Theme 5: Perceptions of care continuity

The theme “perceptions of care continuity” encompasses the views that junior doctors had on the role of GPs, on how discharge summaries relate to GPs, and their own experiences with care continuity between secondary and primary care.

Generally, junior doctors seemed to have a fairly limited understanding of how and why discharge summaries were of such importance to a GP, as with:-

“I think it [the discharge summary] is important so the GP has the information… I think probably communication between GPs and hospitals isn’t always great, and so I think it’s important to do a good summary [JD3E].

This uncertainty of this junior doctor as to why GPs would require good communication at discharge perhaps indicates limited insight on the part of some junior doctors into the workings of primary care and the information needed by GPs to continue care post-discharge. Their insight may be limited due to a lack of postgraduate experience working in

primary care, as junior doctors usually undertake rotations in secondary care for two years after graduation.

The exception was one junior doctor who had spent considerable time working in a GP practice, who expressed her concern where information for GP action on the discharge summary is incomplete or omitted, as with:-

“Often ‘management plan’ and ‘instructions to the GP’ is just left empty [on the summary] and… I find that a little bit unsettling” [JD1E].

And who also demonstrated insight into the potential snowball effect of providing incomplete information on summaries, especially with reference to medicine changes which occurred during admission:-

“What will happen is the patient will be discharged from the hospital and they’ll go to the GP the next day saying they’ve stopped some of my medicine. And you’ll look at the discharge summary and have no idea why. And I found that really difficult, so I try and alter my practice now” [JD1E]

This doctor’s experience in primary care implies a considerable difference between being faced with incomplete information when writing a summary, and being faced with an incomplete discharge summary when seeing a patient in primary care.

At discharge, the responsibility for the patient’s care is passed from the hospital back to the GP, alongside responsibility for follow-up care or action requested by the hospital. Later in this thesis, GPs have reported dissatisfaction with some of the requests that were made of them by the hospital, seemingly ‘passing the buck’. This was recognised by the junior doctor who had spent time in primary care, as with:-

“You can easily put ‘GP to do this, GP to do that’, and when you’re in hospital and you’re really busy you kind of forget GPs are actually really busy as well, and sometimes it’s not really fair to put the onus on them” [JD1E]

This doctor acknowledges the transfer of responsibility when a patient is discharged, and the potential for abuse of this, because the hospital doctor is able to pass on responsibilities to the GP, which this doctor regards as sometimes unfair.

The other junior doctors discussed the quantity of information to provide on discharge summaries, demonstrating a concern over providing too much information to prevent the key messages from being overlooked:-

“It’s a fine balance between putting in too much information and not enough for the GPs to read them – so… if you write paragraphs and paragraphs then it doesn’t get read, and things will get missed because they [the GPs] don’t have the time to read them” [JD7E]

This was not only the case to assist the GP, but to aid hospital doctors when patients are readmitted, in order to allow the key patient information to be identified quickly, as with:-

“You tend to try to put in the bare minimum… what you think the GP might want to know, or what the following doctor might want to know if this patient was readmitted... It’s easier to look through the ones that are more concise and to the point, rather than ones that waffle on and on” [JD2S]

4.6 Discussion

4.6.1 Themes

Figure 4.1 displays links between the themes and sub-themes identified from the findings.

Continuity of care houses all other themes identified, with barriers and facilitators being specifically relevant to the process. Perception of roles is linked to both the process of summary composition and in the overall context of continuity of care.

Figure 4.1: Map of emergent themes showing links between broader themes

4.6.2 Main findings

In this multi-method focused ethnographic study, the aim was to explore the process of composing discharge communications from the perspective of a junior doctor, in order to identify any working practices at discharge where changes could be made to improve the transfer of care pathway.

4.6.3 Strengths and limitations

This study was small in size, conducted at one UK site and investigated only one cohort of junior doctors. I spent limited time (2 weeks only) on wards, rather than actually working on them, and therefore found it more difficult to build those in-depth research relationships with ward staff, which may have facilitated the recruitment of more junior doctors. However, I judged that the sample of 7 junior doctors provided a wide breadth of opinion and experience, whilst remaining consistent with emergent themes generated.

Junior doctors were recruited only at one hospital site, which may have meant that their experience of producing discharge summaries was different to those working at other hospital sites, and this particular sample will not also have been representative of the entire population of junior doctors in the UK. However, the sample included doctors at different stages in their careers, from a variety of backgrounds and working in different rotations, which allowed for a range of views and different experiences to be explored.

PERCEPTION OF ROLES CONTINUITY OF CARE

PROCESS

BARRIERS FACILITATORS

Data was collected by me, and as a pharmacist, which if participants took particular note of my professional role, may have affected the willingness of junior doctors to be completely at ease with entering into discussion about discharge summaries. This is because pharmacists, where available, have a role in the accuracy checking of medicine listed on discharge summaries, and often liaise with doctors to correct ambiguities or inaccurate information on summaries. Essentially, they act as a defence layer to prevent errors made by doctors from reaching patients, which might make doctors feel like pharmacists are there to ‘catch them out’ rather than help them. In particular, where discussion about discharge summaries involved making errors in prescribing or transcribing medicine at discharge, or attitudes towards or experiences of working alongside pharmacists at discharge, doctors may have felt that they could not express their true opinion for fear of being challenged or judged. I attempted to minimise this by informing participants that I was conducting the interview as an impartial and neutral researcher, but it is nonetheless a potential limitation of this study.

However, this study is novel in providing insight into junior doctor culture and their experiences specifically relating to discharge summaries. Additionally, an innovative method combining observations, think-aloud and ethnographic interviews has been designed to access this high pressure setting and the role of junior hospital doctors.

Designing a study to provide such insight has enabled the identification of environmental and process factors affecting junior doctors at discharge which may be related to the poor quality in discharge summaries that is routinely observed. Strategies to improve or alleviate these factors may therefore assist in improving the quality of discharge summaries produced.

4.6.4 Main discussion

4.6.4.1 Environment

The ward environments in which summaries were written were busy and noisy, with multiple interruptions and distractions occurring during doctors’ composition of summaries, which often detracted their attention away from the task. Doctors complained of a lack of a private, designated area in which to write summaries, which were often written on shared computers at the ward nurses’ station. These environmental factors may well increase the risk of errors or omissions being made on discharge summaries as a result of human error (38). Implications for practice are that provision of designated quiet areas

on wards in which to work on summaries might help to alleviate this, but even where doctors chose to write summaries in private rooms, interruptions were still possible, and even desirable according to one of the doctors interviewed. The red tabard system is currently used in UK hospitals, whereby nurses who are undertaking a drugs round and administering medicines wear a red tabard to identify them to other ward staff and patients and so prevent them from being interrupted (123, 124). Adaption of the red tabard system for doctors involved in summary composition may be a system-based approach to reducing errors worth further research.