Análisis de datos

The sub-theme of “environment and interruptions” brings together comments made by junior doctors about the ward environment in which they write summaries. This includes the noise level, number and nature of interruptions, and general comments relating to the workspace.

During the combined fieldwork episodes, which took place on the wards where the doctors general comments about the ward environments in which the combined fieldwork episodes took place.

 Nurse asking doctor to provide patient results

JD3E  Quiet office

 Fun, jovial atmosphere

 Strong sense of team spirit

 Good interactions with other HCPs

 Occasional chatting from other doctors

JD4M  Busy but efficient

 Friendly

 Good morale of staff

 Occasional chatting from nurses and other doctors

JD5M  Excellent rapport with nurses

 Less staff, more workspace on ward

 Busy weekend workload

 Nurse asking about medicines

 Nurse asking about when summary would be ready

JD6M  Modern, large and spacious ward

 Very busy

 Doctor moved to quieter area to write summary

 Limited information available on ward - reliant on patient

 Nurse asking for stool sample

JD7E  Efficient sister on ward

 Well organised

 Busy time of day – post ward round

 Nurse asking for blood sample

Table 4.4: Observations made relating to environment and interruptions during interviews

Junior doctors complained about the lack of a quiet, private space on the ward in which discharge summaries could be written, which would allow the doctor to limit interruptions and help concentration on that task.

“Especially on the weekends when you’re at the AMU, and you’re standing at a computer that’s surrounded by lots of people… it’s not exactly an ideal situation.

We don’t often have… an office or anywhere that we can go into, or anything like that” [JD5M]

However, doctors expressed awareness of the need to make themselves continuously available to ward staff, and so also suggested that removing themselves into a quiet space in order to write summaries could be potentially problematic.

“If you can’t disturb a doctor when they’re doing a TTO, then nurses can’t get their message across, and I think interruptions have to happen... we should be able to talk to a nurse then come back to a TTO” [JD6M].

4.5.4.3.2 Time

The sub-theme of “time” relates to the references made to the need for, and pressures on, time available to junior doctors to compose discharge summaries in the context of their working day.

Time spent composing discharge summaries (acquiring information and writing the text) was frequently identified by the junior doctors as a problem surrounding discharge. The summaries composed during interviews took between 12 to 35 minutes to complete, varying dependent upon patient complexity and the occurrence of interruptions. Writing a discharge summary required careful reading of notes and transcription of medicines from drug charts. One doctor acknowledged the potential effect on quality of the summary associated with a hurried summary:-

“If I had more time, I’d be able to go through the notes thoroughly and find out all the information” [JD5M]

This statement is concerning, as it implies that often notes aren’t reviewed thoroughly and information is often not identified in the interests of producing a summary quickly.

Another described the knock-on effect on time of having to step out of a ward round in order to complete a discharge summary:-

“Everyone just gets pulled from ward rounds to see a discharge summary - and then you got a hundred different jobs to do - so there literally is no time”[JD2S]

For this doctor, addressing discharge summaries has led to a conflict of priorities and subsequent burden on their already large workload.

4.5.4.3.3 Guidance

The sub-theme of “guidance” examines comments made by doctors relating to the training and guidance they have received during their medical degree, at other secondary care institutions, and whilst working at CHUFT.

Variation in the discharge summary writing practice between junior doctors was apparent through observations and interviews. Rather than receiving formal training on what constitutes a good discharge summary, junior doctors instead were left to find their own style of compiling and writing a summary through practical experience and learning by doing, as with:-

“Everyone has their own style of [doing] discharge summaries and… we’ve not really been given a tool as to [how to] do them best… I think it’s difficult to know how much information to actually put in” [JD1E]

When talking about their formal postgraduate training provided by the hospital, most junior doctors said that the training they received was solely focused on how to use the electronic discharge system, not what information should be included within the summary, how to gather that information, and what constitutes a high quality discharge summary:-

“No. I think we got [training], when I first started at the trust. We got shown how to use Bedweb and that’s it” [JD7E]

Some felt that their individual method of summary writing depended on the consultants under which they are working or had shadowed in the past. The ward specialty was also a factor, for example, they described their surgical discharge summaries as being very different in content and length to medical discharges.

“I did respiratory first, and then we did quite good discharge summaries which were quite important because they would have a lot of care in the community. But then when I was doing surgery, the discharge summaries turned into very much ‘this patient came in for an elective this, they’re well and they’ve gone home’ - that kind of thing” [JD5M]

However, it was not common for doctors to share discharge writing skills or practice between themselves. When asked if conferring with peers about discharge practice occurs, one doctor replied:-

“Not really no, I haven’t really spoken to anyone about it really. Everyone just kind of does their own thing” [JD2S]

This implies that doctors perceive ability to write summaries as an individual and individualised skill, rather than something which is standardised across the board. It may also imply that discharge summary writing is not perceived to be that important, if it is not openly discussed between doctors.