[Continuity of care by Pflegeüberleitung? Results of participant observation].

Continuity of care between health care institutions is of increasing importance. In a two-year research project on this topic extensive participant observation was carried out for data gathering in three hospitals in Düsseldorf (Germany). In each institution four patients were observed until their discharge and all interactions between them and health care professionals were documented using a semi-structured data-gathering instrument. Furthermore, the researchers questioned the involved professionals after each situation. Altogether a total of 980 situations were documented during 100 shifts, thus professional activities aiming at continuity of care can be regarded as extensively covered. The results show that care professionals (nurses, physicians, social workers etc.) in the three participating hospitals only incompletely assess individual needs or even fail to do so at all. In addition, there is no regular interprofessional collaboration and the professionals' horizon is essentially limited to their own institution. Patients and their relatives are not systematically involved and their views rarely considered. Two cases are used as examples to illustrate these aspects. A third example shows that also successful processes were observed. In most cases, however, the implicit logic of the hospital system dominates over individual needs and therefore a successful continuity of care processes cannot be assumed. Finally, the necessity for a fundamental change of this counterproductive systems logic is briefly discussed.