant. a
Discussion The purpose of this study was to describe how the continuity of care and the factors connected to it are realised in day surgical care from patients’ viewpoint. Based on patients experiences, continuity of care is well realised as
a rule. There is room for improvement in the subcategories of continuity of care, especially time flow and caring relationship flow. The perception of continuity of care is improved by patients knowing before the procedure who the nurse taking care of them is. The fact that after the operation, © 2013 Nordic College of Caring Science
Patient care continuity patients meet the operating surgeon and the nurse who took care of them before the operation also has a positive impact. The findings above also support earlier research. Patients have expressed a wish to meet the operating surgeon prior to the operation (22). The study of Kanerva (34) also showed that sufficient provision of information was associated with knowledge of caring staff and meeting them before the operation (34). Based on their findings, Fraczyk and Godfrey (45) recommended sending patients to preoperative assessment immediately following their outpatient consultation, which would also provide more seamless service and promote increased patient satisfaction levels (45). In their study, B€ackstr€ om et al. (30) stated that continuity of care can be improved by a postoperative meeting between patients and those who cared for them. Patients who were admitted to treatment in
