Prerequisites for patient self-management learning at hospital discharge – an observational multiple case study

Abstract

Introduction : In recent years much attention has been given to care transitions between healthcare settings and to re-hospitalizations. This is not without reason. Errors in medication, therapy, and in follow-up of tests and procedures following hospitalization are not uncommon and the associated costs are profound. Putting effort on increasing patients’ knowledge on disease control and symptom management has shown an effect on decreased re-hospitalization rates. Yet, little is known about how the information aimed to prepare patients are given to patients during hospital discharge, and how the information make sense to the patients. This study aims to explore how the hospital discharge process provides a learning environment for patients’ understanding of their self-management. Theory/Methods : This study uses observational multiple-case study design. The cases – three wards of internal medicine from different hospital types: one regional, one general and one university hospital, all located in the county council of Stockholm, Sweden – were selected to allow inclusion of patients with varying diagnoses and backgrounds. The observations primarily focused on the discharge encounters but included other events where patient self-management learning was considered to either take place or be discussed: medical distribution, bedside rounds, formal/informal meetings between patients and healthcare professionals. After the observed discharge encounters, patients and their present next-of-kin who agreed to participate in the study, and thereafter the discharging healthcare professional were interviewed. Semi-structured interview guides were used. Data was analysed using cross-case synthesis in which the case under study at each units first were analysed separately, using content analysis, where after the analyses were compared and cross-case conclusions drawn. Results : The wards were overall similar in the prerequisites for patient understanding of self-management in the hospital discharge process. Patient understanding of self-management were supported or constrained during the medical distribution by the registered nurses, the bedside rounds and the discharge encounters. Each of these encounters provided opportunities for the patients to learn about self-management, and for the healthcare professionals to gain and provide information to support the patients’ self-management. Patients were not involved in the decisions preceding discharge. The bed-side rounds overall focused on giving informations to patients and not on involving patients in the communication. The short hospital stays were considered as barriers for patient self-management learning; the patients were too stressed at the discharge encounters to grasp the information and the healthcare professionals lacked time to grasp the patients’ situation and needs. The healthcare professionals used several pedagogical efforts to facilitate patient understanding. The efforts were however not a conscious thought-through strategy and the professionals expressed uncertainty whether the patients had understood the information or not. Upon discharge, patients received a plain language written discharge note and medication list. The oral information followed the structure of the discharge letter, omitting self-management activities. Patients’ made several efforts to facilitate their understanding, they checked that they had understood the healthcare professional, asked for clarification and confirmed when they had understood. Discussion : The discharge letter constituted the base of the discharge information, as both the oral and written information given by the physician sprung out of the letter. As we found that the discharge letter overall had a retrospective focus it only gives patients limited understanding of self-management activities post-discharge. Much time and effort was put into providing patients with accurate information and to facilitate the practical details of the discharge. However, only a small amount of effort was given to involve patients in the decisions, to ensure that patients had understood the information and had the skills to manage the self-management needed. Evidence suggests that information alone does not promote patient adherence to medications. A targeted, person-centred communication, in order to reach common ground for decision-making, is far from realized in healthcare. In contrast we found that patients were not actively involved in the planning of their discharge, and that sensemaking rarely came through in the discharge encounters. Conclusion : The information given at discharge was driven by the needs of the staff of communicating information, rather than patients´ needs or level of understanding. Simple use of pedagogical teaching and patients’ involvement in the decisions preceding discharges with the aim of ensuring patient understanding has the potential to enhance patient self-management knowledge, whereas a system accountability overlapping the gaps could provide patients with comfort to put knowledge into action.