CARE OF THE OLDER PERSON
Experiences of intermediate care among older people: a phenomenological study Bente Martinsen, Annelise Norlyk, Kirsten Lomborg
Bente Martinsen, Associate Professor, Annelise Norlyk, Associate Professor, Kirsten Lomborg, Professor, Section of Nursing, Department of Public Health, Faculty of Health Sciences, Aarhus University, Copenhagen, Denmark Email: [email protected]
Intermediate care in Denmark In Denmark, both hospital and community health care is publicly financed. Together with general practice, these
Abstract
In the UK, intermediate care (IC) is conceived as a range of service models aimed at ‘care closer to home’ and involves the expansion and development of community health and social services. Intermediate care in Denmark is more clearly defined, where approximately 45% of all the counties in Denmark have established a community-based IC unit in which public health-care services are offered to older people who have completed their hospital treatment. The impact of this organisational initiative is yet to be explored. In particular, the knowledge of the patient perspective is sparse and contradictory. The aim of the study was to explore how older people experience being in an IC unit after hospital discharge and before returning to their home. Data were drawn from 12 semi-structured interviews. Transcripts were analysed using a phenomenological approach. The essence of being in an IC unit was envisioned as ‘moments of conditional relief’ that emerged from the following constituents: ‘accessible, embracing care’, ‘a race against time’, ‘meals— conventions with modifications’, ‘contact on uneven terms’, ‘life on others’ terms’, and ‘informal but essential help’.
KEY WORDS
w Intermediate care w Older people w Interview w Phenomenology
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services are an integral part of the Danish national health service. Likewise, rehabilitation programs and communitybased training is provided through public health insurance. As in other Western countries, community-based intermediate care (IC) has gradually been developed in Denmark, primarily in order to safeguard older people from being discharged to their own homes before they are sufficiently recovered. IC was originally developed in the UK as part of the NHS Plan in 2000 (Young, 2009), and numerous definitions and clarifications have been proposed (Andrews et al, 2004;Young, 2009). IC has recently become a crucial part of the Danish government’s policy, with the dual aim of improving public health services for older people and reducing costs (Danish Health and Medicines Authority, 2014). IC offering individually planned physiotherapy, occupational therapy and care bridges the gap between hospital and home, and aims to promote a quicker recovery, prevent unnecessary acute hospital admissions, support timely hospital discharge and enable people to maintain their independence for as long as possible. In a recent Danish survey within 98 municipalities, of which 97 decided to participate, 27% of the municipalities had instigated an IC unit and 19% indicated that they planned to establish IC facilities; only 9% had no IC (Local Government Denmark, 2014).
Previous research Knowledge of the effect of IC is sparse. A Cochrane review (Griffiths et al, 2007) reports that patients in IC units have fewer and reduced odds of discharge to institutional care, are better prepared for discharge and have a higher functional status. IC was also found to reduce the need for community care services compared to prolonged stays in a general hospital in a randomised controlled trial (RCT) (Garåsen et al, 2008). This RCT further concludes that IC reduces the risk of death within the first year after discharge from an IC unit. However, a recent audit in England showed that IC capacity is half of what is actually required (Kilgore, 2014). Moreover, there is significant variation between localities in terms of capacity outside
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T
he number of general hospital beds occupied by older people has been increasing in recent years (Organization for Economic Co-operation and Development, 2013). In 2013, approximately one-third of all Danish general hospital beds were occupied by patients above the age of 65 years, and in 2035, 25% of the population will be over the age of 65 years (Statistics Denmark, 2014). Due to this demographic development and the general improvement of treatment opportunities, there is an increasing need for hospital admissions, and the common solution has been to reduce the length of hospital stay. This may also be a reasonable development, as hospital admissions may increase the risk of premature death or expose older people to harm and dependency that could have been prevented (James, 2013).
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CARE OF THE OLDER PERSON hospital and in the balance of bed-based, home-based and re-enablement services (Kilgore, 2014). A few studies suggest that patient satisfaction may be improved through IC (Griffiths, 2006; Griffiths et al, 2005; 2007). Accordingly, a qualitative study carried out in an IC unit indicated that patients experience care in an IC unit as more therapeutic and more conducive to recuperating than the care provided in a conventional hospital unit (Wiles et al, 2003). A study of the experience of IC in Norway showed that being perceived as a ‘human being’ and cared for in a peaceful setting compared to the hectic hospital environment was also found to be crucial for the patients in an IC unit (Johannessen and Steihaug, 2013). Physiotherapy plays an important role for the patients and if it is cancelled, it causes disappointment. However, in a Norwegian IC unit, small rooms and bathrooms were found to hamper physical training since there was not enough space for patients using walking aids (Johannessen et al, 2013). Furthermore, dining rooms with a pleasant atmosphere contributed to the process of getting patients back on their feet (Johannessen et al, 2013). Since most of the knowledge of IC units is related to policy and findings derived from the patient perspective are sparse, studies providing a richer description of being in an IC unit are necessary.
supported the therapeutic training. In the IC unit in the western part of Denmark, patients stayed approximately 2 weeks. In the urban (Copenhagen) unit, the stay had no explicit limit; however, discharge had to be preceded by a home visit from an occupational therapist in the patient’s home to identify any needs for personal aids and alterations in the home to make it possible for the patient to resume life at home despite reduced mobility. The sample of participants was composed to achieve a variety of data and not to compare the older people or the IC units in accordance with the phenomenological approach (Dahlberg et al, 2008). Baseline function or other social variables were not included, except marital status (Table 1).
Aim
Qualitative interviews, based on a semi-structured interview guide were conducted with all participants during their stay in the IC units. The first-named and second-
The overall aim of this study was to explore experiences among older people of staying in an IC unit after hospital discharge before being discharged to their home.
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Design, setting and participant characteristics The phenomenological interview study took place in two different IC units in Denmark: a 60-bed unit in Copenhagen and a 20-bed unit with five IC beds in a smaller municipality in the western part of Denmark. Six people from each of the two settings, aged 65 to 87, were consecutively recruited for interview. Inclusion criteria were age 65 or older, not being cognitively impaired, having been treated in a hospital and planned to be discharged to their own home after rehabilitation in the IC unit. The ability to give consent to participate, and being physically and mentally robust enough to take part in the interview was assessed by clinical nurses inviting participants and handing out written information about the study. Afterwards, the researchers contacted the participants and provided verbal information. When the older people had agreed to participate, an appointment for each interview was made. All participants had been through various treatments in hospital and transferred to the IC unit for further rehabilitation and care that could not be provided in their own homes. In both settings, the care was provided by caregivers with different levels of education; registered nurses were present, though, at all shifts. All patients received physiotherapy (e.g. walking and balancing training) and some also received occupational therapy during their stay in the IC unit. The care supplied by the careg ivers
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Ethical considerations The study followed basic principles for research in the Helsinki Declaration (2003) and was approved by the Danish Data Protection Agency [ID no: 2012-41-0340]. According to Danish law, no particular ethical approval was needed to conduct this study. The participants received written and verbal information about the purpose of the study, the right to withdraw at any time without any consequences, and the confidential handling of data.
Method
Data collection
Table 1. Characteristics of participants in the study Participant number
Gender
Age
Civil status
Condition before admission to hospital
Intermediate care unit in the provincial county 1
Male
82
Single
Self-reliant
2
Female
87
Single
Receives help for cleaning two hours every other week
3
Female
77
Single
Self-reliant
4
Female
87
Single
Self-reliant
5
Female
78
Single
Self-reliant
6
Female
60
Living with a son
Self-reliant, still in work
Intermediate care unit in the capital 7
Male
94
Single
Receives support from community care for cleaning and shopping every week
8
Female
92
Single
Self-reliant
9
Male
68
Married
Self-reliant, still in work
10
Female
80
Single
Self-reliant
11
Female
71
Single
Self -reliant
12
Female
76
Single
Self-reliant
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CARE OF THE OLDER PERSON
Data analysis The study was carried out using the phenomenological approach of reflective lifeworld research (RLR) (Dahlberg et al, 2008). The aim of RLR is to reflect on lifeworld meanings and make the tacit aspects of human existence explicit. In this search for meaning, the researcher’s openness is important. This openness can be accomplished by the process of ‘bridling’. This includes a reflective process of going beyond taken-for-granted understandings by retaining an open mind to see the world differently and possibly be surprised by new meanings as they arise. The interviews were analysed according to the RLR guidelines. The analysis process focused on discovering patterns of meaning, variations and finally a description of the essential meaning, i.e. the characteristics of a phenomenon and its constituents. The constituents are interrelating aspects of the structure that shows the variation in the data (Dahlberg et al, 2008). The analysis began with repeated readings of all the interview transcriptions to obtain a global sense of each participant’s description. Afterwards, each transcript was re-read and divided into meaning units. The meaning units were carefully examined to explicate all meanings that disclosed aspects of experiences of being in an IC unit. This search for meanings was characterised by an intensive dialogue with the text. Questions such as ‘what is being said?’, ‘how is it said?’, ‘what is the meaning?’ were asked by the authors. Furthermore, critical questions such as ‘is this the actual meaning or can it mean something else?’ were asked. The emerging meaning units were clustered into a temporary pattern of meanings. This was followed by a process of open reflection to synthesise the clustered meaning units and clarify the essential structure of experiences of being in an IC unit among older people.
Results Experiences among older people of being in an IC unit after hospital discharge and before returning to their home are presented below as a structure with the essence or main theme ‘moments of conditional relief ’ and six constituents: 1. Accessible, embracing care 2. A race against time 3. Meals—conventions with modifications 4. Contact on uneven terms 5. Life on other people’s terms 6. Informal but essential help.
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Moments of conditional relief The older people’s experiences of being in an IC unit were characterised by gratefulness for the friendly and individual care provided. The participants experienced the staff as generally accessible and ready to meet their individual needs. This was different from what they experienced in hospital. The participants were aware that the aim of their stay in the IC unit was to improve their mobility to such an extent that they could be discharged to their homes, and they trained persistently to achieve this. The participants had great confidence in their informal helpers (relatives, friends, etc.) stepping in after discharge, although the participants foresaw that coming home would reduce their level of functional ability. They therefore tried to exercise as much as possible during their IC stay. The accessibility of the staff empowered and increased their sense of security so much that they attempted to expand their physical limits. In the IC unit, the contact with the other patients provided an opportunity for the older people to compare their own abilities with others and challenge the existing conventions for social interaction.
1. Accessible, embracing care Being in an IC unit was experienced as a contrast to the preceding stay in hospital. Without prompting, the participants compared their relationship with the staff of the IC unit to that of the hospital staff; the result clearly favoured the IC unit. The accessibility and friendliness of the care staff was repeatedly emphasised. The participants were sensitive to the atmosphere in the unit, and the tone of voice and attitude of staff affected them. They attempted to read the mood of the staff, expecting to be neglected, and were positively surprised when they were treated with respect:
‘When they come [in response to a call], they are not at all disagreeable’ (Participant 3).
Time and accessibility was crucial to the care experience, which was characterised as individualised and attentive. The participants felt that staff kept an eye on them and provided the necessary care. The friendly atmosphere and individual care generated security and high spirits and motivated the older people to test the limits of their physical ability. The care was perceived as an invisible helping hand or a third eye:
‘Someone is there to assist you without you noticing, but you can sense the “helping hand”’ (Participant 5). The older people expressed profound gratitude and attempted to inconvenience the staff minimally. This was conveyed by the participants trying to match their own needs to the tasks that were already being performed in the room, and not trouble the staff unnecessarily:
‘It was usually when I was having my cup of coffee—I would ask them to fetch something for me’ (Participant 3). The participants had some difficulty distinguishing between the various staff groups. They did, however, quickly learn to distinguish between staff they could easily get help from and the more reluctant staff members:
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named authors, both experienced phenomenological researchers, performed six interviews each. Following an opening question ‘what is a typical day like in this ward?’, participants were encouraged to elaborate on their experiences of care and physical training with prompts like ‘please tell me more’ or ‘can you give an example of this?’. All interviews were conducted (confidentially) in separate rooms and lasted from 19 to 86 minutes, depending on the participants’ condition. The interviews were digitally recorded and verbally transcribed by the first-named and second-named author.
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CARE OF THE OLDER PERSON ‘The good ones aren’t here all the time. You soon know exactly who to contact for what. There are days when it is impossible to get into contact with the staff you want to. It’s not very reassuring’ (Participant 9). Although a few caregivers delivered care that was considered less embracing than the majority, the older people expressed faith in the caregivers’ readiness to meet their needs in almost every aspect.
2. A race against time Despite the different lengths of stay, it was striking that the older people in both IC units experienced a time pressure that was crucial for engagement in their training activities, and they tried their best to obtain the best possible functional level before their discharge.Training was experienced as meaningful, but exhausting. The success of the training and the secure feeling motivated them to redefine their own limits, and gave them the energy to take on more training. This created a positive spiral. Getting help quickly from the staff and not risking lying on the floor for an extended time after a fall was extremely important for the participants’ enthusiasm for exercise:
‘Last night was the first time I got up by myself and put my shoes on and thought “I hope I am doing the right thing”, but I have to try and someone will come if it goes wrong—at home, nobody would come’ (Participant 10). The participants’ stay in the IC unit was decisive for the outcome of their rehabilitation. In particular, their previous ability to get around by walking or using a wheelchair was very much in focus. A slow rehabilitation process could cause considerable concern before discharge:
‘I was very nervous about how this would pan out and how long I would be allowed to stay. I am not keen to get home before I can manage by myself’ (Participant 11).
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The encouragement of the staff was extremely important for the participants.Without ordering them around or controlling them, the staff strengthened the older people’s selfconfidence and motivated them to continue the training. The participants were well aware that the most intensive training they would get would be during their stay in the IC unit, and that the initiative would subsequently be up to them. They worried that the discharge would reduce their functional ability or create new problems. In the ward where home visits by a therapist were arranged, the visits were experienced as crucial for returning to their own home. The home visit was anxiously awaited and experienced as a kind of test that was decisive for the time of discharge:
‘I’m scared of going home. I would have preferred if they had kept me a little longer so that I would be in better shape than I am now’ (Participant 2). Even participants who were definitely looking forward to being discharged were concerned about how far they could get with their rehabilitation before this transition to their own home. On one hand, they wanted to go home as soon as pos-
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sible; on the other hand, they feared getting home too early.
3. Meal conventions with modifications The meals in the IC unit were important—both the quality of the meals and the social companionship that could develop from them. The older people spoke without prompting about various aspects of the meals and compared them with the meals at home or in hospital. Meals were most appreciated when they looked and tasted like the meals they were used to. This was not necessarily always the case, making it difficult to work up an appetite at times. The potential for companionship during meals was emphasised as significant, regardless of whether the older people chose to eat alone or took part in the communal meals. Choice was important, but the participants were aware that the staff preferred that they ate together with the other patients. It was sometimes difficult to eat with the others, as the basic norms were not always easy to observe. For example, eating together meant being confronted with one’s own incapability or the incapability of others to eat in an aesthetically pleasant way. One important aspect of communal meals was the possibility of talking to fellow patients during the meal, although the participants were not always guaranteed to be sitting next to someone they could talk to, which could be crucial for their decision:
‘There is no conversation. None at all. You talk perhaps to the person sitting across from you, but it may be someone new next time—morning, noon and night’ (Participant 8). In some cases, the caregivers contributed to the conversation in a way that facilitated a dialogue.
4. Contact on uneven terms Being in an IC unit meant that the participants were forced to socialise with others, which was something they had not chosen themselves. This required extra resources and the participants felt they needed to find their own feet before being able to socialise. They could occasionally pick and choose themselves:
‘It’s not compulsory, and you don’t feel so pressured when you’re not eating with the others’ (Participant 1). The participants would sometimes compare own functional abilities with the other patients in the IC unit. To observe the physical progress of others could strengthen their motivation to train, but at the same time, the reduced mobility of their fellow patients was often difficult to witness and would discourage them from sitting in the communal room:
‘I think I would have great difficulty sitting with the very old and ill people out there. I just can’t take it’ (Participant 12). The participants would approach the other patients with caution, and found it difficult to establish a proper relationship. When they identified a person with a similar functional level, it was natural to try to get closer to them during a meal and have a normal conversation:
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‘I have met some of them, but it’s like nobody tries to be sociable or talk. Someone says something, but there is no inclination to have a chat’ (Participant 6). The staff could operate as ‘invisible helpers’ during the older people’s socialising time and facilitate the interaction by modifying some of their behaviour to comply more with the conventions of society. The participants experienced that the staff generated a particularly good homely atmosphere by, for example, arranging an evening that involved something more than the usual care.
5. Life on other people’s terms The participants spontaneously compared their hospital stay to the stay in the IC unit, and the result strongly disfavoured the hospitals. At times they felt overlooked and the things they found important were ignored, and only got worse. A one-sided emphasis on the reason for hospitalisation and no support for the physical training could result in reduced mobility, which intensified the need for rehabilitation:
‘I was in hospital for about a month because they had to find out what sort of medicine I was to have. But I was lying in bed and didn’t get any exercise at all. In the end, I could hardly sit or stand. I just lay there—and lost all the power of my legs’ (Participant 11). Contact with the hospital staff was not necessarily very good. The participants felt that they were considered as troublesome, not fitting in, or the wrong age:
‘I am sorry to say this, but when you’re over 60— and I am nearly 87—well, you are just a pile of junk’ (Participant 4).
6. Informal but essential help The participants were conscious of becoming a burden to their spouse or adult children. The relatives were supportive of the training through encouragement and a comfortcreating presence:
‘My son and daughter take me for walks along the corridor, so I get a little exercise there. They stand beside me, as I try standing on my own’ (Participant 7). The thought of getting help from friends and neighbours could reduce the anxiety in connection with returning home. In some cases, this informal help was offered because of newly arisen needs, and in other cases it was help that had already been provided before the hospitalisation.
Discussion It is well known that patient satisfaction may be improved through IC (Griffiths, 2006; Griffiths et al, 2005; 2007), but in our study the experience of being in an IC unit was also characterised by a deep sense of gratefulness. In contrast to staying in a hospital, the older people felt they were regarded as important and worth making an effort for. Again and again, the participants highlighted that the caregivers treated them as equal partners and contrasted this friendly approach to the way they were treated in hospital.
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This finding links to the finding of Wiles et al (2003), who reported that patients experience care in an IC unit as more therapeutic and conducive to recovery than the care provided in a conventional unit (Wiles et al, 2003), since a friendly attitude from the caregivers may be therapeutic and recovering in itself. Our study also adds to the findings of Johannesen and Steihaug (2013), who stressed the importance of being seen as a ‘human being’ in the IC unit. The present study showed that being considered a human is linked to feelings of being embraced by care, and experiencing care as individual and attentive. Although the study showed these feelings to be significant to the participants, it was also found that the older people expected a more guarded attitude from the caregivers than they actually exhibited. This filled the older people with gratitude. The present study highlights that the physical environment and also the atmosphere in the ward have several meanings influencing the participants’ wellbeing, contributing positively to their commitment to training. In line with our findings, it is documented that the design of the physical environment as well as patient rooms can be a source of stress for patients; on the other hand, it can also contribute to support the healing process of patients (La Torre, 2006; Lorenz, 2007; Lawson, 2010; Johannesen et al, 2013). Edvardsson et al (2005) focused on the influence of the environment on patients’ experiences of nursing care in institutional settings. They found that both the physical environment and also the psychosocial environment are important for reducing patients’ suffering, e.g. by impacting on patients’ feelings of integrity, interaction and wellbeing. The present study supports these findings, and Edvardsson et al (2005) further revealed that the participants linked the space of the ward to feelings of security because of the ready access to professional help. Moreover, the professionals’ positive attitude towards them created a specific spirit that was transferred to participants. According to the nurse and philosopher Kari Martinsen (2006), the atmosphere in the rooms is a spatial experience. Martinsen (2006) points out that the sickroom is a special space that has its own resonance and dignity, which is transferred to patients. The present study revealed how this specific tone on a ward significantly influenced the patients and not only generated feelings of wellbeing, but also contributed to a sense of courage in living. Concerns regarding the upcoming discharge among some of the participants may be caused by lack of knowledge about the available aids such as fall alarms. According to Honneth (1995), all humans strive to be recognised by others. This recognition is crucially dependent on the development of self-respect, self-confidence and self-esteem. These three modes of relating to oneself represent three distinct species of practical relation to oneself. They are not purely beliefs about oneself, nor are they emotional states, but involve a dynamic process in which individuals experience themselves as having a certain status. Honneth (1995) emphasises that relating to oneself in these ways necessarily involves experiencing recognition from others. The present study’s findings indicate that the older people felt that their relationship with the caregivers had
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CARE OF THE OLDER PERSON
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CARE OF THE OLDER PERSON gone beyond what they expected. In the light of Honneth’s theory, the caregivers’ interest and individualised care can be understood as a sign of recognition of the participants. The relationship to oneself is not a matter of a solitary ego appraising oneself, but an intersubjective process, in which one’s attitude towards oneself emerges in an encounter with another’s attitude towards oneself (Honneth, 1995). Thus, the embracing approach of caregivers generated a feeling of recognition in the participants that was seemingly crucial for their enthusiasm concerning their physical training and striving to be as self-reliant as possible.
Strengths and limitations Key strengths of the study were the use of descriptive phenomenology allowing flexible interviews that provided opportunities for the participants to elaborate freely on their experiences and thoughts regarding care in an IC unit. The participants’ different basic diseases and conditions increased the variation in data; this is important for research based on phenomenology (Dahlberg et al, 2008). Neither the diseases nor the participants’ functional status was, however, the study focus. Rather, the study aimed at providing a snapshot of older people’s experiences of being in an IC unit after hospital discharge and before being discharged to their own home.
Conclusion The experience of being in an IC unit after hospital discharge and before being discharged home was, first and foremost, characterised by satisfaction and gratefulness. This study’s findings showed that the staff had a major influence on the atmosphere of the ward. Accessible, attentive care and the psychosocial and physical environment were found to be of great importance for the older people in IC units. The healing environment and friendly attitude can be understood as a sign of recognition from the caregivers. This personal recognition generated a certain commitment towards the physical training that may be significant for the functional ability of older people over time.
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Implications for practice This study has demonstrated that older people appreciate caregivers in IC units who are sensitive to their needs and adjust care plans to individual needs and preferences. Being friendly and communicating at the same level as the older people contributes to the healing atmosphere just as much as the aesthetic dimension of the ward. Therefore, the significance of the environment should not be underestimated when planning new IC units or renovating existing ones. The fact that IC units offer health-care services to people with different challenges means that caregivers have a special obligation to maintain the current norms of society, and to try to facilitate social interaction between the older people. The results indicate that hospital staff may benefit from feedback based on the experiences of hospitalised older people. Furthermore, the results of this study point to the need for increased cooperation between IC units, general hospitals and community health care. It is suggested that this
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should be implemented in a modern, flexible form without time-consuming, physical face-to-face meetings. BJCN Accepted for publication: 8 December 2014 Andrews J, Manthorpe J, Watson R (2004) Involving older people in intermediate care. J Adv Nurs 46(3): 303–10. doi: 10.1111/j.1365-2648.2004.02990.x Dahlberg K, Dahlberg H, Nyström M (2008) Reflective Lifeworld Research, 2nd edn. Studentlitteratur, Sweden Danish Health and Medicines Authority. Quality in Emergency Services of Municipal Home Nursing. http://bit.ly/1xKtUKR (accessed 1 May 2014) (In Danish.) Edvardsson JD, Sandman P, Rasmussen BH (2005) Sensing an atmosphere of ease: a tentative theory of supportive care settings. Scand J Caring Sci 19(4): 344–53. doi: 10.1111/j.1471-6712.2005.00356.x Garåsen H, Windspoll R, Johnsen R (2008) Long-term patients’ outcomes after intermediate care at a community hospital for elderly patients: 12-month follow-up of a randomized controlled trial. Scand J Public Health 36(2): 197–204. doi: 10.1177/1403494808089685 Griffiths P (2006) Effectiveness of intermediate care delivered in nurse-led units. Br J Community Nurs 11(5): 205–8 Griffiths P, Edwards M, Forbes A, Harris R (2005) Post-acute intermediate care in nursing-led units: a systematic review of effectiveness. Int J Nurs Stud 42(1): 107–16. doi: 10.1016/j.ijnurstu.2004.07.010 Griffiths PD, Edwards MH, Forbes A, Harris RL, Ritchie G (2007) Effectiveness of intermediate care in nursing-led in-patient units. Cochrane Database Syst Rev 18(2): CD002214 Honneth A (1995) The Struggle for Recognition: The Moral Grammar of Social Conflicts. Polity Press, Cambridge James JT (2013) A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 9(3): 122–8. doi: 10.1097/PTS.0b013e3182948a69 Johannessen AK, Steihaug S (2013) The significance of professional roles in collaboration on patients’ transitions from hospital to home via an intermediate unit. Scand J Caring Sci 28(2): 364–72. doi: 10.1111/scs.12066 Johannessen AK, Werner A, Steihaug S (2013) Work in an intermediate unit: balancing between relational, practical and moral care. J Clin Nurs 23(3–4): 586–95. doi: 10.1111/jocn.12213 Kilgore C (2014) Why intermediate care services need to be refreshed. Nurs Older People 26(3): 16–20. doi: 10.7748/nop2014.03.26.3.16.e570. La Torre MA (2006) Creating a healing environment. Perspectives Psychiatric Care 42(4): 262–4. doi:10.1111/j.1744-6163.2006.00086.x Lawson B (2010) Healing architecture. Arts & Health 2(2): 95–108 Lorenz SG (2007) The potential of the patient room to promote healing and well-being in patients and nurses: an integrative review of the research. Holistic Nursing Practice 21(5): 263–77. doi: 10.1097/01.HNP.0000287990.40215.51 Local Government Denmark (2014) Tips for strengthening municipal emergency services. http://bit.ly/1HUUtzL (accessed 20 January 2014) Martinsen K (2006) Care and Vulnerability. Akribe, Oslo Organisation for Economic Co-operation and Development (2013) OECD Regions at a Glance. OECD Publishing, Paris. http://dx.doi.org/10.1787/ reg_glance-2013-en Statistics Denmark (2014) Population in 2014, by sex, age and country of origin. http://bit.ly/1Aum7Ab (accessed 5 June 2014) Wiles R, Postle K, Steiner A, Walsh B (2003) Nurse-led intermediate care: patients’ perceptions. Int J Nurs Stud 40(1): 61–71. doi: 10.1016/S00207489(02)00033-0 Young J (2009) The development of intermediate care services in England. Arch Gerontology Geriatrics 49(suppl. 2): 21–5. doi: 10.1016/S0167-4943(09)70008-1
KEY POINTS
w Being in an intermediate care unit after hospital treatment may be experienced as a relief
w The caregivers’ accessibility is crucial for the older people’s determination and drive to exceed their own limits in their physical training
w The physical environment and the caregivers’ tone of voice play an important role for the constitution of a healing atmosphere
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Experiences of intermediate care among older people: a phenomenological study Bente Martinsen, Annelise Norlyk, Kirsten Lomborg
Bente Martinsen, Associate Professor, Annelise Norlyk, Associate Professor, Kirsten Lomborg, Professor, Section of Nursing, Department of Public Health, Faculty of Health Sciences, Aarhus University, Copenhagen, Denmark Email: [email protected]
Intermediate care in Denmark In Denmark, both hospital and community health care is publicly financed. Together with general practice, these
Abstract
In the UK, intermediate care (IC) is conceived as a range of service models aimed at ‘care closer to home’ and involves the expansion and development of community health and social services. Intermediate care in Denmark is more clearly defined, where approximately 45% of all the counties in Denmark have established a community-based IC unit in which public health-care services are offered to older people who have completed their hospital treatment. The impact of this organisational initiative is yet to be explored. In particular, the knowledge of the patient perspective is sparse and contradictory. The aim of the study was to explore how older people experience being in an IC unit after hospital discharge and before returning to their home. Data were drawn from 12 semi-structured interviews. Transcripts were analysed using a phenomenological approach. The essence of being in an IC unit was envisioned as ‘moments of conditional relief’ that emerged from the following constituents: ‘accessible, embracing care’, ‘a race against time’, ‘meals— conventions with modifications’, ‘contact on uneven terms’, ‘life on others’ terms’, and ‘informal but essential help’.
KEY WORDS
w Intermediate care w Older people w Interview w Phenomenology
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services are an integral part of the Danish national health service. Likewise, rehabilitation programs and communitybased training is provided through public health insurance. As in other Western countries, community-based intermediate care (IC) has gradually been developed in Denmark, primarily in order to safeguard older people from being discharged to their own homes before they are sufficiently recovered. IC was originally developed in the UK as part of the NHS Plan in 2000 (Young, 2009), and numerous definitions and clarifications have been proposed (Andrews et al, 2004;Young, 2009). IC has recently become a crucial part of the Danish government’s policy, with the dual aim of improving public health services for older people and reducing costs (Danish Health and Medicines Authority, 2014). IC offering individually planned physiotherapy, occupational therapy and care bridges the gap between hospital and home, and aims to promote a quicker recovery, prevent unnecessary acute hospital admissions, support timely hospital discharge and enable people to maintain their independence for as long as possible. In a recent Danish survey within 98 municipalities, of which 97 decided to participate, 27% of the municipalities had instigated an IC unit and 19% indicated that they planned to establish IC facilities; only 9% had no IC (Local Government Denmark, 2014).
Previous research Knowledge of the effect of IC is sparse. A Cochrane review (Griffiths et al, 2007) reports that patients in IC units have fewer and reduced odds of discharge to institutional care, are better prepared for discharge and have a higher functional status. IC was also found to reduce the need for community care services compared to prolonged stays in a general hospital in a randomised controlled trial (RCT) (Garåsen et al, 2008). This RCT further concludes that IC reduces the risk of death within the first year after discharge from an IC unit. However, a recent audit in England showed that IC capacity is half of what is actually required (Kilgore, 2014). Moreover, there is significant variation between localities in terms of capacity outside
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T
he number of general hospital beds occupied by older people has been increasing in recent years (Organization for Economic Co-operation and Development, 2013). In 2013, approximately one-third of all Danish general hospital beds were occupied by patients above the age of 65 years, and in 2035, 25% of the population will be over the age of 65 years (Statistics Denmark, 2014). Due to this demographic development and the general improvement of treatment opportunities, there is an increasing need for hospital admissions, and the common solution has been to reduce the length of hospital stay. This may also be a reasonable development, as hospital admissions may increase the risk of premature death or expose older people to harm and dependency that could have been prevented (James, 2013).
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CARE OF THE OLDER PERSON hospital and in the balance of bed-based, home-based and re-enablement services (Kilgore, 2014). A few studies suggest that patient satisfaction may be improved through IC (Griffiths, 2006; Griffiths et al, 2005; 2007). Accordingly, a qualitative study carried out in an IC unit indicated that patients experience care in an IC unit as more therapeutic and more conducive to recuperating than the care provided in a conventional hospital unit (Wiles et al, 2003). A study of the experience of IC in Norway showed that being perceived as a ‘human being’ and cared for in a peaceful setting compared to the hectic hospital environment was also found to be crucial for the patients in an IC unit (Johannessen and Steihaug, 2013). Physiotherapy plays an important role for the patients and if it is cancelled, it causes disappointment. However, in a Norwegian IC unit, small rooms and bathrooms were found to hamper physical training since there was not enough space for patients using walking aids (Johannessen et al, 2013). Furthermore, dining rooms with a pleasant atmosphere contributed to the process of getting patients back on their feet (Johannessen et al, 2013). Since most of the knowledge of IC units is related to policy and findings derived from the patient perspective are sparse, studies providing a richer description of being in an IC unit are necessary.
supported the therapeutic training. In the IC unit in the western part of Denmark, patients stayed approximately 2 weeks. In the urban (Copenhagen) unit, the stay had no explicit limit; however, discharge had to be preceded by a home visit from an occupational therapist in the patient’s home to identify any needs for personal aids and alterations in the home to make it possible for the patient to resume life at home despite reduced mobility. The sample of participants was composed to achieve a variety of data and not to compare the older people or the IC units in accordance with the phenomenological approach (Dahlberg et al, 2008). Baseline function or other social variables were not included, except marital status (Table 1).
Aim
Qualitative interviews, based on a semi-structured interview guide were conducted with all participants during their stay in the IC units. The first-named and second-
The overall aim of this study was to explore experiences among older people of staying in an IC unit after hospital discharge before being discharged to their home.
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Design, setting and participant characteristics The phenomenological interview study took place in two different IC units in Denmark: a 60-bed unit in Copenhagen and a 20-bed unit with five IC beds in a smaller municipality in the western part of Denmark. Six people from each of the two settings, aged 65 to 87, were consecutively recruited for interview. Inclusion criteria were age 65 or older, not being cognitively impaired, having been treated in a hospital and planned to be discharged to their own home after rehabilitation in the IC unit. The ability to give consent to participate, and being physically and mentally robust enough to take part in the interview was assessed by clinical nurses inviting participants and handing out written information about the study. Afterwards, the researchers contacted the participants and provided verbal information. When the older people had agreed to participate, an appointment for each interview was made. All participants had been through various treatments in hospital and transferred to the IC unit for further rehabilitation and care that could not be provided in their own homes. In both settings, the care was provided by caregivers with different levels of education; registered nurses were present, though, at all shifts. All patients received physiotherapy (e.g. walking and balancing training) and some also received occupational therapy during their stay in the IC unit. The care supplied by the careg ivers
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Ethical considerations The study followed basic principles for research in the Helsinki Declaration (2003) and was approved by the Danish Data Protection Agency [ID no: 2012-41-0340]. According to Danish law, no particular ethical approval was needed to conduct this study. The participants received written and verbal information about the purpose of the study, the right to withdraw at any time without any consequences, and the confidential handling of data.
Method
Data collection
Table 1. Characteristics of participants in the study Participant number
Gender
Age
Civil status
Condition before admission to hospital
Intermediate care unit in the provincial county 1
Male
82
Single
Self-reliant
2
Female
87
Single
Receives help for cleaning two hours every other week
3
Female
77
Single
Self-reliant
4
Female
87
Single
Self-reliant
5
Female
78
Single
Self-reliant
6
Female
60
Living with a son
Self-reliant, still in work
Intermediate care unit in the capital 7
Male
94
Single
Receives support from community care for cleaning and shopping every week
8
Female
92
Single
Self-reliant
9
Male
68
Married
Self-reliant, still in work
10
Female
80
Single
Self-reliant
11
Female
71
Single
Self -reliant
12
Female
76
Single
Self-reliant
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CARE OF THE OLDER PERSON
Data analysis The study was carried out using the phenomenological approach of reflective lifeworld research (RLR) (Dahlberg et al, 2008). The aim of RLR is to reflect on lifeworld meanings and make the tacit aspects of human existence explicit. In this search for meaning, the researcher’s openness is important. This openness can be accomplished by the process of ‘bridling’. This includes a reflective process of going beyond taken-for-granted understandings by retaining an open mind to see the world differently and possibly be surprised by new meanings as they arise. The interviews were analysed according to the RLR guidelines. The analysis process focused on discovering patterns of meaning, variations and finally a description of the essential meaning, i.e. the characteristics of a phenomenon and its constituents. The constituents are interrelating aspects of the structure that shows the variation in the data (Dahlberg et al, 2008). The analysis began with repeated readings of all the interview transcriptions to obtain a global sense of each participant’s description. Afterwards, each transcript was re-read and divided into meaning units. The meaning units were carefully examined to explicate all meanings that disclosed aspects of experiences of being in an IC unit. This search for meanings was characterised by an intensive dialogue with the text. Questions such as ‘what is being said?’, ‘how is it said?’, ‘what is the meaning?’ were asked by the authors. Furthermore, critical questions such as ‘is this the actual meaning or can it mean something else?’ were asked. The emerging meaning units were clustered into a temporary pattern of meanings. This was followed by a process of open reflection to synthesise the clustered meaning units and clarify the essential structure of experiences of being in an IC unit among older people.
Results Experiences among older people of being in an IC unit after hospital discharge and before returning to their home are presented below as a structure with the essence or main theme ‘moments of conditional relief ’ and six constituents: 1. Accessible, embracing care 2. A race against time 3. Meals—conventions with modifications 4. Contact on uneven terms 5. Life on other people’s terms 6. Informal but essential help.
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Moments of conditional relief The older people’s experiences of being in an IC unit were characterised by gratefulness for the friendly and individual care provided. The participants experienced the staff as generally accessible and ready to meet their individual needs. This was different from what they experienced in hospital. The participants were aware that the aim of their stay in the IC unit was to improve their mobility to such an extent that they could be discharged to their homes, and they trained persistently to achieve this. The participants had great confidence in their informal helpers (relatives, friends, etc.) stepping in after discharge, although the participants foresaw that coming home would reduce their level of functional ability. They therefore tried to exercise as much as possible during their IC stay. The accessibility of the staff empowered and increased their sense of security so much that they attempted to expand their physical limits. In the IC unit, the contact with the other patients provided an opportunity for the older people to compare their own abilities with others and challenge the existing conventions for social interaction.
1. Accessible, embracing care Being in an IC unit was experienced as a contrast to the preceding stay in hospital. Without prompting, the participants compared their relationship with the staff of the IC unit to that of the hospital staff; the result clearly favoured the IC unit. The accessibility and friendliness of the care staff was repeatedly emphasised. The participants were sensitive to the atmosphere in the unit, and the tone of voice and attitude of staff affected them. They attempted to read the mood of the staff, expecting to be neglected, and were positively surprised when they were treated with respect:
‘When they come [in response to a call], they are not at all disagreeable’ (Participant 3).
Time and accessibility was crucial to the care experience, which was characterised as individualised and attentive. The participants felt that staff kept an eye on them and provided the necessary care. The friendly atmosphere and individual care generated security and high spirits and motivated the older people to test the limits of their physical ability. The care was perceived as an invisible helping hand or a third eye:
‘Someone is there to assist you without you noticing, but you can sense the “helping hand”’ (Participant 5). The older people expressed profound gratitude and attempted to inconvenience the staff minimally. This was conveyed by the participants trying to match their own needs to the tasks that were already being performed in the room, and not trouble the staff unnecessarily:
‘It was usually when I was having my cup of coffee—I would ask them to fetch something for me’ (Participant 3). The participants had some difficulty distinguishing between the various staff groups. They did, however, quickly learn to distinguish between staff they could easily get help from and the more reluctant staff members:
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named authors, both experienced phenomenological researchers, performed six interviews each. Following an opening question ‘what is a typical day like in this ward?’, participants were encouraged to elaborate on their experiences of care and physical training with prompts like ‘please tell me more’ or ‘can you give an example of this?’. All interviews were conducted (confidentially) in separate rooms and lasted from 19 to 86 minutes, depending on the participants’ condition. The interviews were digitally recorded and verbally transcribed by the first-named and second-named author.
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CARE OF THE OLDER PERSON ‘The good ones aren’t here all the time. You soon know exactly who to contact for what. There are days when it is impossible to get into contact with the staff you want to. It’s not very reassuring’ (Participant 9). Although a few caregivers delivered care that was considered less embracing than the majority, the older people expressed faith in the caregivers’ readiness to meet their needs in almost every aspect.
2. A race against time Despite the different lengths of stay, it was striking that the older people in both IC units experienced a time pressure that was crucial for engagement in their training activities, and they tried their best to obtain the best possible functional level before their discharge.Training was experienced as meaningful, but exhausting. The success of the training and the secure feeling motivated them to redefine their own limits, and gave them the energy to take on more training. This created a positive spiral. Getting help quickly from the staff and not risking lying on the floor for an extended time after a fall was extremely important for the participants’ enthusiasm for exercise:
‘Last night was the first time I got up by myself and put my shoes on and thought “I hope I am doing the right thing”, but I have to try and someone will come if it goes wrong—at home, nobody would come’ (Participant 10). The participants’ stay in the IC unit was decisive for the outcome of their rehabilitation. In particular, their previous ability to get around by walking or using a wheelchair was very much in focus. A slow rehabilitation process could cause considerable concern before discharge:
‘I was very nervous about how this would pan out and how long I would be allowed to stay. I am not keen to get home before I can manage by myself’ (Participant 11).
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The encouragement of the staff was extremely important for the participants.Without ordering them around or controlling them, the staff strengthened the older people’s selfconfidence and motivated them to continue the training. The participants were well aware that the most intensive training they would get would be during their stay in the IC unit, and that the initiative would subsequently be up to them. They worried that the discharge would reduce their functional ability or create new problems. In the ward where home visits by a therapist were arranged, the visits were experienced as crucial for returning to their own home. The home visit was anxiously awaited and experienced as a kind of test that was decisive for the time of discharge:
‘I’m scared of going home. I would have preferred if they had kept me a little longer so that I would be in better shape than I am now’ (Participant 2). Even participants who were definitely looking forward to being discharged were concerned about how far they could get with their rehabilitation before this transition to their own home. On one hand, they wanted to go home as soon as pos-
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sible; on the other hand, they feared getting home too early.
3. Meal conventions with modifications The meals in the IC unit were important—both the quality of the meals and the social companionship that could develop from them. The older people spoke without prompting about various aspects of the meals and compared them with the meals at home or in hospital. Meals were most appreciated when they looked and tasted like the meals they were used to. This was not necessarily always the case, making it difficult to work up an appetite at times. The potential for companionship during meals was emphasised as significant, regardless of whether the older people chose to eat alone or took part in the communal meals. Choice was important, but the participants were aware that the staff preferred that they ate together with the other patients. It was sometimes difficult to eat with the others, as the basic norms were not always easy to observe. For example, eating together meant being confronted with one’s own incapability or the incapability of others to eat in an aesthetically pleasant way. One important aspect of communal meals was the possibility of talking to fellow patients during the meal, although the participants were not always guaranteed to be sitting next to someone they could talk to, which could be crucial for their decision:
‘There is no conversation. None at all. You talk perhaps to the person sitting across from you, but it may be someone new next time—morning, noon and night’ (Participant 8). In some cases, the caregivers contributed to the conversation in a way that facilitated a dialogue.
4. Contact on uneven terms Being in an IC unit meant that the participants were forced to socialise with others, which was something they had not chosen themselves. This required extra resources and the participants felt they needed to find their own feet before being able to socialise. They could occasionally pick and choose themselves:
‘It’s not compulsory, and you don’t feel so pressured when you’re not eating with the others’ (Participant 1). The participants would sometimes compare own functional abilities with the other patients in the IC unit. To observe the physical progress of others could strengthen their motivation to train, but at the same time, the reduced mobility of their fellow patients was often difficult to witness and would discourage them from sitting in the communal room:
‘I think I would have great difficulty sitting with the very old and ill people out there. I just can’t take it’ (Participant 12). The participants would approach the other patients with caution, and found it difficult to establish a proper relationship. When they identified a person with a similar functional level, it was natural to try to get closer to them during a meal and have a normal conversation:
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‘I have met some of them, but it’s like nobody tries to be sociable or talk. Someone says something, but there is no inclination to have a chat’ (Participant 6). The staff could operate as ‘invisible helpers’ during the older people’s socialising time and facilitate the interaction by modifying some of their behaviour to comply more with the conventions of society. The participants experienced that the staff generated a particularly good homely atmosphere by, for example, arranging an evening that involved something more than the usual care.
5. Life on other people’s terms The participants spontaneously compared their hospital stay to the stay in the IC unit, and the result strongly disfavoured the hospitals. At times they felt overlooked and the things they found important were ignored, and only got worse. A one-sided emphasis on the reason for hospitalisation and no support for the physical training could result in reduced mobility, which intensified the need for rehabilitation:
‘I was in hospital for about a month because they had to find out what sort of medicine I was to have. But I was lying in bed and didn’t get any exercise at all. In the end, I could hardly sit or stand. I just lay there—and lost all the power of my legs’ (Participant 11). Contact with the hospital staff was not necessarily very good. The participants felt that they were considered as troublesome, not fitting in, or the wrong age:
‘I am sorry to say this, but when you’re over 60— and I am nearly 87—well, you are just a pile of junk’ (Participant 4).
6. Informal but essential help The participants were conscious of becoming a burden to their spouse or adult children. The relatives were supportive of the training through encouragement and a comfortcreating presence:
‘My son and daughter take me for walks along the corridor, so I get a little exercise there. They stand beside me, as I try standing on my own’ (Participant 7). The thought of getting help from friends and neighbours could reduce the anxiety in connection with returning home. In some cases, this informal help was offered because of newly arisen needs, and in other cases it was help that had already been provided before the hospitalisation.
Discussion It is well known that patient satisfaction may be improved through IC (Griffiths, 2006; Griffiths et al, 2005; 2007), but in our study the experience of being in an IC unit was also characterised by a deep sense of gratefulness. In contrast to staying in a hospital, the older people felt they were regarded as important and worth making an effort for. Again and again, the participants highlighted that the caregivers treated them as equal partners and contrasted this friendly approach to the way they were treated in hospital.
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This finding links to the finding of Wiles et al (2003), who reported that patients experience care in an IC unit as more therapeutic and conducive to recovery than the care provided in a conventional unit (Wiles et al, 2003), since a friendly attitude from the caregivers may be therapeutic and recovering in itself. Our study also adds to the findings of Johannesen and Steihaug (2013), who stressed the importance of being seen as a ‘human being’ in the IC unit. The present study showed that being considered a human is linked to feelings of being embraced by care, and experiencing care as individual and attentive. Although the study showed these feelings to be significant to the participants, it was also found that the older people expected a more guarded attitude from the caregivers than they actually exhibited. This filled the older people with gratitude. The present study highlights that the physical environment and also the atmosphere in the ward have several meanings influencing the participants’ wellbeing, contributing positively to their commitment to training. In line with our findings, it is documented that the design of the physical environment as well as patient rooms can be a source of stress for patients; on the other hand, it can also contribute to support the healing process of patients (La Torre, 2006; Lorenz, 2007; Lawson, 2010; Johannesen et al, 2013). Edvardsson et al (2005) focused on the influence of the environment on patients’ experiences of nursing care in institutional settings. They found that both the physical environment and also the psychosocial environment are important for reducing patients’ suffering, e.g. by impacting on patients’ feelings of integrity, interaction and wellbeing. The present study supports these findings, and Edvardsson et al (2005) further revealed that the participants linked the space of the ward to feelings of security because of the ready access to professional help. Moreover, the professionals’ positive attitude towards them created a specific spirit that was transferred to participants. According to the nurse and philosopher Kari Martinsen (2006), the atmosphere in the rooms is a spatial experience. Martinsen (2006) points out that the sickroom is a special space that has its own resonance and dignity, which is transferred to patients. The present study revealed how this specific tone on a ward significantly influenced the patients and not only generated feelings of wellbeing, but also contributed to a sense of courage in living. Concerns regarding the upcoming discharge among some of the participants may be caused by lack of knowledge about the available aids such as fall alarms. According to Honneth (1995), all humans strive to be recognised by others. This recognition is crucially dependent on the development of self-respect, self-confidence and self-esteem. These three modes of relating to oneself represent three distinct species of practical relation to oneself. They are not purely beliefs about oneself, nor are they emotional states, but involve a dynamic process in which individuals experience themselves as having a certain status. Honneth (1995) emphasises that relating to oneself in these ways necessarily involves experiencing recognition from others. The present study’s findings indicate that the older people felt that their relationship with the caregivers had
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CARE OF THE OLDER PERSON
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CARE OF THE OLDER PERSON gone beyond what they expected. In the light of Honneth’s theory, the caregivers’ interest and individualised care can be understood as a sign of recognition of the participants. The relationship to oneself is not a matter of a solitary ego appraising oneself, but an intersubjective process, in which one’s attitude towards oneself emerges in an encounter with another’s attitude towards oneself (Honneth, 1995). Thus, the embracing approach of caregivers generated a feeling of recognition in the participants that was seemingly crucial for their enthusiasm concerning their physical training and striving to be as self-reliant as possible.
Strengths and limitations Key strengths of the study were the use of descriptive phenomenology allowing flexible interviews that provided opportunities for the participants to elaborate freely on their experiences and thoughts regarding care in an IC unit. The participants’ different basic diseases and conditions increased the variation in data; this is important for research based on phenomenology (Dahlberg et al, 2008). Neither the diseases nor the participants’ functional status was, however, the study focus. Rather, the study aimed at providing a snapshot of older people’s experiences of being in an IC unit after hospital discharge and before being discharged to their own home.
Conclusion The experience of being in an IC unit after hospital discharge and before being discharged home was, first and foremost, characterised by satisfaction and gratefulness. This study’s findings showed that the staff had a major influence on the atmosphere of the ward. Accessible, attentive care and the psychosocial and physical environment were found to be of great importance for the older people in IC units. The healing environment and friendly attitude can be understood as a sign of recognition from the caregivers. This personal recognition generated a certain commitment towards the physical training that may be significant for the functional ability of older people over time.
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Implications for practice This study has demonstrated that older people appreciate caregivers in IC units who are sensitive to their needs and adjust care plans to individual needs and preferences. Being friendly and communicating at the same level as the older people contributes to the healing atmosphere just as much as the aesthetic dimension of the ward. Therefore, the significance of the environment should not be underestimated when planning new IC units or renovating existing ones. The fact that IC units offer health-care services to people with different challenges means that caregivers have a special obligation to maintain the current norms of society, and to try to facilitate social interaction between the older people. The results indicate that hospital staff may benefit from feedback based on the experiences of hospitalised older people. Furthermore, the results of this study point to the need for increased cooperation between IC units, general hospitals and community health care. It is suggested that this
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should be implemented in a modern, flexible form without time-consuming, physical face-to-face meetings. BJCN Accepted for publication: 8 December 2014 Andrews J, Manthorpe J, Watson R (2004) Involving older people in intermediate care. J Adv Nurs 46(3): 303–10. doi: 10.1111/j.1365-2648.2004.02990.x Dahlberg K, Dahlberg H, Nyström M (2008) Reflective Lifeworld Research, 2nd edn. Studentlitteratur, Sweden Danish Health and Medicines Authority. Quality in Emergency Services of Municipal Home Nursing. http://bit.ly/1xKtUKR (accessed 1 May 2014) (In Danish.) Edvardsson JD, Sandman P, Rasmussen BH (2005) Sensing an atmosphere of ease: a tentative theory of supportive care settings. Scand J Caring Sci 19(4): 344–53. doi: 10.1111/j.1471-6712.2005.00356.x Garåsen H, Windspoll R, Johnsen R (2008) Long-term patients’ outcomes after intermediate care at a community hospital for elderly patients: 12-month follow-up of a randomized controlled trial. Scand J Public Health 36(2): 197–204. doi: 10.1177/1403494808089685 Griffiths P (2006) Effectiveness of intermediate care delivered in nurse-led units. Br J Community Nurs 11(5): 205–8 Griffiths P, Edwards M, Forbes A, Harris R (2005) Post-acute intermediate care in nursing-led units: a systematic review of effectiveness. Int J Nurs Stud 42(1): 107–16. doi: 10.1016/j.ijnurstu.2004.07.010 Griffiths PD, Edwards MH, Forbes A, Harris RL, Ritchie G (2007) Effectiveness of intermediate care in nursing-led in-patient units. Cochrane Database Syst Rev 18(2): CD002214 Honneth A (1995) The Struggle for Recognition: The Moral Grammar of Social Conflicts. Polity Press, Cambridge James JT (2013) A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 9(3): 122–8. doi: 10.1097/PTS.0b013e3182948a69 Johannessen AK, Steihaug S (2013) The significance of professional roles in collaboration on patients’ transitions from hospital to home via an intermediate unit. Scand J Caring Sci 28(2): 364–72. doi: 10.1111/scs.12066 Johannessen AK, Werner A, Steihaug S (2013) Work in an intermediate unit: balancing between relational, practical and moral care. J Clin Nurs 23(3–4): 586–95. doi: 10.1111/jocn.12213 Kilgore C (2014) Why intermediate care services need to be refreshed. Nurs Older People 26(3): 16–20. doi: 10.7748/nop2014.03.26.3.16.e570. La Torre MA (2006) Creating a healing environment. Perspectives Psychiatric Care 42(4): 262–4. doi:10.1111/j.1744-6163.2006.00086.x Lawson B (2010) Healing architecture. Arts & Health 2(2): 95–108 Lorenz SG (2007) The potential of the patient room to promote healing and well-being in patients and nurses: an integrative review of the research. Holistic Nursing Practice 21(5): 263–77. doi: 10.1097/01.HNP.0000287990.40215.51 Local Government Denmark (2014) Tips for strengthening municipal emergency services. http://bit.ly/1HUUtzL (accessed 20 January 2014) Martinsen K (2006) Care and Vulnerability. Akribe, Oslo Organisation for Economic Co-operation and Development (2013) OECD Regions at a Glance. OECD Publishing, Paris. http://dx.doi.org/10.1787/ reg_glance-2013-en Statistics Denmark (2014) Population in 2014, by sex, age and country of origin. http://bit.ly/1Aum7Ab (accessed 5 June 2014) Wiles R, Postle K, Steiner A, Walsh B (2003) Nurse-led intermediate care: patients’ perceptions. Int J Nurs Stud 40(1): 61–71. doi: 10.1016/S00207489(02)00033-0 Young J (2009) The development of intermediate care services in England. Arch Gerontology Geriatrics 49(suppl. 2): 21–5. doi: 10.1016/S0167-4943(09)70008-1
KEY POINTS
w Being in an intermediate care unit after hospital treatment may be experienced as a relief
w The caregivers’ accessibility is crucial for the older people’s determination and drive to exceed their own limits in their physical training
w The physical environment and the caregivers’ tone of voice play an important role for the constitution of a healing atmosphere
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