Introduction
Methods
Design
The Norwegian context and the care-planning intervention
Recruitment and sample
Data collection
Analysis
Empirical close codes | Code group |
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‘Cannot let you know if I faint, it happens so fast’. Scared by the risks surrounding the symptoms. Wanted to live at home but did not manage to. Unsure how long things will continue to go well. I wish to await the decision about rehabilitation service at home. My symptoms determine the plans. | Patients’ experience of uncertainty |
But you just came here; you may recover quickly. Your symptoms are common in old age. ‘We can predict that your situation will improve’. We test if the patient is ready to go home through a few days’ home visit. We will do anything for you to be safe at home. | Health professionals’ efforts to take control of uncertainty |
Inclusion of theory
Results
Patient’s gender, age | Patient’s main health problem, number of diagnoses, and ward | Participants in the care-planning meeting |
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P#1 Female, 86 years | Fractured arm. > 2 diagnoses. Start of stay at rehabilitation/intermediate care unit, city municipality. | Patient and a nurse. |
P#2 Female, 96 years | Chest pains and abdominal pain. > 4 diagnoses. Start of stay at rehabilitation/intermediate care unit, city municipality. | Patient and a nurse. |
P#3 Female, 97 years | Fall, fractured neck of femur, with infection. > 5 diagnoses. End of stay at rehabilitation ward, city municipality. | Patient, case manager from office handling allocation of services, physiotherapist, nurse, home care nurse, and daughter. Three nursing students observed the meeting. |
P#4 Female, 98 years | Several falls assumed to be caused by orthostatic hypotension. > 2 diagnoses. End of stay at rehabilitation ward, city municipality. | Patient, case manager from office handling allocation of services, nurse at the ward, home care nurse, daughter, and adult granddaughter. |
P#5 Female, 62 years | Pneumonia. > 5 diseases. Middle of stay at intermediate care unit, city municipality. | Patient, husband, case manager from office handling allocation of services, and nurse from the ward. One nursing student observed the meeting. |
P#6 Female, 91 years | Weakened by cumulative effect of multiple conditions. > 5 diagnoses. Middle of stay at rehabilitation ward, city municipality. | Patient, case manager from office handling allocation of services, home care nurse, and ward nurse. Daughter and two sons. |
P#7 Male, 94 years | Functional decline and emerging needs for home care services. > 5 diagnoses. Meeting at patient’s home before short-term stay at nursing home, rural municipality. | Patient, wife, and nurse in home care services. |
P#8 Female, 96 years | Syncope. > 2 diagnoses. Meeting at patient’s home, right after stay in intermediate unit, rural municipality. | Patient and nurse in home care services. |
P#9 Female, 86 years | Hip surgery. > 5 diagnoses. Middle of stay at short-term ward, rural municipality. | The patient did not wish to participate in the meeting. Four daughters, head nurse at care home, physiotherapist, and nurse. |
P#10 Male, 75 years | Fractured neck of femur. > 4 diagnoses. End of stay at short-time ward, rural municipality. | Patient, head nurse in home care services, physician, physiotherapist, mental health nurse, case manager, daughter, son, and nurse from home care services. |
The care-planning games of uncertainty
The game of chance
Patient: I really hope the infection stays under control so that I can go through with this. This is the fifth time the operation has been scheduled. (meeting, P#5).
Interviewer: So you were at the hospital not too long ago?
Patient: Hip surgery. And it went just fine. Now afterwards, it’s been a big mess. I fell a few times.
Interviewer: Oh, you have, huh? I see.
Patient: It was all going so well when I got back, but then things just took a turn. I don’t know what caused it. (interview, P#9).
Case manager: What do you think if you look ahead a bit, what is important to you in the situation you are in now?
Patient: Just that you all keep being good to me and, well, I don’t feel so positively about me getting better. (meeting, P#6).
Patient: It all just snowballs.
Nurse: And I think it’s important for you and [spouse], now that you are juggling a lot of things at once what with your ear and your stomach and your back that you had looked at a few days ago, that you try to focus on only one thing at a time. And right now, it’s the surgery. Have some fun this weekend.
Patient: Ok, ok.
Nurse: Come back on Monday. We have it under control. We will help you with what you need. And only focus on that. When that’s done with...we’ll take the next thing. If you think about everything it’ll just create this chaos in your ...
Patient: I know, I know. But I have to say, I’m dreading that operation, because she said so many things that could go wrong if...but that was only a percentage, of course. Even paralysis.... (meeting, P#5).
The competitive game
Youngest son: Then I would like to take it a step further: if she isn’t functioning well enough to come home—then what do you do?
Coordinator: Then we apply for a different living situation. Right? Like a different level of care. Yeah. But we’re not there yet, no. (light laughter).
Youngest son: Right, no. But just to have asked that question in time.
Coordinator: Right. Well, we’ll deal with it when it’s ... (…).
Youngest son: Well, I still think it’s relevant to ask that. She is nearly 92, after all. (meeting, P#6).
Nurse: Is there something you have been thinking about that might be important to you that you can tell us, something you’d like to continue with or achieve?
Patient: It’s a little difficult, that, right now.
Wife: I think it’s important for you, I have to say, that I am there to help you. (…) I’m the one responsible. You wouldn’t manage alone. (…).
Nurse: Have you given that any thought? (short silence) Is there something she does for you that we at home care services can help you with?
Patient: No, that would ... What might that be?
(15 s silence)
Nurse: You can’t think of anything? (meeting, P#7).
The coordination game
Grandchild: ... We’ll have to discuss it with the home care services, I think. Maybe get more frequent visits and ...
Daughter: But she is scared at home, you know.
Coordinator: It’s all the hours when you aren’t here, that’s a lot of hours in a day.
Home care nurse: And the nights, especially.
Coordinator: A day center is an alternative, but that still won’t cover all 24 h, you know. It’s about finding a solution. Yes.
Grandchild: I’m sure there is. There is always a solution.
Coordinator: It’s just that ...you feel unsafe being at home.
Patient: Yes, and I never know what might happen. (meeting, P#4).
The concept of the game of uncertainty
Game of chance | Competitive game | Collaborative game | |
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Uncertainty | The patient assessed uncertainty to a greater degree than other players. Temporal focus: did not look forward. | The players assessed the level of uncertainty differently. | The patient’s understanding of uncertainty was shared with other players. Temporal focus: the future. |
Participants’ roles | Patient fighting alone against Nature. | Two sides, in which one of the sides saw Nature as an opponent. | All players were teammates, either aligning against Nature or not feeling threatened by it. |
Level of patient participation | Low: the patient received information, was less active. Health professionals set goals for care. | Varied: depended on which side of the game the patient took. Difficult to agree on goals for care. | Higher: the patient functioned as an equal player within the team. Easier to agree on goals for care. |