Perspectives on Metanarrative as a Way of Factoring Complexity into Health Services: Research Synthesis for Transforming Seniors’ Care in Canada

Abstract

There is a critical need to improve functional outcomes in hospitalized seniors for both the individual and their caregivers, and to plan for a sustainable healthcare system in the face of an aging population. Over 50% of acute care hospital beds in Canada are occupied by seniors; one-third of these older patients will be discharged at a significantly reduced level of functional ability. Most will never recover to their previous level of independence. This article offers perspectives on research and implementation strategies that take into account the complex, interacting challenges to improving hospital outcomes in seniors. To this end, we describe two cost-neutral strategies with demonstrated successful outcomes. One developed as a focused care strategy and related care processes on a geriatric medicine/rehabilitation unit. The other describes a change in staff-mix and hours of interdisciplinary coverage that resulted in increased hours of direct care and improved outcomes for older adults on acute care units. Both strategies demonstrated reductions in length of stay in the initial context; however, we identified a number of challenges to translating these strategies to a broader context. We contend that this difficulty is understandable given the complexity of seniors’ health, health services and organizational change. Research methods and approaches to change in health service delivery need to take complexity into account. We propose a metanarrative research methodology that combines qualitative and quantitative methods, as one way of taking complexity into account in health service research. Finally, we propose a way of thinking about organizational change that offers an alternative to typical ‘roll-out’ strategies that cannot take into account the inevitable uniqueness of each context in which a strategy may be implemented.

Characteristics of Patients Described as Sub-acute in an Acute Care Hospital

“…Research on the appropriate use of acute care resources has historically relied on professional opinion and quantifiable outcomes. This has often come at the expense of individual patient preferences and, in any case, is most problematic where the problems with which patients present do not conform to how acute care is provided (McElhaney et al, 2012). This situation is not new.…”

“…At a minimum, staff should be trained to assess mobility and balance in these patients and ensure that this is done every day, as it is a very sensitive sign of illness and recovery and, thereby, can help guide treatment decisions (Hubbard et al, 2011). Putting such assessment in place would build the capacity for subsequently introducing the “48/5” system (McElhaney et al, 2012). This system requires that five things be done in the first 48 hours including ensuring that patients are (a) fed, (b) mobilized, (c) have pain treated, (d) have a medication review aimed at reducing polypharmacy, and (e) have care goals set in collaboration with their families.…”

“…With these come more focused interventions. This can form the basis for a new initiative on inter-professional collaborative practice (McElhaney et al, 2012).…”

Investigating practical wisdom in complex system management: What is it and how do we get more?

“…The concept of PW has not been fully explored in the systems domain. Existing studies, for example, those of McElhaney et al (2012) and Riedler and Eryaman (2016), are limited in their explication and application of PW. A paper by Bontemps-Hommen et al (2019) does discuss the value of PW in a complex medical setting, but is limited to a theoretical discussion, as is the paper by Marker (2013).…”