Table 3

Themes, categories and quotes related to handovers at patient discharge

ThemeCategoryRepresentative quotes
I. Care provider prioritisation of discharge consultationsA lack of timeHospital physician: …sometimes the discharge instructions do not go well enough. (…) because the intern is busy again or is called for an emergency. Meanwhile the patient cannot wait to go home. Well, at a certain moment you have to let the patient go.
Hospital nurse: There are communication gaps due to the rush everywhere. Sometimes a patient would like to ask a question, but (…) the physicians are in the operation room or away all day long.
Giving priority to delivering medical or nursing careHospital physician: Our scope is restricted to pure medical care. (…) We are not very aware of how patients are discharged.
Lack of a standard discharge consultationHospital nurse: There is no specific discharge consultation with the patient. (…) Nurses talk a lot with patients during the whole day, but there is no specific moment when one says to the patient: "listen, I organised this and that".
GP: There are patients that are discharged and start complaining to me that they did not see the physician for two weeks and suddenly were informed with: "you can leave tomorrow". And on the next day there was no consult with the physician on duty. Nothing, but: "you can pack your belongings".
II. Decision-making within the discharge processInvolving patients in decisions regarding their follow-upPatient: Three physicians arrived at my bed. My physician, the physician at the ward, and…then it is like: "your treatment here is over. We found a follow-up location for you. You can go." Actually, they force you (…) they are a bit authoritarian.
Community nurse: It is important to be sensitive to patient needs (…). But there is rush and insensitivity. It would be better if everyone, starting with the hospital physician, would ask the patient about what is needed.
Dealing with competing interestsHospital physician: I will never keep the patient here against its will. If a patient does not want to go to a nursing home and even though the family (…) and nurses say: "he does not take care of himself and he will fall at home" (…) this person has the right to go home with the possibility to fall. (…) That the patient's autonomy.
Hospital nurse: I understand when a patient says: "I will not take these medicines". (…) But that is his own responsibility. Unfortunately we often see such patients returning to the hospital and unfortunately this happened in this case as well, because the patient did not take is blood thinning medicines…that's his own choice. (…) It [influence] stops when they leave the hospital door.
III. Care provider anticipation of patient-specific needs and preferencesEstimating patients’ resources, capabilities and skillsPatient: After the amputation of my toes I was sent home with two sets for wound care dressing and told to treat this by myself. (…) I got one bleeding after the other.
Community nurse: In several occasions patients have been discharged without us being informed about their insulin treatment, resulting in patients not receiving insulin after discharge. Sometimes it seems that the ward personnel thinks that these patients can manage everything by themselves and that they are all well functioning while, in reality, they suffer from dementia.
Patient emotions and emotional supportRelative: It was clear that my mother was frightened to go home. A little more compassion and understanding would have made it much easier (…) Well, there was a consultation just before discharge, but it was a real technical-medical conversation. Not in the sense of "are you looking forward to go home?"
Patient: It was not possible to ask something because all the time you got the answer…”no this is not the right moment, later…”.
Patient preparedness for dischargeGP: I often hear from patients that they were overwhelmed by the discharge, like: "suddenly I have to go home".
Hospital nurse: As soon as we talked about going home we saw that he panicked and got another asthma attack. We strongly had the feeling this was correlated with the fear to go home. You often see these patients quickly return to the hospital. I think: "this patient was not capable to go home" (…) apparently not with the right preconditions. For example, it would be better to put those [COPD] patients back on the inhaler. (…) Now it often happens that patients are using a nebuliser in the morning, are discharged in the midday and have to continue with their own [different] inhalers at home while we did not see if they switch easily. And that is why often things go wrong.
Quality of information provided at discharge to patients and family membersRelative: We came back home with all this drugs without the slightest idea of how long the therapy was supposed to last.
GP: The hospital does not understand that information to the patient should be restricted to one page. I see patients arriving here with a complete set of brochures. (…) That is no information. (…) It only confuses or scares them. You should explain the few essential things.
Patient: So, the cardiologist stood next to me and said all sorts of things in Latin. (…) I do not speak Latin!
Exchange of patient-specific information between hospital and community care providersCommunity nurse: A hospital should inform us about patient discharge in case when a patient lives alone. These are elderly, sometimes with dementia. The doctor tells him things in the hospital, but the patient has already forgotten half of that when he gets home.
Hospital physician: We sometimes give information to the community nurse too late, really close to discharge and the community nurse does not have the time to organise the handover.
Community nurse: We see patients leaving the hospital with the medical report and they can have four ulcers…and not a soul knows about that! Until you visit them at home. That is very heavy.
Community care providers’ role in monitoring patients after dischargePatient: To be honest I did not receive any calls from my GP and I would have appreciated it.
IV. Organisational factorsShift work structures of hospital care providersHospital physician: The lack of consultations with patients and family at discharge has to do with work schedules of the attending physicians at the ward. (…) We have evening shifts, night shifts, weekend shifts. (…) The physician who takes over also needs time to get to know the patient. (…) This means that the information exchanged is not sufficient, because you do not know the patient well.
Patient: You constantly see new physicians (…) it makes you crazy, because at a certain moment you do not know who you need.
Accessibility of hospital care providers to patientsGP: I think a patient should have better access to the physician who still treats that patient. I mean, when this patient is recently discharged and still has a question related to his hospitalisation I think it is odd that it he is advised to contact the GP. At the outpatient clinic they say: "no, you cannot speak to the physician".
Pressure on available hospital bedsHospital nurse: Sometimes you feel that the hospital physicians have made a decision about discharge, and then you feel that it is actually a little bit too early, actually. But you don't have that much of a choice since the pressure is high.
Hospital nurse: If a physician needs a hospital bed during the weekend, he or she will discharge the patient without any notification.
Discharges on weekendsPatient: At Friday they told me that I could go home the next day. But the offices are closed on Saturdays and they could not give me all the proper discharge information and equipment. (…) That was not pleasant. (…) So I did the medication and all other things on my own.
  • GP, general practitioner.