The above literatures show that hospital discharge is a vulnerable or unsafe stage in the care pathway, often because of the challenges of co-ordinating different health and social care agencies. Extending this idea, this study suggests that hospital discharge might be thought of as a complex system, whereby interdependencies and couplings between caring professionals and agencies can be a source of and threat to patient safety, depending on how they are co-ordinated. The literature repeatedly emphasises communication as helping to reduce this complexity and support co-ordination, for example, in discharge planning or the use of checklists.27–29,86,87,94Extending this idea, we propose the concept of knowledge
sharing as a way of supporting the co-ordination and integration of health and social care agencies and mitigating the uncertainties inherent within complex health-care systems.
Knowledge sharing involves more than the communication of information, but instead denotes the exchange and use of meanings, assumptions, practices and know-how between different groups to engender shared understandings and collaborative practices.11For many improvement strategies, such as
knowledge management and evidence-based medicine, knowledge is conceived as an explicit, abstract and tangible resource that can be accessed, codified and exchanged, for example in the form of formal policies or incident reports. In other words, it is an explicit‘thing’to be shared with others in the form of documents or evidence. This contrasts with the idea that knowledge or know-how is often tacit,
experiential and situated in practice.116In this sense, knowledge is difficult to share and is typically acquired
and developed through participation in communities of practice.117In short, knowledge is not a‘thing’
that a community‘has’, but rather it is what they‘do’and who they‘are’.117This distinction is important
because efforts to understand and indeed promote knowledge sharing should not only focus on the formal assemblages of knowledge, but also the more informal and unarticulated manifestations of know-how. Knowledge sharing is therefore more than the communication of information; it refers to how the meanings,‘know-how’and practices of one group or organisation can be shared and integrated into the practices of another.10
The research literature highlights a range of factors that facilitate or inhibit knowledge sharing.10–12,118
This includes the characteristics of both‘donor’and‘recipient’actors, such as their motivations, accessibility, levels of trust, values, hierarchies and absorptive capacity.119–121For example, competitive
pressures can inhibit knowledge sharing where it threatens competitive advantage.11The‘structural
configuration’of relationships can also channel knowledge flows through‘central actors’or knowledge brokers, rather than between peripheral actors.122Similarly, power hierarchies and cultural difference
between actors can have an impact on knowledge sharing, especially where powerful actors assume control of knowledge to advance their own interests.12,123For professional work, these issues are
exacerbated where expert knowledge is closely linked to sociolegal jurisdiction within the division of labour.124In this context, knowledge sharing can threaten professional boundaries and identities.13,125
The research literature highlights a number of key dimensions that shape the potential for knowledge sharing.117,122,126–128Drawing together this literature, three inter-related factors are identified as shaping
knowledge sharing and collaboration within and between health-care organisations:
l Knowledge Related to differences in epistemology, cognition and sense-making, for example how actorsmake senseof discharge; the types of knowledge that guide practice; and whether or not knowledge represents a competitive resource.
l Culture Related to the shared norms, attitudes and values that guide practices, for example when knowledgeshouldbe shared and withwhom; how identities and trust reinforce knowledge hoarding; the different philosophies of care that guide work organisation.
l Organisation Related to the influence of (inter/intra)organisational structures, processes, regulatory factors and management priorities that shape knowledge sharing, such as sociolegal rules, professional jurisdictions, organisational connections and resource constraints.
Knowledge sharing for safe discharge
Applying the above literatures to hospital discharge, this study investigates how patterns of knowledge sharing among health and social care agencies influence discharge planning and care transition. Developing this view, knowledge sharing is conceptualised as a latent source of safety that, through shaping the patterns of co-ordination, shared decision-making and integrated working, can mitigate system complexity. As such, understanding the barriers to and drivers of knowledge sharing can contribute to the development of new knowledge on the possibilities for improved integration and safety in hospital discharge. These lines of analysis are tentatively outlined inTable 3.
TABLE 3 Application of framework to hospital discharge
Dimension of
knowledge sharing Examples in context of hospital discharge
Knowledge (a) Whether discharge is seen as an‘end-stage’or‘beginning-stage’activity (b) How the meaning of‘fit’for discharge is constructed differently according to
clinical speciality
Culture (a) How discharge is valued within the care pathway (b) Attitudes towards patient involvement
Organisation (a) Where discharge resources are controlled
Summary
This chapter has reviewed research literatures on hospital discharge and patient safety to suggest that discharge from hospital to community is located within a complex and vulnerable system, involving a diverse range of heterogeneous actors interacting in dynamic and non-linear ways. Policy and research highlight the need for improved integration, especially in discharge planning and care transition; however, given the complex, dynamic patterns of interaction and the variable institutional environments in which caring professionals work, this integration remains problematic. The idea of communication and collaborative decision-making is frequently cited as a basis for integration.27–29,86,87The study extends
this idea by suggesting that knowledge sharing can support enhanced integration and collaboration among system actors, based upon the exchange and alignment of different meanings, assumptions and know-how, as well as more explicit knowledge and information. Knowledge sharing is therefore presented as a source of (and threat to) safety within the complex systems involved in hospital discharge, and