Table 3.
Transition facilitators and inhibitors.
| Theme |
Transition conditions PC = Personal conditions, CC = Community conditions, SC = Societal conditions |
References |
|---|---|---|
| Resilience in older adults; | Facilitators | |
| • Coping strategies (PC): such as - Acting on past experience - Creating a schedule, adapting the home environment - Integrating effective information - Learning self-care skills |
(4, 25, 41–43) | |
| • Personal Traits (PC):positive, cooperative | (4, 43, 44) | |
| Inhibitors | ||
| • Negative perception transition (PC) | (25, 39, 41, 43, 46) | |
| • Knowledge gap in managing symptoms (PC) | (39, 46) | |
| Interpersonal connections and relationships | ||
| Patient-caregiver connections and relationships | Facilitators | |
| • A positive, caring relationship (CC) | (4, 43, 46) | |
| • Family caregivers actively empower, advocate, and motivate patients (CC): - Practical support e.g., life care, professional care - Emotional support e.g., courage, willingness to care |
(4, 25, 41–43, 45, 47, 48) | |
| • Cultural concept of filial piety (CC) | (49) | |
| Inhibitors | ||
| • Residence status: especially widowed elderly living alone (PC) | (38, 45) | |
| • Physical and mental symptoms and financial burden of caregivers (PC) | (39, 40) | |
| Patient/caregiver-healthcare provider connections and relationships | Facilitators | |
| • Healthcare providers making efforts to understand patients (CC) | (44) | |
| • Caring from a healthcare providers (CC) | (4) | |
| • Patients and families participate in care decisions together (CC) | (4, 43) | |
| • Setting Navigator/Transitional Care Coordinator (CC) | (38, 46) | |
| Inhibitors | ||
| • Indifferent tone and attitude of health care providers (PC) | (40) | |
| • Use of terminology in conversation (PC) | (25, 26) | |
| • Ignore identity presentation and interaction (CC) | (4) | |
| • Organizational factors: such as specific time and workload constraints (CC) | (25, 43) | |
| • E-health literacy (CC) | (50) | |
| Connections an relationships between health care providers | Facilitators | |
| • Regular meetings (CC) | (44, 50) | |
| • Mutual trust between healthcare providers to support or quickly respond to requests (CC) | (44) | |
| • Communication media e.g., letters, electronic medical records or digital calls supported by technology (CC) | (46) | |
| Inhibitors | ||
| • Employee rotation and reorganization (CC) | (44, 50) | |
| • Hospitals and community organizations are independent (CC) | (44, 50) | |
| • Communication media e.g., letters, electronic medical records or digital calls supported by technology (CC) | (50) | |
| Uninterrupted transfer of care supply chain | Facilitators | |
| • Care coordination practices (CC), for example - Discharge coordinator: transition nurse - Multidisciplinary team to reach consensus on care transition delivery through meetings. - Patient and family participation in decision making, monitoring or supplementing the care transition process. - well-developed electronic systems and written information from a holistic perspective |
(25, 38, 43, 44, 46, 47, 49) | |
| Inhibitors | ||
| • Lack of standardized processes and fragmented communication (CC) | (43, 46, 50) | |
| • Different positioning of healthcare providers (CC) | (44, 50) | |
| • Gaps in discharge planning (CC): handover of discharge t information | (24, 26, 46, 47, 50) | |
| • Approaches to care (CC), such as - Care provider-centered care - Organization of care (e.g., organizational responsibilities are not clearly defined) |
(4, 38, 40, 43, 50) | |
| • Human resource limitations (CC), for example - Inadequate staffing - Insufficient staff knowledge and skill level - Family caregiver avoidance and misconceptions about caregiving responsibilities |
(24, 38, 45, 47, 49) | |
| • Patients' residential distance (CC), | (45, 49) | |
| • Adherence to healthcare authority (PC) | (25) |