Data collection involved two sustained periods of data collection within each local care system
(Glipton and Farnchester), starting in the respective stroke and hip fracture services of each hospital before moving to the wider health and social care system. Data collection typically involved 2–3 months of research in and around each stroke and hip fracture service (i.e. 5–6 months of research in each hospital) and a further 2–3 months of research in the local community health and social care sector, including patient tracking (i.e. approximately 8 months of research within each health-care system).
Glipton locality Farnchester locality Stroke
Hip fracture
Patient tracking commenced around the same time that community health and social care agencies were involved in the research.
Qualitative interviews
Semistructured qualitative interviews were used to understand how hospital discharge is planned,
organised and experienced from the perspectives of different health and social care professionals, patients and family members. Interviews were especially important for identifying the roles and responsibilities of actors within the discharge process, the patterns of knowledge sharing between actors and how actors’ knowledge domains, cultures and organisational context shaped their interactions. The interviews were designed to be conducted in a semistructured, conversational style, giving participants the opportunity to explore emergent issues. All semistructured interviews were guided by a topic guide developed to reflect the study objectives. Draft questions were developed by the project team and representatives from the PPI group and piloted at one research site with three clinicians. These topics (see alsoAppendix 1) included:
l career biographies and backgrounds
l details of roles and responsibilities, with a specific focus on discharge activities
l an account of the discharge process, including the broad process, planning issues, and working with patients and families
l the role of communication and knowledge sharing in discharge processes
l identification of individuals or groups contacted during discharge activities
l exploratory accounts of knowledge-sharing relationships with identified individuals
l perceptions and experiences of risk and safety
l recommendations and improvements.
A modified guide was developed for patients, family members and carers, based on the advice and feedback from the PPI representatives. This included:
l ways in which discharge plans were discussed and planned with patient and carer
l how the discharge was expected and experienced
l whether or not the plan met the needs of the patient
l ways in which discharge can be improved.
An important feature of the interview questions was that they were structured to generate participant narratives, or stories of discharge processes. These stories were not read necessarily as‘truths’but rather as analytical windows into how participants make sense of and give meaning to discharge, thereby highlighting differences in knowledge and culture. These narratives were particular insightful when exploring how participants make sense of the discharge process, and especially the sources of safety and risk. A further feature of the interviews was that they were used to inform snowball sampling, that is, to help identify other potential, unanticipated actors or groups involved in the discharge process and the patterns of knowledge sharing with these actors. For example, all participants were asked to describe the different people, groups or organisations they communicate and share knowledge with in the processes of discharge planning and care transition.
Most participants were invited in writing to participate in the study. This invitation included a participant information sheet and an opportunity to contact the project team for further information.
Other participants were recruited during ethnographic observations; for example, where an individual was observed as having an important role they would be asked to participate in the study and provided with a participant information sheet. All participants were asked to confirm that they had understood the participant information sheet and give written consent. The majority of interviews were digitally recorded with the consent of participants and all were transcribed verbatim for the purpose of subsequent data analysis.Table 5details the interview participants according to location and number, andTable 6further details the interview participants by their occupational background.
Alongside semistructured interviews, the research involved more informal ethnographic-type interviews with participants, normally as part of observations. These ranged from small interactions or‘chats’to clarify an observed occurrence or activity (i.e. asking a participant what they are doing or to explain a technical procedure) to more open, unstructured and lengthy exchanges (i.e. to explain a series of events or a particular situation in greater detail). Many of these interviews occurred when shadowing participants or in other informal settings, such as rest areas or cafés. As such, it was not always feasible to digitally record these interactions and most were recorded as handwritten notes in field journals.
Observations
Ethnographic observations of discharge activities provided the main source of data. Observations focused on how discharge was planned, organised and supported as a series of complex interactions between various health and social care agencies. These involved non-participatory or passive observations144of
everyday practices; that is, the research team did not have a formal, legitimate membership role in discharge activities, but they did build rapport and shared understanding with participants through interacting and engaging in other forms of participatory engagement, such as conversations and non-clinical (technical) interactions. The observations combined different activities to build rapport and understanding:
l Guided tours and structured familiarisation Undertaken at the start of the research over a period of 3–5 days, including‘walking tours’with service leaders, introductory meetings with stakeholder groups, informal presentations at weekly meetings and collection of relevant documents, policies and procedures.
TABLE 5 Interview participants detailed by organisational location in the health-care system
Organisational location Number of interviews
Glipton system total 98
Glipton Hospital: stroke unit 45
Glipton Hospital: hip unit 16
Glipton Hospital: management 2
Glipton community hospitals 7
Glipton Community NHS Healthcare 9
Glipton social care 6
Glipton community health care 7
Primary care/CCG/GP 6
Farnchester system total 64
Farnchester Hospital: stroke unit 17
Farnchester Hospital: hip unit 20
Farnchester Hospital: management 2
Farnchester community health care 7
Farnchester social care 5
Farnchester community others 10
Primary care/CCG/GP 3
Ambulance service (regional) 2
National organisations 5
l Work process observations More in-depth workplace observations undertaken over a period of 1–6 weeks (depending on the location). These included mapping the temporary and spatial
organisation of daily work (schedule of ward rounds, meetings, handovers, discharge times); identifying key events and activities (MDTs, drug rounds); identifying key individuals or groups (discharge
co-ordinators, clinical leads); and drawing together these data into a complex descriptive account of the social setting. For the main research settings, i.e. hospital wards, observations were undertaken on a daily basis (3–4 days per week, including evenings and weekends) for 4–6 weeks; in other settings, such as community hospitals or care homes, they were undertaken over 1–2 weeks, and in more dispersed or peripheral settings, such as social service departments, they were undertaken over a shorter time period, i.e. day visits. Some settings were not amenable to observation given the diversity and demands of their workload, such as GP surgeries and community pharmacies, where interviews provided the primary source of data.
l In-depth observations of situational activities, tasks and settings Prolonged follow-up observations of key knowledge-sharing activities, tasks and settings. These observations were usually conducted concurrently with other research activities, including shadowing or interviews. Each setting was observed at least three times and some settings, such as weekly MDTs, were observed up to 10 times. This included observations of:
¢ daily/weekly planning and decision-making meetings (MDTs)
¢ trauma and assessment ward rounds
¢ patient and family consultation meetings
¢ community hospital reception
¢ nurses’station ambulance handover
TABLE 6 Interview participants by occupational and organisational designation
Group Glipton Farnchester Total
Medical (hospital) 10 8 18
Nursing 18 15 33
HCAs 5 2 7
OTs 10 10 20
PTs 16 8 24
Other therapists (speech, dieticians) 2 3 5
Pharmacists 1 2 3
Ambulance (regional) n/a n/a 2
Administrative 2 2 4 Managerial/leadership 3 3 6 Social work 9 5 14 Social care 2 2 4 Community nursing 2 7 9 GPs 1 2 3 GP/CCG administration 2 0 2 Support group/voluntary 4 2 6
Patients (interview stage 1) 16 14 30
Carers/family (unpaid) 12 11 23
¢ social services assessment
¢ use of ICT and manual records relating to discharge planning
¢ pharmacy ward checking of medications to take out (TTO) on discharge
¢ fast-track planning and handovers
¢ referrals to multiple agencies by phone.
l Shadowing of individuals To deepen understanding of the roles and contributions of certain individuals or groups, shadowing observations were also undertaken with key individuals (leaders or discharge co-ordinators) or representatives from professional groups (nurses or therapists). These ranged from several hours (ward clerks) to several days (discharge co-ordinators) of observing individuals as they went about their day-to-day work. These individuals included:
¢ discharge co-ordinators
¢ ward nurses
¢ junior doctors
¢ consultants
¢ hospital social workers
¢ ward clerks and administrators
¢ OTs
¢ PTs.
Using these techniques, it is estimated that the research involved over 180 hours of direct observations and many more opportunistic observations, in a variety of health and social care settings. All observations were recorded, first in handwritten field journals including rich description and separate interpretations. These were later typed up electronically as corresponding text and interpretation, as well as a summary overview of key points.
Patient tracking
A key feature of the research design was the use of‘patient tracking’to understand the first-hand experiences of patients and their families/carers as they were discharged from hospital to a community setting. This involves a series of short semistructured interviews (up to five), with patients both before and after discharge, focused observations of their discharge planning and arrangements, and the collection of patient diaries (where possible) (seeAppendix 2for extracts of patient diaries). These activities led to the collection of rich and diverse data that enabled the research team to construct a picture of how patients and family members experience hospital discharge.
In the first instance, patients/families were approached in hospital after admission, usually when an initial date of discharge had been set (within 72–48 hours of planned discharge). Each patient was asked to participate in a series of short follow-up interviews, starting in hospital and then at 1, 2, 4 and 6 weeks post discharge. Although every effort was made to schedule interviews at these times, in some instances they needed to be moved±1 week owing to other appointments. Furthermore, not all patients were able to participate in the full series of interviews because of withdrawal (their health had worsened), readmission to hospital or death. Observations were also undertaken with patients, families and carers, on the wards and at home or in a care setting (nursing home) to understand how care was organised and provided. Patients were also invited to keep diaries about their discharge experiences (Table 7). In consultation with PPI representatives, a short, open-text diary was designed and printed and given to each participant with a short description explaining its voluntary use. The diary had a minimal structure and allowed for open text. Specifically, it stated that:
The purpose of this diary is to give the researchers a way of understanding how you are living your life since leaving hospital. The team are interested in what happens each day, especially when you have contact with health and social care workers. Please spend at least 10 minutes each day writing in your diary, but don’t worry if you miss a day.
It also included a number of prompts asking participants to consider which health and social care providers they had interacted with, what they talked about, what kind of decisions were made and who else helped with their care. Participants were asked to keep the diaries for up to 30 days. Diaries were collected following the last interview or earlier if patients needed to withdraw from the study. In most instances, patients withdrew from the study because of continuing illness or moving out of area, in most cases around the time of the second interview.
Focus groups and validation workshops
The research involved a number of focus groups and workshops at each research site, together with a validation workshop at a third hospital site. The focus groups aimed to explore similarities and differences in staff members’understandings of the discharge process. Each involved structured activities with representatives from professional groups in ward or community settings. Each started by asking participants to individually visualise and draw what they saw as the key stages or activities involved in hospital discharge. These were used to prompt reflection and to gather insight into how discharge was understood by different groups (seeAppendix 6). Each group was then tasked with collectively drawing the discharge process on large sheets of A2 paper, using pens and Post-it notes. These usually took the form of flow diagrams, but varied as they were revised and amended. Throughout this process, a member of the research team asked probing questions to clarify the choices made, differences between participants and to surface shared or divergent reasoning. Finally, each focus group involved an open discussion about the sources of risk and breakdowns within the discharge process. Although focus groups were organised with all four sites, the Farnchester hip fracture service was unable to participate in the activity owing to staff shortages and workload pressures. As such, only three of these focus groups were undertaken. Table 8details the numbers and staff representatives involved in the focus groups.
At each research site a feedback (validation) workshop was organised after data collection to outline preliminary findings, raise any unresolved questions and seek validation on emerging interpretations. These were organised in consultation with service leaders to include staff representatives and clinical leads, usually involving between five and 10 people. They each involved a short visual presentation and provided a written report about the study aims and design, data collection and key findings, including a list of anonymised recommendations from participants for service improvement. These workshops were particularly useful for validating and confirming the early analysis.
An extended‘validation workshop’was organised with an additional acute care provider of hip fracture services, not involved in data collection. This aimed to further validate and confirm the research findings through exploring relevance and similarity with professionals and managers from another locality, thereby helping to develop more generalisable lessons. This workshop was organised after all data collection and early analysis was complete. It was attended by the hip services clinical leader and representatives from different professional groups, including nursing, occupational therapy, physiotherapy, and administrative TABLE 7 Patient tracking participants
Patient participant numbers Farnchester stroke Farnchester hip Glipton stroke Glipton hip Total
Pre-discharge interview 7 9 8 8 32 Interview one 6 6 8 7 27 Interview two 4 3 5 3 17 Interview three 2 0 4 2 8 Withdrawals 2 5 1 0 8 Deaths 1 3 2 0 6 Readmissions 1 0 1 2 4 Diaries 2 2 2 2 6
and support staff. The workshop was structured with an overview of the research design and data, including the main points of convergence and divergence across the research sites, and analysis of the common barriers to and facilitators of hospital discharge. Participants were asked to discuss the relevance of the findings to their own service, the growing complexity of patient comorbidities, resource demands in the acute and community settings and the challenges of meeting increased patient expectations. This workshop helped to identify additional lines of analysis to test emerging conclusions.
Overall, the validation workshops identified and help clarify the following issues:
l the range and number of actors involved
l discharge pathways and structure of interactions
l communication and knowledge-sharing problems
l the main perceived threats to patient safety
l contextual factors, i.e. staffing, resource constraints, targets
l wider contextual changes, i.e. CCG priorities
l recommendations for future interventions. Documents, policies and routine data
Through the study, various documents were collected from each research site. These included formal policies and pathways for discharge planning, patient leaflets and guides, and pictures of posters, fact sheets and other information. These were used to contextualise observational and interview data and provide a point of comparison between expected or planned discharge and observed discharge. The research also aimed to gather routinely collected performance data related to hospital discharge at each site, including data about staffing, bed usage, safety incidents, number of patients, average length of stay and number of readmissions. In three participating sites much of this information was made available by service leaders, and with additional third-party data, specifically health profiles and ONS data. As with the focus groups, however, one site was reported as too busy to help provide these data and, as such, only third-party data were collected. These statistical data were used to help contextualise the organisation and performance of each site, and were not used for formal statistical analysis. The range of data collected included:
l British Heart Foundation Stroke Statistics 2009
l British Heart Foundation Statistics Database 2009–12
l Health Profiles 2012 (Public Health Observatory) TABLE 8 Focus group participants: staff groups represented
Glipton stroke Glipton hip Glipton community Farnchester stroke Farnchester community Regional OTs PTs SaLTs ESD services (n=11) OTs PTs (n=6) Rehabilitation nurses Stroke support group (n=17) PTs OTs Ward nurses (n=15) OTs PTs Social services (n=4) GP and PCT leads (CCG) (n=4) End-of-life group (n=4) Ambulance service (n=3)
l commissioned discharge support documentation
l annual reviews per authority
l National Hip Fracture Database (NHFD) 201242
l national stroke audit 2011.32