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The importance of relational coordination for integrated care delivery to older patients in the hospital

Authors


Abstract

Aim

This study investigated relational coordination among professionals providing healthcare to hospitalized older patients and assessed its impact on integrated care delivery.

Background

Previous studies have shown that relational coordination is positively associated with the delivery of acute, emergency and trauma care. The effect of relational coordination in integrated care delivery to hospitalized older patients remains unknown.

Methods

This cross-sectional study was part of an examination of integrated care delivery to hospitalized older patients. Data were collected using questionnaires distributed to hospital professionals (192 respondents; 44% response rate).

Results

After controlling for demographic variables, regression analyses showed that relational coordination was positively related to integrated care delivery (β = 0.20;  0.05). Relational coordination was lower among professionals in the same discipline, and higher between nurses and others than between medical specialists and others. Relational coordination and integrated care delivery were significantly higher in geriatrics than in other units (both  0.001).

Conclusions

The enhancement of relational coordination among healthcare professionals is positively associated with integrated care delivery to older patients.

Implications for nursing management

Relational coordination should be improved between medical specialists and others and higher levels of relational coordination and integrated care delivery should be achieved in all hospital units.

Introduction

The proportional increase in the ageing population is resulting in an ever-growing percentage of older hospitalized patients. Individuals older than 65 years of age are more likely than those in other age groups to be admitted to acute care from the emergency department. Once admitted, they are at an increased risk for poor outcomes such as readmission, increased length of stay, functional decline, iatrogenic complications and nursing home placement (Palmer 1998). Schwarz (2000) found a 33% rate of readmission within 3 months for older patients, which is consistent with other studies of readmission rates among these patients. Complications associated with hospitalization, such as acute confusion and nosocomial infection, are common among older patients, resulting in increased morbidity and mortality. Lefevre et al. (1992) found that 58% of older patients experienced at least one iatrogenic complication. Loss of function and independence is another common consequence of hospitalization for older patients. Wu et al. (2000) found that one or more limitations developed within 2 months in 42% of older patients with no baseline dependency at admission. Sager et al. (1996) found that the ability to perform one or more activities of daily living had declined in 32% of older patients at the time of discharge. This amount of functional decline has an impact on discharge planning and the level of subsequent care required for older patients. Given that 34–50% of hospitalized older patients have been found to experience functional decline resulting in increased length of hospital stay, mortality, nursing home placement and healthcare costs (Inouye et al. 1993, McCusker et al. 2002), it is likely that current healthcare is not meeting the needs of acutely ill older patients. If acute care is not designed to address the functional needs, psychosocial issues and altered response of these patients to illness and treatment (Hart et al. 2002, Moyle et al. 2008), older patients are at significant risk for hospital-acquired complications and loss of functionality.

Fortunately, many of the described complications are preventable (Lefevre et al. 1992, Jacelon 1999, Fletcher 2007). The healthcare delivery system is a major factor contributing to poor outcomes for hospitalized older adults (Reuben 2000, Boyd et al. 2005, Cowdell 2010). The organisation and delivery of hospital care is fragmented, uncoordinated, and duplicated (WHO Study Group 1996). Furthermore, most interventions in the clinical and organisational processes of hospital care are isolated, focusing on issues such as medication supply or multidisciplinary coordination. The literature strongly suggests, however, that holistic and personalized integrated care delivery encompassing the total care process is required (WHO Study Group 1996, Grol 2000, Moyle et al. 2010).

Older patients have complex medical, social and psychological problems that are expected to benefit from integrated care delivery (WHO Study Group 1996), which is based on the coordinated response of all activities and information to the needs of these patients in a manner that is organised through horizontal work processes, rather than through functional profiles. The complementary role of each professional and the interdependency among them are important features of integrated care (Batalden & Mohr 1997, McCormack et al. 2008). Coordination among professionals of different disciplines is thus a crucial element of effective integrated care delivery for older patients (Wagner et al. 1996, 2001, Ouwens et al. 2005). Coordination is a relational process among team members that is based on task interdependencies (Van de Ven et al. 1976, Weick & Roberts 1993, Gittell 2002a,b, Bechky 2006). One of these relational perspectives – relational coordination – identifies specific dimensions of relationships that are integral to the coordination of work. The effectiveness of coordination is determined by the quality of communication among professionals in a work process, which depends on the quality of their underlying relationships (Gittell 2006). The quality of their relationships, in turn, reinforces the quality of their communication. According to this theory, coordination that occurs through frequent, high-quality communication supported by relationships of shared goals, shared knowledge and mutual respect enables an organisation to better achieve the desired outcomes (Gittell 2006). Defined as ‘a mutually reinforcing process of interaction between communication and relationships carried out for the purpose of task integration' (Gittell 2002b, p. 301), relational coordination is a type of professional relationship that is particularly relevant for coordinating work that is highly interdependent, uncertain and time-constrained (Gittell et al. 2000).

The emphasis on relationships among roles, rather than on those among individual actors, is found in the management of flight departures, acute and emergency care, trauma units, nursing homes, hospital care and disease-management programmes (Young et al. 1998, Gittell 2001, 2002a, Gittell et al. 2008, Havens et al. 2010, Cramm & Nieboer 2011). However, in the healthcare sector this focus has been applied primarily to nurses providing care to a general patient population. We argue that relational coordination among multiple professionals, not only among nurses, is an important element in the delivery of high-quality integrated care to hospitalized older patients. The provision of such care is a complex undertaking that requires input from and high levels of interdependency among professionals from various disciplines (Grol 2000). The uncertain and interdependent work requirements limit the utility of simple standardized care processes. Feedback among professionals from a variety of disciplines as new patient information emerges is considered to be a critical mode of coordination in integrated care delivery for older patients (Young et al. 1998, Anderson et al. 2003). Relational coordination among professionals providing care to older patients is therefore expected to improve the delivery of integrated care by enhancing the exchange of relevant information for each older patient and by strengthening shared goals and the degree of mutual respect among diverse professionals.

This study had three objectives; the first was to investigate whether relational coordination among hospital professionals was positively associated with the delivery of high-quality integrated care to older patients. The second aim of the study was to compare relational coordination and integrated care delivery between the geriatric unit and other hospital units. Because professionals in the geriatric unit are more familiar with older patients and their complex needs, we expected that relational coordination and integrated care delivery among professionals working in the geriatric unit would be higher than in other hospital units. The third objective of this study was to increase our understanding of relational coordination in hospital teams through an investigation of the relative levels of relational coordination among nurses, between nurses and other professionals, among specialists, and between specialists and other professionals. The effectiveness of integrated care for older patients depends on the ability to coordinate beyond individual tasks more fully to encompass the entire range of care (Wolff et al. 2002), which underscores the need for coordination among professionals of different disciplines (Shortell et al. 1993, 1995a,b). Because nurses and specialists are the main coordinators of integrated care for hospitalized older patients, we were especially interested in examining the degree of relational coordination between these two professional roles and others.

Methods

Setting and design

This cross-sectional study was performed as part of a larger evaluation study examining the delivery of integrated care to hospitalized older patients in the Netherlands (Asmus-Szepesi et al. 2011). Data were collected in 2010 by means of questionnaires distributed in the hospital. Professionals involved in the delivery of care to older patients were invited to complete the questionnaire (192 respondents; 44% response rate).

Questionnaire

In addition to collecting demographic information, the questionnaire incorporated instruments that have demonstrated reliability and validity in prior research.

The relational coordination measure was aggregated from six survey questions, including three questions about communication (frequency/timeliness, accuracy and problem solving) and three questions about relationships (shared goals, shared knowledge and mutual respect). The questionnaire was originally developed to measure airline operations (Gittell 2001) and has been applied in hospitals (Gittell et al. 2000, Havens et al. 2010). A four-point scale was used to measure professionals' perceptions of relational coordination by asking about communication and relationships with others involved in delivering care to hospitalized older patients: medical specialists, nurses, physical/speech therapists, dieticians, social workers, transfer nurses, case managers and family physicians (Gittell et al. 2008, Relational Coordination Research Collaborative 2011). The Cronbach's alpha coefficient of the scale was 0.96, indicating excellent reliability.

The assessment of chronic illness care (ACIC) addresses self-management support (four items), delivery system design (six items), decision support (four items) and clinical information systems (five items) (MacColl Institute for Healthcare Innovation 2000, Cramm et al. 2011). The ACIC was originally developed to measure the degree to which a healthcare system adheres to elements of the chronic care model (CCM) (Bonomi et al. 2002) and the integration effect that occurs when all model elements are engaged. The instrument has been validated and used for the evaluation of hospital care (Wagner et al. 2001, Bonomi et al. 2002, Minkman et al. 2007, Lemmens et al. 2009). Since chronic illness care is a complex intervention that contains several interacting components, partly performed within the hospital (Campbell et al. 2000), we generalized the ACIC to the current setting of integrated care delivery for hospitalized older patients. Responses were structured on a scale of 0–11, with higher scores indicating more complete integrated care delivery. The ACIC is responsive to the system changes made by teams and correlates well with other measures of productivity in system change (Glasgow et al. 2001, Wagner et al. 2001, Bonomi et al. 2002). The Cronbach's alpha coefficient of this instrument was 0.87, indicating good reliability.

Statistical analysis

Since the professionals are nested in hospital units we tested for influence of hospital unit-level on integrated care delivery using a multilevel model. Results indicated that the hospital unit-level did not influence our results (−2 loglikelihood 493.991 vs. 491.687: = 0.13). Therefore, we used individual-level data only. Descriptive statistics were used to analyse professionals' gender, occupation and organisational work history. Correlation analysis was used to investigate the relationship between relational coordination and integrated care delivery. We also tested the relative levels of relational coordination and integrated care delivery in the geriatric unit and in other hospital units. The degree to which differences in relational coordination existed among medical specialists and other professionals and among nurses and other professionals was assessed through a series of paired-sample t-tests. Multiple regression analyses were used to determine whether relational coordination predicted integrated care delivery. Data were analysed using the SPSS software package (ver. 18.0 for Windows; SPSS Inc., Chicago, IL, USA). A significance level of 0.05 was used for all statistical tests.

Results

The eligible study population consisted of 440 professionals, 192 of whom completed the questionnaire (44% response rate). Table 1 displays the descriptive characteristics of the study sample. Of those who completed the questionnaire, the majority was female (76%) and worked as a nurse (64%) or medical specialist (27%).

Table 1. Characteristics of professionals participating in the delivery of care to hospitalized older patients
Characteristics%
Sex
Female76
Profession
Medical specialist27
Nurse64
Paramedic9
Years working in the organisation
>1 year96

Most of the respondents worked on the wards of internal medicine (15%), cardiology (13%), neurology (9%), surgery (8%) and geriatrics (7%).

On a 1–4 scale, the mean overall relational coordination was 2.57 (±0.95). Subscale scores indicating the extent to which the professionals felt that they delivered integrated care ranged from 5.13 (±2.01) for decision support to 6.20 (±2.00) for delivery system design. The overall mean score for all elements was 5.58 (±1.79), indicating that basic support for integrated care was present.

As expected, we found that the level of integrated care delivery for older patients was significantly higher (more than 1/3 SD) in the geriatric unit than in other hospital units (mean, 6.23 vs. 5.58; < 0.001). Relational coordination was also significantly higher among professionals working in the geriatric unit than among those working in other units (mean, 3.02 vs. 2.57; < 0.001), namely more than 1/2 SD.

Relational coordination among healthcare professionals

Tables 2 and 3 display the levels of relational coordination between medical specialists and other professionals and between nurses and other professionals. These results show that relational coordination was much higher between nurses and other professionals than between specialists and other professionals. We found a higher degree of relational coordination among medical specialists (mean, 2.74) than between medical specialists and other professionals, including nurses (mean, 2.38), physical/speech therapists (mean, 1.98), dieticians (mean, 1.79), social workers (mean, 1.97), transfer nurses (mean, 1.94) and general practitioners (mean, 2.50; < 0.001 for all; Table 2). Relational coordination was also higher among nurses (mean, 3.34) than between nurses and other professionals, including medical specialists (mean, 3.10), physical/speech therapists (mean, 2.96), dieticians (mean, 3.09), social workers (mean, 2.91), transfer nurses (mean, 3.06) and general practitioners (mean, 1.62; < 0.001 for all; Table 3). These findings indicate that relational coordination plays a larger role among healthcare professionals in the same discipline than among those in different disciplines. In general, relational coordination scores were higher among nurses than among medical specialists.

Table 2. Relational coordination among medical specialists vs. between medical specialists and other professionals (= 48)
 MeanSD
  1. SD, standard deviation.

  2. a

    < 0.001.

Among medical specialists2.741.07
Between medical specialists and nurses2.38a1.18
Between medical specialists and physical/speech therapists1.98a1.12
Between medical specialists and dieticians1.79a0.97
Between medical specialists and social workers1.97a1.08
Between medical specialists and transfer nurses1.94a1.09
Between medical specialists and general practitioners2.50a1.00
Table 3. Relational coordination among nurses vs. between nurses and other professionals (= 113)
 MeanSD
  1. SD, standard deviation.

  2. a

    < 0.001.

Among nurses3.340.99
Between nurses and medical specialists3.10a1.00
Between nurses and physical/speech therapists2.96a1.10
Between nurses and dieticians3.09a1.06
Between nurses and social workers2.91a1.06
Between nurses and transfer nurses3.06a1.13
Between nurses and general practitioners1.62a0.84

Relational coordination and integrated care delivery to older patients

Correlation analysis revealed a positive relationship between relational coordination and the overall ACIC score (= 0.21; < 0.01). The results of multiple regression analyses performed to identify predictors for the delivery of integrated care demonstrated that integrated care delivery was positively influenced by relational coordination (β = 0.20; < 0.05), even after controlling for demographic variables (Table 4). No significant relationship was found between occupation or number of years working in the current organisation and integrated care delivery.

Table 4. Multiple regression analysis of the effects of background characteristics and relational coordination on chronic care delivery
 βBSE
  1. a

     0.05.

Background characteristics
Nurse−0.03−0.120.40
Paramedic−0.13−0.850.62
Gender0.020.070.39
Number of years working in the current organisation−0.07−0.610.75
Relational coordination
Overall relational coordination0.20a0.440.22
Adjusted R2 for equation0.11  
 F 3.071  

Discussion

Given the aging population and especially the rapid increase in the ‘oldest-old’ segment expected in the next few decades (WHO Study Group 1996), health issues related to the care of older patients pose an urgent challenge. Older patients need integrated care, but the present system is far from satisfactory. As our population ages, healthcare professionals face the challenge of working with a variety of professionals to reshape care delivery so that it is more integrated and responsive to the needs and desires of older patients. Relational coordination among healthcare professionals in the hospital is expected to be a useful tool for the achievement of this goal. Indeed, the results of this study provide support for the theoretically proposed positive associations between relational coordination among healthcare professionals and integrated care delivery to older patients in the hospital.

Our finding that levels of relational coordination and integrated care delivery were higher among professionals in the geriatric unit than among those in other units confirmed our expectation that these professionals are familiar with the process of working together to provide holistic integrated care to older patients that meets their complex needs. However, these results also indicate that there is room for improvement in both relational coordination and the delivery of integrated care to older patients. The challenge for the future is to expand geriatric awareness and competence to other hospital units. This finding is in agreement with those of previous research, which have suggested that geriatric nurses are in a position to provide expertise and leadership within interdisciplinary groups to improve the care provided to older adults in acute care settings. The provision of coordinated, geriatric-specific care to support physicians who do not specialize in caring for older adults can minimize complications and improve outcomes (Tucker et al. 2006).

Finally, the effectiveness of integrated care delivery for older patients depends on the ability of professionals in different disciplines to coordinate in the holistic provision of care (Wolff et al. 2002). We found higher levels of relational coordination among nurses and among medical specialists, both of whom are the main coordinators of integrated care for hospitalized older patients, than between each of these professionals and others. This finding is in agreement with those of previous research, which have shown higher levels of relational coordination among healthcare professionals in the same discipline (Havens et al. 2010, O'Leary et al. 2010). The higher relational coordination scores we found among nurses than among medical specialists indicate that the former play an active, central role in integrated care delivery. Thus, our findings suggest that frequent, high-quality communication supported by relationships of shared goals, shared knowledge and mutual respect among medical specialists and nurses plays an important role in integrated care delivery; however, there is room for improvement in relational coordination among medical specialists in hospitals who provide care to older patients.

This study has several limitations. First, the cross-sectional design allowed us to identify associations but not to determine causality. Longitudinal data would provide the opportunity to disentangle the dynamic relationships among relational coordination and integrated care delivery. We were not able to control for all possible confounders such as personality traits. A confounding factor that may have influenced this research has to do with a more positive attitude of some professionals towards coordination as well as integrated care delivery. The philosophy of care and nursing model could also be a confounding factor in the current research. If team nursing does not support coordinated care delivery with other professionals, relational coordination may not develop fully. Differences in coordination may in part reflect these different personality, team and organisational characteristics, rather than differences in relational competence. To explore these possibilities, further research has to be performed. Finally, although we examined the relationship between relational coordination among professionals and integrated care delivery to older patients, further research is necessary to assess the effects of relational coordination on patient experiences and outcomes.

Despite these limitations, our results have important implications for theory and practice. Our findings support the importance of coordination in the effectiveness of integrated care delivery and suggest that better relations, communication and coordination among healthcare professionals from various disciplines can improve integrated care delivery to hospitalized older patients. The coordinated response of activities and information through supportive relationships is an important feature of effective and efficient care delivery (Wagner et al. 1996, 2001, Batalden & Mohr 1997, Ouwens et al. 2005). Special attention is needed to improve relational coordination among medical specialists and professionals from other disciplines in providing care to older patients.

Several practical implications can be drawn from the results of this study. The relational coordination perspective focuses on connections among professionals and their impact on organisational outcomes (Gittell 2006). Human resource theories argue that healthcare team effectiveness depends not only on objective outcomes (e.g. patients' functional status, adherence to medicine, costs), but also on team members' perceptions and attitudes (Cohen & Bailey 1997, Lemieux-Charles & McGuire 2006). The results of our research indicate that the development of effective relationships and coordination among professionals is of utmost importance. Professionals who deliver integrated care to older patients should be encouraged to communicate and interact, thereby enabling the recognition of others' perspectives, understanding of others' visions, and respect for others' input in providing such care. These findings are consistent with a patient-centred approach, which aims to bring together multiple members of professional teams and others with significant relationships to the patient. In such an approach, the patient not only has strong one-on-one connections with each professional involved in the delivery of care, but professionals themselves are connected in a web of supportive relationships. In previous interventions, nursing homes have attempted to create holistic care through ‘a phased and deliberate effort by the nursing home's leadership to rethink how care is provided and how staff relate to each other' (Stone et al. 2002, Lynch et al. 2011). To give care in such a holistic way that encompasses physical and psychosocial dimensions (Bowers et al. 2001), requires that coordination among professionals is carried out through relationships of shared goals, shared knowledge and mutual respect. Current findings provide support for models of patient-centred care and suggest that relational coordination may be a component of their effectiveness.

The challenge for the future is, however, to expand the high levels of relational coordination and integrated care delivery observed in geriatric units to other hospital units. Training programmes should be integrated and should target professionals in diverse disciplines so that all providers can come to a better understanding of their interdependence in care delivery to older patients. Continuing education programmes should target on currently practising professionals and will have to present new integrated perspectives and concepts, new approaches for understanding old issues, or new responses that are chosen for their power to address the challenges facing professionals (Clark 2002). This can be operationalised in discussion sessions, panels and workshops following theme-setting lecture-based presentations. Additionally, topics reflecting current realities and issues in the health care system in general and in geriatrics in particular should be chosen for a directed discussion in which participants express their own observations and recommendations on promoting coordination. To maximize the effect of these education programmes, the focus should be on interprofessional collaboration, creating the possibility of different groups of professionals with multiple backgrounds to learn from each other (Morrison & Glebby 2012). In this way, the goals and objectives for teamwork training should be redefined from the old way of thinking about training as education in group processes and development to a much more flexible and dynamic conceptualization of teamwork (Clark et al. 2002), focusing on both relational and functional competence.

Acknowledgements

The authors would like to thank the project members who contributed to this study: Ewout Steyerberg, Paul de Vreede, Kirsten Asmus-Szepesi, Jeroen van Wijngaarden, Annemarie de Vos and Marc Koopmanschap.

Source of funding

This study is funded with a grant (grant number: 60-61900-98-130) from the Netherlands organisation for health research and development (ZonMw) as part of the National Care for the Elderly Programme, which aims to improve the quality of care for elderly by means of developing integrated health care that is adjusted to the individual needs of the elderly.

Ethical approval

The study protocol was approved by the METC of the Erasmus Medical Center Rotterdam, the Netherlands, under protocol number METC 2011-041.

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