Accepted Manuscript

Collaboration in discharge planning in relation to an implicit

framework

Angela Bngsbo, Anna Dunr, Synneve Dahlin-Ivanoff, Eva

Lidn

PII: S0897-1897(16)30272-5
DOI: doi: 10.1016/j.apnr.2017.05.010
Reference: YAPNR 50918
To appear in: Applied Nursing Research
Received date: 21 October 2016
Revised date: 31 March 2017
Accepted date: 27 May 2017

Please cite this article as: Angela Bngsbo, Anna Dunr, Synneve Dahlin-Ivanoff, Eva
Lidn , Collaboration in discharge planning in relation to an implicit framework, Applied
Nursing Research (2017), doi: 10.1016/j.apnr.2017.05.010

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 ACCEPTED MANUSCRIPT
Running head: COLLABORATION IN DISCHARGE PLANNING 1

Collaboration in Discharge Planning in Relation to an Implicit Framework

Angela Bngsbo, MSc, Reg OT, PhD student a,c,e, Anna Dunr, Associate Professor b,c,

Synneve Dahlin-Ivanoff, Professor a,c, Eva Lidn, Associate Professor c,d

PT
a
Sahlgrenska Academy, University of Gothenburg, Institute of Neuroscience and Physiology,

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Arvid Wallgrens Backe hus 2, Box 455, 405 30 Gteborg.

SC
b
Department of Social Work, University of Gothenburg, Sprngkullsgat. 23, Box 720, 405 30

Gteborg, Sweden.
NU
c
Sahlgrenska Academy, Centre of Ageing and Health, University of Gothenburg, 405 30

Gteborg.
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b
Sahlgrenska Academy, University of Gothenburg, Institute of Health and Care Sciences, Arvid

Wallgrens Backe hus 1, Box 457, 405 30 Gteborg, Sweden.

ED

e
R & D Sjuhrad Vlfrd, University of Bors, 501 90 Bors, Sweden
PT
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Corresponding author at:

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Sahlgrenska Academy, University of Gothenburg, Institute of Neuroscience and Physiology,

Arvid Wallgrens Backe hus 2, Box 455, 405 30, Gothenburg, Sweden. E-mail address:

angela.bangsbo@hb.se. Phone: + 46 33 435 47 99. Mobile: + 46 (0)73 200 20 90.

Introduction
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COLLABORATION IN DISCHARGE PLANNING 2

As elderly peoples needs are becoming more complex, healthcare and medical
professionals are becoming more specialized to provide better care (WHO, 2015). New
technology and specialization leads to safer and better healthcare, but it simultaneously
increases the risks of unforeseen injuries from the new innovations (Leonard, Graham, &
Bonacum, 2004). There is a demand for structured collaboration and communication to
practice safe and integrated care as deficiencies in these aspects have been shown to risk
patient safety (Shepperd et al., 2013). There is a need to highlight potential pitfalls in care

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since nurses and professionals from several institutions are engaged in discharge planning
activities, and that increases the risk of patients not receiving the care they need. In this

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context then, collaboration, both interorganizationally and interprofessionally, is essential in

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order to secure care continuity for frail elderly patients with complex care needs (Kodner,
2009; Minkman, 2012; Paulsen, Romren, & Grimsmo, 2013).
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Legal standard formulations and guidelines in Sweden urge for collaboration between
health professionals and patients (National Board of Health and Welfare, 2009; SFS
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2014:821), and research has shown that an individualized discharge plan may increase
patients and professionals satisfaction and reduce the length of hospital stay and readmission
rates (Goncalves-Bradley, Lannin, Clemson, & Shepperd, 2016). Despite this fact, studies
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have demonstrated that elderly people are often discharged from hospitals with insufficient
planning because of a poor transferral of information, poor patient instructions, and
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inadequate follow-up plans (Dahl, Steinsbekk, Jensen, & Johnsen, 2014; Groene, Orrego,
Sunol, Barach, & Groene, 2012). Nurses, rehabilitation therapists, and social work
professionals are each responsible for supporting elderly peoples individual needs in terms of
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treatment (Gabrielsson & Nilsen, 2016). Therefore, the question about how collaboration and
communication amongst these healthcare professionals can be strengthened to ensure
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patients safety and well-being is a crucial to raise.

Collaborative Challenges within the Swedish Context from an Organizational and

Professional Perspective

From an international perspective, transitional care for frail elderly patients is organized in
various ways (Birmingham, 2004; Rhudy, Holland, & Bowles, 2010; Wong et al., 2011). In
Sweden, eldercare is a shared responsibility between county councils (e.g., nursing,
rehabilitation, and medical care run by health centers) and municipal healthcare and social
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COLLABORATION IN DISCHARGE PLANNING 3

care (e.g., long-term nursing and basic healthcare) (SFS 1982:763). Eldercare includes a
policy that promotes and supports elderly peoples rights to remain in their homes and receive
treatment there (SFS 1982:763). This results in few elderly people living in nursing or
residential care facilities as well as earlier discharge from hospitals (Lagergren, 2002). The
hospital discharge of frail elderly people involves the municipality, the county council, or
both (SFS 1982:763). The regulations state that the healthcare providers are required to
collaborate. Information from specialized care should be transferred to primary care and

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municipal health and social care before discharge (SOSFS 2005:27) and establish an
individual care plan (SFS, 1982:763; SFS, 2001:453). However, depending on the laws on

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professional privacy (SFS 2008:355; SFS 2009:400), information transfer between healthcare

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providers can be obstructed. Moreover, the organizations continue to use separate
administrative systems for patient documentation, leading to potential discrepancies and/or
missing information (National Board of Health and Welfare, 2011).
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A strong financial incentive for the municipalities to expedite the discharge process is the
municipalities payment liability to the county councils that comes into effect five business
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days after the patient has been medically cleared for discharge at the hospital. If the
municipalities have not arranged for elderly patients to receive homecare or other care, the
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municipalities are billed by the county councils for the extra days the patients remain in the
hospital (SFS 2003:193). According to Swedish regulations, municipal social workers are
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responsible for assessing and making decisions about the continuity of care be it basic home
care, nursing care, or even possibly residential care after discharge (SOSFS 2005:27). Thus,
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the social workers need professional input from other healthcare professionals, especially
nurses, occupational therapists, and physiotherapists, to be able to make well-founded
decisions. To make decisions with the most comprehensive information, discharge planning
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conferences are organized as cross-professional meetings, which also include the patients
and/or next-of-kin. However, representatives from the health centers (county council) are
rarely taking part.

Discharge Collaboration

Interorganizational collaboration can be defined as mainly horizontal where its

integration is accomplished through: (1) the will to collaborate and (2) mutual and voluntary
agreements with frequent communication and contact between the organizations (Axelsson &
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COLLABORATION IN DISCHARGE PLANNING 4

Axelsson, 2006). Horizontal professional collaboration may improve the coordination and
impact in the discharge process (Hjalmarsson, hgren, & Kjlsrud, 2013), and collaboration
may overcome organizational and professional obstacles, thus establishing new mutual
boundaries (Lfstrm, 2010).

Collaboration in the discharge process may be temporarily organized as

interprofessional teams at discharge planning conferences. However, professional roles may

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influence the outcome of the conferences, leading attendees to focus more on professional
boundaries rather than what is the best care for the elderly patient (Baker, Egan-Lee,

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Martimianakis, & Reeves, 2011; Berglund, Dunr, Blomberg, & Kjellgren, 2012; Dunr,
2013). However, it has also been shown when interprofessional collaboration, including

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coordination and communication, is successful, it can lead to improvements in patient care,
such as shorter stays in hospital (Zwarenstein, Goldman, & Reeves, 2009) and patient
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satisfaction (Berglund, Hasson, Kjellgren, & Wilhelmsson, 2015). Despite regulations that
expressively state that collaboration should form the basis for discharge of frail elderly
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patients and research showing that professionals are willing to collaborate, it fails when care
needs are complex and affected by diverging organizational and professional conflicts of
interests (e.g., post-discharge arrangements like a short-term nursing home care) (Dahl,
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Steinsbekk, & Johnsen, 2014; Mesteig, Helbostad, & Saltvedt, 2010). It is, therefore,
important to explore the preconditions to collaboration in a highly ecological study. That is
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why the aim of this study was to explore healthcare and social care professionals experiences
of preconditions to interorganizational and interprofessional collaboration to support frail
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elderly patients in discharge planning conferences.

Materials and Methods

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Study Design

Discharge planning conferences are examples of what is categorized as institutional

talks (Sarangi & Roberts, 1999). The design of the study was influenced by a social
constructionist perspective (Gergen, 2009), which claims that knowledge is constructed
through communication and social interaction. We chose a focus group (FG) design to allow
participants to express their experiences to provide insight into processes in everyday
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COLLABORATION IN DISCHARGE PLANNING 5

discharge decisions and facilitate a mutual understanding among themselves (Dahlin-Ivanoff

& Hultberg, 2006; Krueger & Casey, 2009). Collaboration in discharge planning conferences
was thus explored in this study in the FGs. Data collection was carried out in 2010-2011. The
FG interactions illuminate how skilled professionals communicated about the preconditions to
interprofessional and interorganizational collaboration. Participants were strategically
sampled for heterogeneity to represent professional, geographical, and organizational
variation (Patton, 2002); this variation aimed to encourage interprofessional discussions.

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The FG discussions were initiated by inviting participants to speak about their

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experiences in discharge planning, an experience they all shared and about which they were
all willing to discuss. A five-minute-long video-recorded vignette, developed by researchers

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at the School of Health Sciences, University of Jnkping, was shown as a teaser for
reflection and inspiration for discussion at the first FG. The film showed Anders, 82, sitting in
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an empty room waiting for the professionals to have their pre-meeting before the discharge
planning conference. Further, it illustrated the dialogue between Anders and the professionals
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at the conference where he was overlooked or ignored, and decisions were made without his
consent. The moderator opened the FG discussions by asking how the participants perceived
the collaboration in the video and if and how it could be compared with their own experiences
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of discharge planning conferences. At the end of each session, the moderator summarized the
discussions together with the participants. Each group was scheduled to interact twice, so the
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participants could get acquainted to enable more thorough discussions. This resulted in seven
audio-recorded FG conversations of approximately two hours in duration each. Four groups
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attended the first session of FGs, and three groups attended the second one two months after
the first FG. There was a mutual decision in Group 3 that saturation in reflections on the topic
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was reached after the first session. Therefore, Group 3 did not meet for the second FG as
Krueger and Casey (2009) recommended allowing in such situations.

The participants were briefed according to the research ethical standards based on the
WMA Declaration of Helsinkis ethical principles for medical research. The data were
handled confidentially, and only the researchers had access to them.

Participants and Setting

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In this study, there were 30 participants divided into four FGs. The participants were
recruited based on their experiences at discharge planning meetings by their managers
responsible for primary and specialized care and municipal healthcare and social care. Each
FG included one nurse specializing in discharge planning from specialized care. One nurse
who specialized in discharge planning and one social worker failed to participate in the study
due to their work schedules. In total, there were 13 registered nurses (RN), 10 occupational
therapists (OT), two physical therapists (PT), and five social workers in elderly care (SW).

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Table 1

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The Focus Groups Recruited Participants and Attendance Rate
RNH RNHC RNM OTH OTHC OTM RPTH SW

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FG
session
FG 1 1 1 3 1 - - 1 1 8
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recruited
FG 1 sessions 1 - 1 3 1 - - 1 1 7/8
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2 1 1 3 1 - - 1 - 7/8
FG 2 1 1 1 1 - - 1 3 8
recruited
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FG 2 sessions 1 1 - 1 - - - - 3 5/8
2 1 1 - 1 - - 1 3 7/8
PT

FG 3 1 - 1 1 1 3 - 1 8
recruited
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FG 3 sessions 1 * - 1 1 1 2 - * 5/8
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FG 4 1 1 2 1 - 2 - 1 8
recruited
FG 4 sessions 1 1 1 2 1 - 2 - 1 8/8
2 1 1 2 1 - 2 - 1 8/8
*Missing

hospitals (H), health center (HC), and municipal health and social care (M)

Data Analysis
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COLLABORATION IN DISCHARGE PLANNING 7

The analysis was performed from the authors preunderstanding of social

constructionism (Gergen, 2009), as inspired by Kreuger and Casey (2009) and Rabiee (2004).
Initially, the audio recorded data material was listened to several times to reach an overall
understanding of the context, existent words used and the meaning of them. The recordings
were then transcribed verbatim. The authors worked with the texts in their native language
(Swedish) to understand their significance before translating them to English. The authors
then read the translated transcribed recordings a couple of times to obtain an overall

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understanding. While reviewing the transcription material for internal consistency, the authors
found it showed not only concrete expressions of collaboration but also disagreement in

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certain cases. A focused analysis of the transcripts was conducted to identify common themes

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for interprofessional and interorganizational collaborative preconditions versus obstacles. The
data were coded to identify and categorize the variation for preconditions to
interorganizational and interprofessional collaboration.
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Results
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In the FG discussions, the participants talked about how contextual circumstances

affected collaboration in care planning. In some cases, it appeared as if the participants
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disagreed upon whether the judgement at a discharge planning conference was correct or not.
In other cases, we could identify frictions in the discussion that indicated that the topic was
about issues of concern that particularly seemed to engage the participants. In these
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sequences, differences in both professional and organizational perspectives were revealed.

The argumentation revealed and highlighted how underlying norms and values within each
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organization implicitly, but strongly, influenced the healthcare and social care professionals
collaboration (e.g., appropriate care activities after discharge) as well as the elderly patients
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participation in discharge planning (e.g., in relation to ethically sensitive information). These

normative and contextual aspects that function alongside the explicit legal acts and guidelines
seemed to have a great impact on collaboration in discharge planning. In this study, these
aspects were interpreted as the tacit framing of collaboration in discharge planning and
consisted of the following four categories: (1) Different perceptions of prioritizing the elderly
patients involvement in practice; (2) Choice of method for information transferal affecting
collaboration; (3) The limited timeframe affecting assessments and choice of actions; and (4)
Underlying professional hierarchies.
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COLLABORATION IN DISCHARGE PLANNING 8

Different Perceptions of Prioritizing the Elderly Patients Involvement in Practice

Although the participants stated they adhered to the formal framework, (i.e., acts and
regulations supporting elderly patients participation in discharge planning), it appeared as if
the discharge planning conference was perceived more as an arena for a professional
exchange of ideas than for a dialogue including the elderly person. Ethically problematic
questions arose in discussions when they disagreed on which line they would push during the

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meeting: to provide accurate information to their collaborators, to secure patient safety, or to
respect the opinion of the elderly person. Another debate arose about to what degree the

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wishes of the elderly person themselves could or should be met.

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The FG participants expressed concern that the elderly persons opinion would not be
heard if too many participants attended the meeting. Others found the presence of
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representatives from different organizations essential for decision-making. Situations were
highlighted wherein information that was unknown to the elderly person was presented
without reflection at the discharge planning conference. For example, how ethically sensitive
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information, such as cognitive deficits, could or should be reported while facing the elderly
person and/or the next-of-kin and the consequences of this. Different perceptions regarding
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whether professional pre-meetings in the absence of elderly patients could be appropriate are
illustrated by the following quote:
PT

F1: In the absence of the elderly person?

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F2: Yes, and if the elderly person or next-of-kin wishes to take part, then--

F3: I feel that one has lost//then the elderly person does not get an explanation of the
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illness, a repetition of the course of events, and what the problem is and what is positive.

F2: There was no intention to keep secrets from the elderly, but it was for work efficiency.
(FG 3, session 1).

Choice of Method for Information Transferal Affecting Collaboration

Diverging views among the participants appeared related to how the information was
transferred and how it should be documented. As the method for information transfer had
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COLLABORATION IN DISCHARGE PLANNING 9

consequences for its accessibility for other care providers (e.g., municipal health and social
care), this was an essential issue. However, the participants knowledge about these
implications seemed to vary. This quote illustrates how information is at risk of being
excluded for municipal nurses:

F1: Most important is that the information is included in the care plan [IT-based].

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F2: But I am a little more concerned when it comes to the IT system, we had wished that
primary care was more involved [in information transfer]-

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F3: Yes.

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F2: ..//.. one of my elderly patients was sent from the health center [to the hospital], and I
asked the nurse at the health center, Do you have a demand for care? No, but we made a
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referral, thats what counts? [referring to the law]. Then, when she [the patient] came there
[to the hospital for assessment in emergency care without being hospitalized]--
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F3: Yes.

F2: --when no demand for care followed the patient, and the nurse at the health center didnt
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know if the elderly has home healthcare, and we [municipal health and social care] do not
get an enrollment message, it resulted in that the elderly patient fell out of the system (FG 1,
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session 2).
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The Limited Timeframe Affecting Assessments and Choice of Actions

One consequence of the short care periods at the hospital was that the health
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professionals in specialized care had to make assessments of the elderly patients self-care
abilities quicker and at an earlier stage. This led to social workers basing their discharge
decisions on the original assessment, which may not contain the most up-to-date information.
For the sake of safety, the social workers then generally decided on more extensive care
actions as it, for organizational reasons, was considered to be easier to reduce than to increase
care actions at a later stage. However, these priorities were not always shared by other
participants in the FGs as demonstrated in the discussion below:
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F1: And then it is these five days to plan before discharge, they [professionals] often have
both belt and braces, and hedge with all possible efforts because one doesnt know how it will
be in the end--

M: No.

F1: --and it feels then a little like going over the head of this man, that one urges actions

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related to him.

M: You must not in any case--

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F1: Yes. In the beginning, at least, and we can take things away when we see how it goes.

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(FG 2, session 1)
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Underlying Professional Hierarchies
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The discussion showed that participants expressed different views about the
responsibilities that were applied in connection with the discharge of patients. The different
perceptions could be related to interpretations of the regulations that govern their own as well
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as other organizations. For example, when and how a patient could be assessed as ready for
discharge was interpreted differently by the municipality compared to the hospital staff. There
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were also different views about who should have the authority to make decisions about what
would be the appropriate care activities after discharge:
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F1: Yes, it would perhaps be good if we did know that they had come to a short-term nursing
home, to have the right to assess the need as such from the inside [the hospital], but the
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municipality says differently.

M: But you do it at the discharge planning conference? [trying to emphasize her view]

F2: Yes.

(FG 1, session 1).

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Another aspect of transfer of responsibility that was expressed in the FGs was
concerning primary care where the participants agreed upon them having a passive role at
discharge. Interorganizational collaboration is influenced by different statuses among
employees depending on organizational and professional affiliations. According to the FG
discussions, conflicts took place where professionals felt challenged. One example was when
physicians gave promises of aftercare without having the authority to decide on actions in
municipal health services:

PT
F1: The problem is when our doctor says, "You get a short term" [directed to short-term

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stays].
F2: Yes.

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F3: That, they should absolutely not say. NU
F4: It's not good.
F1: No, and we say to the patient, "I'm sorry, but the doctor cannot ...".
F2: No.
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F1: I have become an enemy to two doctors over there, I mean they cannot say ... "
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(FG 4, session 1).

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Discussion

Nurses, social workers, occupational therapists, and physiotherapists work together to

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coordinate the discharge and take part in a cross-professional team setting. Therefore, it is
essential for all health professionals, nurses as well as others, to become aware of the
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preconditions to interprofessional and interorganizational collaboration, how it functions, and

its consequences for the patients.

Through our FGs, we explored the dialogue on how healthcare and social care
professionals viewed the hospital discharge of frail elderly patients. The results of the analysis
showed that preconditions to collaboration (e.g., in relation to transfer of care
responsibilities), to a considerable degree, were related to both an explicit formal and a tacit,
informal framework. We found the participants professional commitment made them move
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between the formal and the tacit frameworks in order to fulfill their obligations towards both
the elderly patients and their employer. The studys participants described situations where
healthcare professionals prioritized loyalty towards the organizational demands of efficiency
before the participation of the elderly. For example, there were times when the participants
admitted they arranged interprofessional pre-meetings and excluded the elderly patient,
despite being aware of formal guidelines that support patient participation, simply to save
time in the discharge process. The impact of this professional balancing act sometimes

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supported and sometimes obstructed collaboration with other professions and organizations
that judged the situation differently. However, we discovered this unspoken framing was

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rarely addressed in clinical practice.

SC
The results showed that there are a number of factors constituting the healthcare and
social care professionals opinions on and attitudes in relation to discharge planning
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conferences. For example, we found that in some cases there was a lack of knowledge about
the laws that governed hospital-based healthcare and the municipality. Furthermore, lack of
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knowledge about the existence of two different methods for information transfer could lead to
decision making based on incomplete information with serious consequences for the patient.
Another example of risky practices was decision making with incomplete information
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because of the limited timeframe originating from economic restrictions. This often results in
under- or overestimating frail elderly peoples abilities, which in turn leads to longer,
PT

unnecessary hospital stays or situations where the elderly patients health is jeopardized at
home (Hesselink et al., 2014).
CE

In the analyses, we found expressions of awareness among the professionals of the

importance of the elderly patients participation in discharge planning meetings. Research has
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also shown that frail elderly people can be supported to participate in discharge planning
meetings when professionals have a conscious approach, and the elderly are prepared,
supported, and encouraged to be active in those meetings (Bngsbo, Dunr, & Lidn, 2014).
However, in this study, we found that the professionals drive to be time-efficient had the
consequence that the discharge planning meeting was mainly perceived as the professional
arena for information transfer; whereas discussions about how to establish closer
collaboration with the elderly was less salient. This rush could result in assessments of elderly
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COLLABORATION IN DISCHARGE PLANNING 13

patients lack of abilities presented in an unethical manner, extraneous to the elderly. This
result is in line with previous research (Dyrstad, Testad, Aase, & Storm, 2015).

This study showed the FGs participants prioritized keeping within their own
professional framework, making clear limits for what they considered were their professional
tasks, instead of having a more open approach to the sharing of tasks and responsibilities.
This attitude has been discussed in previous research, which has pointed out this as an

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obstacle for interprofessional interaction (Engel & Prentice, 2013; Lundgren, 2009). In
contrast, successful interprofessional teamwork can improve patient care and access to

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healthcare through enhanced communication between the organizations (Engel & Prentice,
2013).

SC
Another tacit obstacle for collaboration had hierarchical origins. We found that the staff
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from the municipality, while carrying out their task, was put under pressure by professionals
at the hospital. The social workers authority was sometimes undermined by hospital staff by
making promises to patients about, for example, access to short-term stay, without any legal
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mandate to do so. This situation preempts the social workers role in making that decision.
These results are supported by Dunr and Wolmesj (2014), who argue that social workers
perceive their professional status to be low in relation to hospital staff, which complicates
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collaboration.
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In the FGs, there were disagreements regarding whether the healthcare professionals
took either too much or too little responsibility during discharge planning. This could be
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interpreted as an expression of diverging organizational and professional perspectives

regarding the purpose of the discharge planning meeting. These results are supported by
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Waring, Marshall, and Bishop (2015), who argue that various professional groups perceive
discharge planning conferences significance differently. Doctors and nurses in hospitals see
discharge planning conferences as a conclusion; while occupational therapists and care
planning coordinators consider discharge planning to be an ongoing process that requires
specific actions in collaboration between organizations and professions. If the professionals
do not agree on the division of responsibilities between the organizations, problems occur at
discharge (Waring et al., 2015). However, discharge from specialized care to primary care
could benefit from improved care coordination, discharge information, and communication
interorganizationally, where patients and/or next-of-kin participate in the process (Hesselink
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COLLABORATION IN DISCHARGE PLANNING 14

et al., 2014). Similar results were shown in a social worker navigated discharge model, where
social workers were the hub from hospital to home (Watkins, Hall, & Kring, 2012). Such
models can be beneficial to overcome organizational boundaries and improve
interprofessional collaboration.

Studies have shown when patients are involved in the decision process, they have
higher life satisfaction (Berglund, Hasson, Kjellgren, & Wilhelmsson, 2015) and are more

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self-determined (Ekelund & Eklund, 2015). Strengthening professional collaboration where
effective communication and knowledge of professional responsibilities are important skills

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for nurses to collaborate to support patients (Suter et al., 2009). We found the preconditions to
collaboration are problematic both from the patients and next-of-kin point of view as well as

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from an organizational standpoint. There are huge challenges to balance shorter care periods
with organizational demands on efficiency and creating possibilities for patients and next-of-
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kin to participate.

This study, through the collection of interview data in FG discussions, explored health-
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and social care professionals experiences of collaboration preconditions where discharge

planning conferences were the arena. The FGs in this study were assembled on the basis of
their experience in participating in discharge planning meetings. Yet the composition was also
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heterogeneous as the participants represented various professions, organizations, and

geographical areas. However, the composition was somewhat uneven due to some absences,
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which meant that important perspectives possibly did not enter into the discussions in those
groups. A heterogeneous composition of FGs is supported by Kitzinger (1995), who argues
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that it is possible to discover more perspectives within these groups. The vignette aimed to
initiate the FG discussions and its illustration of the discharge planning conference may have
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influenced the outcome of the FGs. However, participants appreciated the FGs as they felt
there was a need to discuss the issues that arise at discharge especially since there is no other
existing arena for such open interprofessional dialogue.

Conclusion

Collaboration between professionals within and between organizations in connection

with discharge planning conferences implicate an unspoken tacit framework in which
collaboration is accomplished. Within the collaborative framework, there are boundaries
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COLLABORATION IN DISCHARGE PLANNING 15

between professionals and organizations that are exceeded, inciting conflict. Collaboration in
discharge planning conferences focused to a greater extent on professional boundaries and
hierarchies rather than on the participation of frail elderly patients. The insufficient
knowledge of the discharge process initiated at each professionals organization was biased
by its own norms and values, obstructing collaboration.

The prevailing preconditions to collaboration need development on the local and

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systematic levels. Shorter-term care periods complicate the discharge process where new
ways of working must be implemented to strengthen interprofessional work and reduce the

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impact of the tacit framework. This includes having cross-professional arenas for nurses,
social workers, occupational therapists, and physiotherapists to exchange their knowledge and

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experiences with the discharge process and methods for improved teamwork. It is of
importance for the professions to better understand the preconditions for collaboration
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interprofessionally and interorganizationally to support professional development in relation
to discharge planning. Further research is needed to investigate how collaboration can be
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successfully accomplished to support frail elderly patients in coordinated discharge process

programs. Therefore, we make the following three recommendations to improve the
preconditions for collaboration:
ED

There should be collaborative arenas to develop knowledge about discharge planning,

regulations, teamwork, ethical considerations, and support of frail elderly patients.
PT

Coordinated discharge process programs, including interventions to support elderly

patients and next-of-kin, should be developed and implemented.
CE

Universal IT-systems need to be developed to bridge organizational gaps and facilitate

information transfer in relation to shorter term care periods.
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Declarations of Interest

The authors declare there are no conflicts of interest.

Acknowledgements

This study has been supported by R&D Sjuhrad Welfare at the University of Bors, the
R&D Council in Southern lvsborg, Agnetha and Gsta Folkes Prytz foundation, and the
Swedish Research Council for Health, Working Life and Welfare (AGECAP 2013-2300). We
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would like to thank Berith Hedberg, PhD, and Felicia Gabrielsson-Jrhult, PhD-student, at the
University of Jnkping, the language editor, and all the professionals who participated.

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